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Recommendations for Pharmacological Treatment of Acute Stress Reactions

 

Recommendations for Pharmacological Treatment of Acute Stress Reactions

Clinicians are understandably reluctant to utilize pharmacotherapy during the immediate aftermath of exposure to a traumatic event. Although most people will be distressed during the acute post-impact phase, the great majority will recover during the following weeks. As a result, clinicians are hesitant to "pathologize" such normal reactions to traumatic stress by utilizing medications.

However, the use of medications may be necessary when the survivor is dangerous, extremely agitated, or psychotic. In such circumstances, the individual should be taken to an emergency room. In the emergency room, short-acting benzodiazepines (e.g., lorazepam) or high potency neuroleptics (e.g. haldol) with minimal sedative, anticholinergic, and orthostatic side effects may prove effective. Atypical neuroleptics (e.g., risperidone), at relatively low doses, may also be useful in treating impulsive aggression. Such use should be limited to no more than five days with the understanding that this is for short-term symptomatic relief.

There is currently no evidence that acute pharmacotherapy following exposure to a traumatic event can prevent the later development of PTSD. Although there have been a number of interesting attempts to discover such a "morning after pill," the current evidence is too ambiguous to support any recommendations at this time. Indeed, the current VA/DoD Clinical Practice Guideline makes no recommendations for prophylactic pharmacotherapy during the acute aftermath of a traumatic event. There is even some evidence that chronic treatment with anti-anxiety or sedative/hypnotic medications (such as benzodiazepines) may actually hinder the normal recovery from such events.

Generally, the trauma survivor should have a thorough psychiatric and medical examination prior to receiving medication. Ongoing medical conditions, psychiatric diagnoses, current medications, and possible drug allergies should be assessed. In addition, clinicians should ask questions regarding alcohol, marijuana, stimulants, and other drugs since these substances may interact with prescribed medications and may complicate an individual's psychological and physiological response to the trauma. For individuals with medical and/or surgical concerns, a clinician may need to take special precautions when prescribing psychotropic medications. It is also extremely important to consider possible drug interactions for individuals who are taking other prescribed or over-the-counter medications.

What other factors need to be considered for distress that persists for more than one month?

Also see our Clinician's Guide to Medications for PTSD fact sheet for a review of medications to treat PTSD.

Recent trauma survivors may also suffer from debilitating symptoms of depression, with or without PTSD. Since selective serotonin reuptake inhibitors (SSRI's) and the selective serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine, effectively ameliorate both depression and PTSD symptoms, it is recommended that SSRI's and SNRI's be considered for persistent posttraumatic depression. In addition, SSRI's may be useful for controlling anxiety and irritability. SSRI's, SNRI's, and other antidepressants should be administered in a "start low and go slow" dosing regimen because some individuals may develop increased anxiety, agitation, or other side effects in response to them. The alpha-adrenergic post-synaptic antagonist, prazosin, is recommended for amelioration of traumatic nightmares and may have beneficial effects on other posttraumatic symptoms.

Some individuals have preexisting psychiatric disorders, including preexisting PTSD, at the time that they experience trauma. The most recent trauma may exacerbate these preexisting conditions, making it essential to carefully assess the individual's psychotherapeutic and pharmacological needs. It is imperative that a clinician contact any other current providers and maintain continuity of care.

It is also possible that trauma will precipitate disorders other than depression, traumatic grief, acute stress disorder, or PTSD. In such cases, careful assessment and diagnosis should inform appropriate treatment.

Finally, it is essential that providers educate patients about their medication's interactions with alcohol, other medications, or substances of abuse. Providers also need to inform their patients of the medication's potential side effects, and remain in close touch with their patients after initiating the use of these and other psychotropic agents. This will allow providers to gauge the severity of any side effects, encourage compliance, and forestall complications that might arise as a result of extreme or otherwise idiosyncratic reactions to these medications. In addition, the added therapeutic support can help relieve the psychological burden from which people with posttraumatic distress suffer.

For more information, see: Friedman, M. J. (2008). The role of pharmacotherapy in early interventions. In M. Blumenfield & R. Ursano (Eds.), Intervention and resilience after mass trauma (pp. 107-125). Cambridge, UK; New York: Cambridge University Press.

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