A Cowboy’s Lesson — Antidepressants Won’t Work Well With Alcohol

“I wants me some of them-there antidepressant pills.”

He was a 47 year old good old boy of the sort I had treated in Oklahoma and other rural parts west –a real cowboy. He had herded animals and done the rodeo and all of that.

No, he had never seen a psychiatrist before, ever.  He had been out crying on the front porch, and it was a next door neighbor who had somehow convinced him that there were medications and he did not have to tell his whole life story to get pills. Well, maybe that would work with a general practitioner, but he was not only disappointed but also angry that it was plainly NOT going to work with me. Figuring he had been had, he broke down and told me the story.  I could understand at once why he had been reluctant to get into this, for we went through half a box of Kleenex while he gave me a plot that was worthy of a tear-jerky country song.

His wife had left with a young neighbor about one week before, after telling him that she had never loved him.  His son got out of jail (finally) and so he gave the son the keys to the car.  The son had totaled the car — and of course nobody had any money to replace it — so he had come to the appointment on the bus.  His other child, a young woman, was still in jail for armed robbery.

Holidays in prison; well, that is another discourse — one I would not embark upon with this man who was single-handedly creating a Kleenex shortage in this particular clinic.

He had primary care of his daughter’s baby, something he was not particularly knowledgeable about, so he was begging and borrowing help of all sorts. “I need some of them there antidepressant pills. Yes. Ma’am, I do.”

“Maybe,” said I, “and you will end up with some at least temporarily, but there could be other stuff to help you, and you need other kinds of help.”

I told him that his needs included a new woman-friend, a new car, some reform of his daughter at some point, and maybe some lessons in very young child care.

He thought that getting a new woman-friend would solve his need for childcare. I had to admit there was maybe some truth in that, as I certainly knew enough women who were wired that way, but I told him manly men had made errors by choosing a woman-friend for that reason only, taking the first available when they really had other criteria for what they really wanted. “Maybe so,” he said.

I asked him if he would do some screening blood work, just because I sometimes found out thyroid abnormalities and blood sugar problems and a couple of other things could cause symptoms that looked a lot like depression. Nobody had told him this, he said. But of course (once I had eliminated manic depression) I could give him some of those antidepressant pills while we were waiting. An informed consent, honest and complete, from zero, is never easy. It is easy for people who have been on a half-dozen antidepressants and nobody, including them, can remember most of the details about what other meds. This guy only knew some mythology about them-there antidepressant pills. I told him about how we studied them and they help with things like sleep and appetite and energy level.  And if you have thoughts about whether life is worth it, the pills can help with that sort of thing. Give him more energy — He thought this was a pretty good deal. But I told him that he needed someone to help him learn to communicate effectively with a daughter in jail and scrape together enough money for a car and all of those things. The notion of therapy was scary.  We could deal with that later when the medicine kicked in.

“They aren’t happy pills.  You need more than pills.” I found myself giving an apologia for therapy.  He found himself telling me he thought I was describing the function of his bartender. Ah HAH! I caught him! “Gee, I thought you said you didn’t drink!”

Well this wizened old cowboy had a lot of reasons to visit a bartender, and had graduated from the occasional social drink to a pretty impressive drinking habit. He blushed. His blood work came back normal and I started him on some medicine a couple of weeks later.  The sertraline (generic Zoloft) did not work terribly well because he didn’t follow through on his promise to cut back on his drinking — from what turned out to be at least three weekly blackouts.  I was amazed his liver functions still tested normal.

Within a month, the sertraline began to kick in, and he started getting better, and within a couple of more weeks, the next-door neighbor lady was bringing food and spending the whole evening with him instead of just changing a diaper out of some sense of either duty or pity.

A simple case, but it proves a couple of things:

First — depression seems to be, in the first analysis, chemical. Medications that have been tested well do actually seem to help. They are only to be expected to help in the things they have been tested for.  This is what has to be explained in an informed consent (which is required by law before EVER prescribing, but which most clinics just blow off in their haste to move more people through the mill faster).

Second — lots of people have noticed what antidepressants DON’T do. One of my favorites, who has written many books, is Dr. David Burns.  He started out as a pharmacologist and found out people’s lives don’t get better just from taking pills.  Only the things that have been measured get better – like sleep, appetite and ruminations. He became interested in and applied cognitive therapy to his patients, and did see life-changes.

If you do take care of the chemical part correctly, parts of life can get better subsequently.  This cowboy actually started to believe he could have another relationship with a woman after about four weeks of reasonable — if simple — antidepressant treatment.

Alcohol is often part of people’s lives.  They think it is “normal” or “social.”  Sometimes, like with this man, they drink enough that they can’t remember or report how much they are drinking. Alcohol is a central nervous system depressant.  Yes, it can cause a depression all by itself, so I always do my best to ask not only about alcohol, but about what people’s lives are like during the periods they are free from alcohol.  Often there is an underlying depression, which they are self treating with (what else?) alcohol — another depressant.But wait,there’s more.  Besides a depressant, it is a disinhibitor. It seems to remove the perception of social restrictions, and people do things they otherwise wouldn’t do. An amazingly hard thing for some people to believe, I ask them to remember an experience common to most everyone, the mixer-dance, in high school that degenerated early to all of the boys being on one side of the room, and all of the girls on the other.  In the days when the boys had to ask the girls to dance, it took a lot of nerve, and they were pretty inhibited. Of course the young men wanted to go for the alcohol. Their central nervous systems would generally get depressed enough (acutely — they would have had a depression if anyone thought to measure it).

Sometimes I wonder if we can find anyone who does not drink at all in these United States — other than a few religious sects, perhaps. Most clinical trials permit people to have one to three standard drinks (a can of beer, a glass of wine, a shot of whisky) — mainly because if these few drinks were not permitted, we could never recruit enough subjects for the clinical trial.  With anything more, there are a few studies I have seen that suggest that antidepressants just don’t work as well on people who consume larger amounts of alcohol. Gag me with a spoon — somebody actually PAID for this research — If you are trying to undepress people, it is much harder if they are taking alcohol, which is a depressant.

The exact amounts and thresh-holds are different for different people. Even (although it is politically incorrect to say it) for different races.  I can speak of myself, as it takes very little alcohol to exhaust my alcohol dehydrogenase-based ability to get alcohol out of my system, which means I could be a rather impressive cheap drunk.  (I have heard the same complaint from other people of Jewish background). Well the take-home lesson here is that fixing the chemical part of the depression does make sense.  Doing so is not going to work if there is something working against it.

Alcohol is far and away the most frequent.  Some medications (sedatives, antihypertensives)– sometimes, many — can be depressants that work against antidepressants, too. And then, after all the chemical stuff is done, there are lots of ways to get lessons in living that might be a cut above what you can get from a bartender. Just might.