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What are Antidepressants?

Antidepressants are medications commonly prescribed to treat people suffering from depression. There are several different types of antidepressants, and they can come with a variety of side effects. 

Antidepressant medications are also known to negatively interact with other drugs, particularly alcohol. If you drink alcohol while taking certain antidepressants, you may put yourself at increased risk for serious side effects.1

Many Americans have loved ones currently in addiction treatment who struggle with mixing alcohol and antidepressants.

Types of Antidepressants

There are five major classes of antidepressants. Each takes a different approach to treating symptoms of depression and has different side effects. The five classes are:

  1. Selective serotonin reuptake inhibitors (SSRIs) —  SSRIs are the most popular class of antidepressants. SSRIs increase serotonin levels in the brain by inhibiting its reuptake into the nerve cells. Serotonin is a neurotransmitter responsible for feelings of well-being. Although the exact mechanism is not well-understood, by increasing overall levels of serotonin, SSRIs have the potential to alleviate depressive symptoms. Common SSRI brands include Lexapro, Zoloft, and Prozac.
  2. Serotonin-norepinephrine reuptake inhibitors (SNRIs) — SNRIs are a class of antidepressants. Similar to SSRIs, they block the reuptake of serotonin. The difference is they also block the reuptake of a neurotransmitter called norepinephrine, responsible for focus and memory recall. Popular SNRI brands include Cymbalta, Effexor, Pristiq, and Paxil. 
  3. Tricyclic antidepressants (TCAs) — TCAs are an older class of antidepressants that have been in use since the 1950's. Similar to SNRIs, TCAs increase serotonin and norepinephrine levels in the brain. They generally have more side effects than newer medications and are used less often today. Some notable TCA brand names include Anafranil and Norpramin.
  4. Monoamine oxidase inhibitors (MAOIs) — MAOIs were the earliest developed class of antidepressants. They have mostly been discontinued due to a range of unpleasant side effects and interactions with alcohol and other drugs. MAOIs increase  serotonin, norepinephrine, and dopamine levels in the brain. Brands include Nardil, Marplam, and Emsam.
  5. Atypical antidepressants — These include everything not mentioned above. Atypical antidepressants include Bupropion (Wellbutrin), Trazodone, Nefazodone, and Mirtazapine, among others. As the name implies, these medications do not fit into any particular class of antidepressants. Because of this, the mechanisms of action and possible side effects all differ.

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Side Effects & Risks of Antidepressants

The side effects of antidepressants depend on the class of antidepressant and your specific biology.

Other common side effects of SSRIs include:

  • Sexual dysfunction
  • Dry mouth
  • Constipation
  • Weight fluctuation
  • Headaches
  • Insomnia

Some more serious side effects in rare cases include:

  • Bleeding
  • Extreme agitation
  • Withdrawal symptoms

One fact that surprises many: SSRIs may actually raise the risk of suicidal thoughts and behaviors, at least at first. Since depressive symptoms are eased, but not eliminated, patients may develop suicidal thoughts or tendencies. 

For some, this could include taking their own lives. Because of this, it is recommended that patients’ loved ones and healthcare providers closely watch them during the first few weeks of SSRI treatment.

Side effects of MAOIs include headaches and insomnia. In rare cases, they can interact with an enzyme that breaks down tyramine, a chemical found in certain foods, causing hypertension and cerebral hemorrhage. An early MAOI, Iproniazid, was discontinued due to it being linked to Hepatic necrosis (acute liver failure).11 

Common side effects of TCAs include unwanted weight gain, sedation, sexual dysfunction, and risk of suicidal thoughts.

The side effects of atypical antidepressants can vary. For example: 

  • Trazodone has been linked to orthostatic hypotension, dizziness, and headaches.
  • Bupropion side effects include irritability, insomnia, headache, tremors, and nausea. 
  • Mirtazapine side effects include sedation, irritability, dizziness, dry mouth, and disturbing dreams.

What Happens When You Mix Antidepressants and Alcohol?

