Psychopharmacological possibilities in the acute disaster setting

The primary goals of psychiatric interventions after a disaster include reducing psychobiological distress, reducing the effects of secondary stressors, and facilitating successful coping (defined as one's ability to continue task-oriented activity, regulate self-emotion, sustain a positive self-value, and maintain and enjoy interpersonal contacts [224]). Given the paucity of evidence for or against pharmacological interventions in the immediate postdisaster setting, it would seem prudent to advise psychotherapy as a primary intervention, only to be followed by the conservative use of medications when relaxation and family, social, and professional supports have failed [15,174]. There is evidence, however, that some forms of psychotherapy, namely single-session critical incident stress debriefing (CISD), may not reduce psychological stressors or prevent PTSD and may be associated with an increased risk of developing PTSD following the traumatic event [225]. Psychotherapy is not innocent and without its own adverse effects. One also could argue, however, that the presence of identifiable risk factors could push one in the direction of medicating so as to prevent a pathological outcome from the disaster. There are various ways of looking at this idea, and some conclude that cognitive therapies ultimately may have the same effects on the brain as certain medications. For instance, cognitive therapies may strengthen the PFC, increasing its ability to inhibit the amygdala, and positive active coping strategies may reroute neural circuitry, transforming the freezing pathway into a pathway mediating movement [9]. There is no way to fully know which interventions to offer, but some things are clear. Although it remains prudent to attempt to determine if the symptoms are either normal reactions in the postdisaster phasealthough one must evaluate for the presence of secondary stressors before one assumes that the patient is out of the first phase of the responseor secondary to a budding pathological process, often pure and simple symptomatic management is all that is called for, especially when one cannot address etiologic considerations. When a patient presents with intense psychiatric symptoms that are impairing his/her functioning (eg, psychosis, mania, prolonged insomnia, suicidality, or exceedingly poor judgment) and threatening his/her well-being, one must not hesitate to provide relief in the form of medications.