To push back on stigma and cut through the confusion, Open Minds is a series that explores your most pressing questions about mental health.
I was just prescribed antidepressants and mood stabilizers, and my doc said I shouldn't drink or do drugs. But I don't want to stop going out! What will actually happen if I ignore her warning?
I've never liked that doctors don't tend to give specifics about this. I get that highlighting dangerous drug interactions runs the risk of implying the ones not mentioned are safe. So it's important the first point made here be that with drugs—illicit, but to some degree therapeutic, too—nothing is ever entirely safe. I'm not just saying that to cover my ass, but because I genuinely want you to have a long life filled with nice things. When it comes to drugs, nothing is promised to you.
First up: alcohol. There's a widely held belief among doctors that antidepressants are most effective when the patient is sober, says Victor Karpyak, associate professor of psychiatry at the Mayo Clinic. That's one reason alcohol use is suspected to be a reason that drug trials sometimes fail.
"If we're hearing that somebody didn't have much luck with antidepressants, one of the things we're going to check is if they were using alcohol or maybe cannabis," Karpyak says. "I hear quite often from colleagues that the effect is the same [with mood stabilizers and antipsychotics], but more people are prescribed antidepressants, so the number of studies conducted or cases we see is higher. That's why there's a better understanding of those drugs."
When people combine stimulants with alcohol, Karpyak says, the rush of energy and seeming invincibility leads them to consume significant amounts of alcohol—much larger than they're used to or normally capable of, which leads to "miscalculations." But of greater concern than alcohol and stimulants is actually alcohol and sedatives, or a combination of sedatives with each other.
You've probably heard that combining alcohol and Ambien can make you act weird—loopy, irrational, generally embarrassing—because people are always getting kicked off airplanes after trying too hard to relax. (Occasionally a nun will consume a glass of altar wine and then try to fall asleep before waking up in a different state with no recollection of how she got there or how she managed to crash a car into a building.) Benzodiazepines, the popular class of medication for anxiety, are also frequently prescribed for insomnia. These include Klonopin, Valium, Ativan, and, of course, America's long-standing psychiatric favorite, Xanax. The same sedating effect that makes them useful for anxiety is what makes them some of the most dangerous things you can mix with alcohol, and if your psychiatrist prescribed you a benzo without making sure you understand that fact, then you should find a new one. Benzos also have a high risk of lethal overdose when mixed with opioids, so if your particular brand of fun involves OxyContin, Codeine, or anything else on this list, I highly recommend you take it a bit easier. There are both opioid receptors and GABA receptors—the ones activated by alcohol and benzos—in the neurons that control your respiratory function, which is why fatal opioid overdoses often involve benzos, too.
When two substances interact, their effect can be additive—meaning, the same as if you had taken them separately; antagonistic, meaning one or both cancels out the other to some degree; or synergistic, meaning exponential, more than either could have achieved alone. The last one is why anxiety medication is not to be fucked with. Take a benzo, and you might become relaxed. Take it with painkillers or alcohol, and you might become so relaxed you stop breathing. (And because Xanax remains a popular selection for taking the edge off of coke, a gentle reminder that you always risk over-sedation when you mix benzos with anything, even if that other thing is not also a sedative.)
It's usually okay to drink moderately on your more standard SSRIs (the largest category of the newer generation of antidepressants, which act on the neurotransmitter serotonin). They contain most of the big names—Prozac, Zoloft, Celexa, and so forth, though you should still go over everything with your doctor. The belief that depression is caused by a deficiency of serotonin in the brain is reductive and not really an answer, but the internet loves to tell you you're depressed because your brain doesn't have enough happy juice nonetheless.
This fixation with serotonin has resulted in some overemphasis of serotonin syndrome, in which serotonergic substances have been combined to deliver too much of the stuff—so, a combo like an SSRI and MDMA. We associate the overload with drugs that, like MDMA, release serotonin, but people don't usually realize it can also be brought on by amphetamines like cocaine that block serotonin reuptake.