Alcohol affects your body's ability to metabolize many medications, complicating the task of getting the right dosage into the bloodstream. 

There are two ways that alcohol alters the body’s ability to metabolize certain antidepressants:

  1. Pharmacokinetic interactions, in which alcohol can slow down your body's processing of the medication. An enzyme called CYP2E1 plays a role in processing both alcohol and many drugs. The presence of alcohol can slow down the metabolism of the medicine because the enzyme is "busy" metabolizing the alcohol. When this happens, more of the drug remains in the blood than expected, which can lead to an overdose. The bodies of heavy drinkers produce more of this enzyme, metabolizing the medicine too fast for it to be effective.
  2. Pharmacodynamic interactions, in which there is an additive effect of the drug and alcohol. In this situation, alcohol does not change the concentration of the medicine in the bloodstream. Instead, the sedative effect of alcohol adds to that of some drugs. This can happen with moderate drinking or even in a single episode of mixing alcohol and medication. 

It is also important to note that there is a wide variety in how individuals metabolize alcohol and medicines separately. For example, some people's genetic makeup makes them feel nauseous and flush when they consume alcohol. Because of the disparity in how different people metabolize substances, it is hard to assess the risk of a bad interaction in a particular person. 

Alcohol and Antidepressants Side Effects

Alcohol consumption while taking antidepressants can lead to a variety of adverse side effects. In addition, antidepressants can end up strengthening the effects of alcohol, increasing impairment. 

For example, alcohol and certain antidepressants both have sedative effects, which can combine when taken together. When combining alcohol with MAOIs, there is an increased risk of dangerously high blood pressure. 

More serious side effects of mixing alcohol and antidepressants include greater risk of impulsive and violent behavior.

Does Alcohol Counteract Antidepressants?

Drinking alcohol can undermine treatment for depression since alcohol is a depressant. 

According to the Mayo Clinic, people with alcohol use disorder are often diagnosed with depression and other co-occurring mental health conditions. 

Evidence suggests that even moderate drinking can interfere with the production of serotonin.  Heavy drinking is linked to a higher risk for mood disorders. Alcohol dependence can also induce feelings of guilt and low self-worth, worsening symptoms of depression.

Antidepressants and Alcohol Blackouts

Evidence shows some people have a lower tolerance for alcohol while taking antidepressants.5 

Possible consequences for drinking while on antidepressants include impaired memory, risky sexual behavior, and violence. 

If you take antidepressants and then drink alcohol, you may experience a "blackout." A blackout is when your memory is so impaired that you may not remember what you did the night before.

Can You Die From Mixing Antidepressants and Alcohol? 

Serious health problems from mixing alcohol and certain medications include difficulty breathing, heart problems, and internal bleeding. 

One study found combining SSRIs with alcohol raises the risk for Rhabdomyolysis, a life-threatening condition.10 

If you drink alcohol while taking MAOIs, you may increase your risk for dangerously high blood pressure.  

And while it may produce euphoria in the moment, drinking alcohol worsens symptoms of depression in the long run. When combined with alcohol's ability to lower inhibitions, this may lead to an increased risk for suicide.

Is Mixing Alcohol With Antidepressants a Sign of Alcoholism?

According to a national survey, 16.9% of the 20.3 million people who suffered depression also reported substance use disorder (SUD).1 Of those that reported SUD 17.1% said alcohol was their drug of choice.1 

Another survey of 43,093 adults showed 20.5% of those with an alcohol addiction reported having depression.7 This suggests if you are dependent on alcohol, you are 3.7 times more likely to suffer from depression.7 

People who mix alcohol with antidepressants may therefore be at greater risk of alcohol use disorder.

