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Daniel Nelson, MD
Daniel Nelson, MD, Doctor (MD)
Category: Health
Satisfied Customers: 258
Experience:  Licensed MD. Mayo Clinic Rochester trained physician in Internal Medicine - Critical Care Medicine.
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I have a question for a doctor or pharmascist. I have taken

Customer Question

I have a question for a doctor or pharmascist. I have taken zoloft for 9 years and I also drink alcohol moderatly. the amount of alcohol i consume has varied over the years. Some weeks it could be 2 to 3 drinks 2 or 3 nights of the week. Then some weeks it could be 1 drink twice per week...then some weeks it might be on the weekend where I had 4 drinks both nights...then some weeks none...The consumption varied like this...that's as close as i can come to approximating it. I just worry that I have given myself brain damage beyond what the alcohol does by itself because I also have taken zoloft the whole time. I mean if it says that alcohol could intensify the effects would taking the two together for years hurt your brain? My doctor has said moderate drinking is ok but I mean they don't study alcohol and zoloft long term so how would we really know what it does to the brain? or is there really no biochemical basis to believe that brain dysfunction could result.?
Submitted: 9 years ago.
Category: Health
Expert:  Daniel Nelson, MD replied 9 years ago.

Greetings,Customer Thank you for submitting your question(s) to in the category of HEALTH. My name is ***** *****, MD. I am a licensed physician, trained throughout Internship, Residency/Fellowship at the Mayo Clinic in Rochester, MN in the specialties of Internal Medicine and Critical Care.

Zoloft and alcohol are listed as two items to be avoided together because of CNS (central nervouse system) depression, meaning that they are concerned that your level of consciousness will be reduced dangerously low. As you know, these warnings are very often true, but also stated for reasons of liability for the manufacturer.

You have taken Zoloft for many years while ingesting a moderate alchohol intake. I know of no evidence listed for brain damage from Zoloft. We do know that alcohol is a nerve toxin when present in significant levels.

The toxic effects of alcohol on the brain, per se, are not intesified by Zoloft. In viewing the most recent literature of this issue, I just do not see this listed as a concern. The alcohol alone brings about concerns of neuron injury in the brain, but no additive effect of Zoloft to this process has been studied.

There is no long-term evidence of Zoloft damaging the brain or causing neuron injury. There is a suggestion that I can offer, however, if you truly wish to evaluate this process, realising that there is some degradation in cognitive thinking and processing possible with again alone.

You could take an extensive biobehavioural and cognitive series of tests, that can be arranged by your psychiatrist or healthcare provider. These testing series can be repeated at intervals to assess you for any cognitive decline or biobehavioural injuries or changes.

From a molecular biology standpoint, I cannot propose a mechanism of interactive brain cell (neuron) injury from the combination, but from the standpoint of alcohol as a neurotoxin itself, I can expect on at least some scale, perhaps small or large, there is neuron injury occurring.

Thank you for visiting's Health Information. I hope that all of your concerns have been addressed and that your experience here was positive and helpful. We truly do care a great deal that you are completely satisfied with the information provided, so click ACCEPT only when you are satisfied and comfortable that your question has been adequately addressed.

Again, my name is ***** *****, MD. If you have a new or different question for us, please don't hesitate to come back or submit a new question. It has been a pleasure helping you. You feedback is always appreciated. Take Care.

Customer: replied 9 years ago.
Thanks for the answer . I do have an additional question. It has just been so difficult over the years to not consume alcohol in moderate amounts. I worry so much because I have noticed memory difficulties. I have never been tested though. I am told by my psychiatrist that these issues most likely have to do with the depression/ocd that I stuggle with. So from the amount of alcohol consumption that I noted you would not be concerned about permanent effects in combination with zoloft even though the two have not been studied long term together? I was able to get through college and I have a good job now (im a paramedic) but I feel that my memory has declined... and I feel much anxiety over this.
Expert:  Daniel Nelson, MD replied 9 years ago.

Depression, OCD, anxiety ... all of these as well as alcohol can lead to varying levels of memory concerns. The memory concerns you may have notices could very well be transient and vary from day to day related to the former, while the alcohol tends to have a slower, rather insidious accumulative effect.

You seem incredibly insightful to me. That degree of insight, recall, and your fluency in describing your concerns reassures me, as a physician, that the most important memory and cognitive functions are quite capable. Your being a paramedic, as well, clearly shows that you have had to assimilate vast amounts of knowledge, and be able to apply them in a logical, organised, and orderly manner in your testing and recertifications.

Medicine, be it as an MD or a paramedic, is an anxiety provoking field. We all have little or more traces of OCD because of the organisational requirements thrust upon us. We also see the best and worst in people, which in itself can be a source of anxiety and depression. It's a diffucult and stress-drenched field we work in, don't you think? I sure do.

I am not concerned about the Zoloft-Alcohol combination being synergistic to memory decline or nerve injury. I haven't seen any studies on this specific issue to show me this to be true. I am more concerned about the purely neurotoxic effects of alcohol.