Serotonin syndrome can be serious, but the attention it gets online has resulted in a lot of misinformation that might be just as bad. Because the internet's told MDMA-seekers that their antidepressant will either kill them or get in the way of their high, people will sometimes drop their meds ahead of time if they know they'll be rolling on a set date, like a music festival. I've done variations of it myself—I'm not here to judge—but I want to make sure you're aware that this is serious, too.
Whatever you're on, you probably remember spending about three to six weeks titrating it up to your current dose after it was first prescribed. I regret to inform you that it usually needs to leave your system the same way. Sudden discontinuation is dangerous no matter the drug(s) involved, which is why you've been told to never stop taking your medications without first consulting your doctor. (In the event you have not: Please never stop taking your medications without first consulting your doctor).
The most well-known mood-stabilizer, Lithium, is another one that merits extra caution because its mechanism of action is unique. Since it's a salt that works by reaching a certain level in your bloodstream, it has an unusually narrow therapeutic window—even a tiny increase can make you sick, because the difference between a therapeutic level and a toxic one is small. So if you introduce an additional substance with which it reacts synergistically, it can rocket you past the toxic threshold with less encouragement than you might think. Dehydration compounds Lithium toxicity, and if you are thinking that makes the drug riskier in combination with things like MDMA and alcohol because they dehydrate you already, you are correct. There's some evidence that Lithium and cocaine react antagonistically, so you could be working against your medication's effectiveness without even getting high for your trouble.
"I suspect that physicians who are aware the patient is using street drugs might be unlikely to choose Lithium," says Jennifer Brasch, a psychiatrist at St. Joseph's Healthcare Hamilton in Ontario, Canada. "They might try something like valproic acid or carbamazepine."
Carbamazepine (brand named Tegretol) has a lot of drug interactions in general, including a greater risk of cardiac episodes with stimulants. Because of the way it affects enzyme action in the liver, Brasch says it often "chews up" whatever else enter the system—commonly methadone, but basically all other opioids, prescribed or not.
Antipsychotics are sometimes prescribed for depression or mood disorders, and there's support for antagonistic interactions between numerous antipsychotics and illicit drugs (including weed). This can make people reach for higher doses of the latter to compensate for the reduced high. Stimulants, of course, work on dopamine receptors by stimulating them, but antipsychotics, which have a sedative effect, work in part by blocking them. This is why some people who use stimulants also sometimes use antipsychotics to help come down, though as a class they're not nearly as popular here as benzos.
For a few months during my senior year I took the antipsychotic Seroquel as part of one psychiatrist's valiant quest to make me go to sleep, and it was so effective that, looking back, remembering how much other stuff I was still messing around with at the time gives me that slightly shaky feeling you get when a car nearly hits you but does not.
"With sedating medications, all bets are off," Brasch says. "When patients do end up on— 'cocktails' is the wrong word, but concerning combinations of substances—it can be hard to sort out what's most important and help [navigate] non-evidence based combinations safely."
Trafficking in anecdotal evidence is not anyone's first choice, but the body of research on interactions between psychiatric drugs and illicit ones is not especially large. Doctors aren't always in a position to tell you something helpful even if you do ask. The whole question is tangled even more by the fact that therapeutic drugs are separated from half the nation's party drugs by an increasingly blurry line. Ketamine and MDMA and mushrooms and weed are being clinically investigated as psychiatric treatments, after years of people trying to temporarily blunt their PTSD with weed or overpower their depression with uppers on their own; meanwhile, people who are otherwise psychologically healthy are trying Adderall and Xanax for the high.
Perhaps consider holding off on your more extracurricular substances while you're still adjusting to your new regimen, so you can see how you function on it without anything else muddying the waters. Doctors or parents or guidance counselors will often caution against self-medication disguised as good fun.
But I think this misses the point that, for a lot of people, these amount to the same thing—a fact that seems not unrelated to the explosion of interest in developing drugs people take illegally to actually treat psychiatric disease. When your own brain is what's hurting you, it is fun to escape from it for a while. And drugs and alcohol truly can ablate some of your symptoms in the short term. But now that you're on medication, you're playing the long game, and that's the one that stands to give you better quality of life. Give it time.