Some symptoms of alcohol use disorder include:

  • Solitary drinking
  • Drinking to excess
  • Inability to stop drinking or drink in moderation
  • Issues with friends, work, or family members centered around drinking
  • Craving alcohol

Treatment for Antidepressants and Alcohol Misuse

Treatment options for alcohol misuse by people taking antidepressants break down into three principal approaches: 

  1. Sequential — treating the primary disorder first, then addressing the secondary disorder
  2. Parallel — treating both disorders at the same time but in different settings
  3. Integrated — treating both disorders at the same time

Limited research indicates the third approach is the most effective in many situations. One possible technique is called a "motivational intervention," which means respectfully confronting the patient about their substance use.

The patient is made to understand the importance of taking responsibility for themself. This approach can take place in both one-on-one settings within the confines of a wider support group.

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Resources

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(1) DeVido, Jeffrey J., and Roger D. Weiss. “Treatment of the Depressed Alcoholic Patient.” DeVido, Jeffrey J, and Roger D Weiss. “Treatment of the depressed alcoholic patient.” Current psychiatry reports vol. 14,6 (2012): 610-8. doi:10.1007/s11920-012-0314-7, vol. 14, no. 6, 2012, pp. 610-8. Treatment of the Depressed Alcoholic Patient, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712746/.

(2) Hall-Flavin, Daniel K. “Antidepressants and alcohol: What's the concern?” Mayo Clinic, 2017, Antidepressants and alcohol: What's the concern?

(3) Herxheimer, Andrew, and David B. Menkes. “Drinking Alcohol during antidepressant treatment - a cause for concern?” The Pharmaceutical Journal. Drinking alcohol during antidepressant treatment — a cause for concern?, Drinking alcohol during antidepressant treatment — a cause for concern?.

(4) Laban, Tahier Sub, and Abdolreza Saabadi. “Monoamine Oxidase Inhibitors (MAOI).” NCBI Bookshelf, 2020, Monoamine Oxidase Inhibitors (MAOI). Accessed 23 May 2021.

(5) National Institute on Alcohol Abuse and Alcoholism. “Harmful Interactions Mixing Alcohol with Medicines.” Harmful Interactions Mixing Alcohol with Medicines, Harmful Interactions: Mixing Alcohol with Medicines. Accessed 23 May 2021.

(6) Ogbru, Omud, and Jay W. Marks. “Antidepressants Side Effects, List, Types, Uses, and Alcohol Interactions.” https://www.medicinenet.com, 28 Antidepressants Types, Side Effects, List & Alcohol Interactions.

(7) Pettinati, Helen M., and William D. Dundon. “Comorbid Depression and Alcohol Dependence.” Psychiatric Times, Comorbid Depression and Alcohol Dependence. Accessed 24 May 2021.

(8) Ramsey, Susan E., et al. “Alcohol Use Among Depressed Patients: The Need for Assessment and Intervention.” Professional psychology, research and practice, vol. 36, no. 2, 2005, pp. 203-207. Alcohol Use Among Depressed Patients: The Need for Assessment and Intervention, Alcohol Use Among Depressed Patients: The Need for Assessment and Intervention.

(9) Weatherman, Ron, and David W. Crabb. “Alcohol and Medication Interactions.” Weathermon, R, and D W Crabb. “Alcohol and medication interactions.” Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism vol. 23,1 (1999): 40-54., vol. 23, no. 1, 1999, pp. 40-54. https://www.ncbi.nlm.nih.gov/, Alcohol and Medication Interactions.

(10) Sung, Dong Jun, et al. “Combination of Antidepressant and Alcohol Intake as a Potential Risk Factor for Rhabdomyolysis.” Iranian journal of public health, vol. 47, no. 2, 2018, pp. 1424-1425. Combination of Antidepressant and Alcohol Intake as a Potential Risk Factor for Rhabdomyolysis, Combination of Antidepressant and Alcohol Intake as a Potential Risk Factor for Rhabdomyolysis.

(11) Khawam, Elias A., et al. “Side effects of antidepressants: An overview.” Cleveland Clinic journal of medicine, vol. 73, no. 4, 2006 351-3, 356-61. PubMed.gov, Side effects of antidepressants: an overview

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