In contrast, studies have show that people with 1-2 ounces of ethanol consumption per day receive benefit in terms of longevity and blood pressure. So there is a study showing moderate intake with benefit. Don't you love all these strangely contradictory studies we have to wade through and about?

I don't think the alcohol intake that you have is excessive, and I also do not see patterns of alcoholism as it's generally applied. I do like the idea of serial studies testing memory and cognition over time. I think it will not only give us a more objective answer, but if it shows no memory decline or deficits outside of those that are age-adjusted, that it may put a great deal of your anxiety at ease. I hope this makes sense and seems a helpful respsonse.

I understand that you have also approached Dr. Gould about this subject, and his answer is quite in line with my own. The two together are not going to present you with a synergistic brain damage scenario, like 1+1=5. The alcohol you take in, is not excessive, and that likewise doesn't give me great concern.

Please don't hesitate to ask further questions or present additional concerns. As always, I wish you the best and am happy to help.

Customer: replied 9 years ago.
Thanks again. Yes I do am a paramedic but I find it increasingly difficult to remember much of the theory of what I have had to learn. Even going back and studying it and reading things over and over I still forget. When I go back and re read I will recognize but am not able to recall much of the information that I study. But again this may have to do with OCD/depression instead of the alcohol/zoloft combination ?
Expert:  Daniel Nelson, MD replied 9 years ago.

I agree, I think that with time, everything you describe could be explained a great deal by multiple factors involved more than a scenario of neuron damage or injury. I think the Depression, OCD, Anxiety likely play a role along with our normal aging process. With age, there is that untangible loss of wonderful plasticity and dynamic nature we once enjoyed in earlier years. There are memory and brain exercises, however, that may be helpful. I have often considered these myself, and recently have found Sudoku Puzzles to challenge me, maintain my interest and attention span, and make me feel better and more mentally sharpened. I also like certain video games that keep my hand-eye coordination honed.

Here are a few sites I visit on a regular basis:

These things, and things of this sort, along with proper treatment of the underlying psychiatric health, physical health & exercise, a healthy appetite for good things surrounding you in your life -- good friends, positive surroundings, and pleasant or soothing ambience -- will also strengthen your overall sense of well being. I am truly of the opinion that we are all captains of our own ships, and we must make every effort to keep her in safe and sound waters, condition, and direction. Part of this process, at least for me, also includes my spiritual health being exercised and strengthened. I love being a scientist, but I always try to emulate the greatest scientist of them all, my Lord. I don't want to proselytise or even attempt to force my beliefs in this regard on anyone, but it is helpful to me and other whom I know who share similar faith.

If you have any other concerns or questions, please don't hesitate to ask!

Customer: replied 9 years ago.
I however am only 26 years old. At this age you shouldn't expect memory loss from aging should you? I have another drug interaction question. Drinking coffee with zoloft is not an issue correct? no one has ever said limit your caffeine intake...I have been a coffee drinker for a long time. Somedays a few cups some days none. Again thanks very much for your well thought out answers.
Expert:  Daniel Nelson, MD replied 9 years ago.

Welcome backCustomer

I wouldn't expect significant memory lost in a 26 year old, but once we added in the other contribtory and additive factors as mentioned earlier, the perceived memory loss may seem disproportionate.

There are no interactions between coffee and Zoloft, other than the antagonism between Zoloft's "sleepy" side effect and caffeine pushing the other way. Otherwise there is nothing in the literature on problems with these two chemicals. :)

Customer: replied 9 years ago.
Thanks. Alcohol is removed from the blood at a rate of 1 drink per hour is that correct? so if you consume 2 drinks over an hour then after roughly 2 hours from the last drink you would be ok to take tylenol with codeine...which i use someetimes for a back injury...this could also contribute to my memory issues! But it is not permanent from my understanding.
Expert:  Daniel Nelson, MD replied 9 years ago.

Correct, sort of. Generally, ethanol is removed from an averaged size person of 60-70kg at a rate of 1 ounce per hour. In light of no liver disease, it's okay to take up to 4 grams of Tylenol per 24 hour period. Ah yes, a little codeine cloud may slow the neurons a bit, too, and may have some amnestic effects. Ah yes, a little codeine cloud may slow the neurons a bit, too, and may have some amnestic effects.

Ah yes ... j/k

Expert:  Daniel Nelson, MD replied 9 years ago.


I will be leaving for business to Chicago over the weekend and I won't be available to answer questions for a couple of days. It has been a pleasure discussing your concerns with you. I hope that I have put many of your worries to rest or at least offered you dependable information that help you gain even more insight into your health. I think you are an intellectual young man with a lot on his plate in term of anxiety and a frequent need for reassurance. I do believe you will be fine doing as you are, addressing and treating the underlying conditions that interfere with your living a normal life. It seems to me that you are doing the right things to maintain a long and healthy life. I will try to check in early this morning to see how you are doing and wrap up any loose ends or other concerns you might have.

Customer: replied 9 years ago.
Hello thanks again for all your help. I have not been using much codeine for a year now,however for a couple of years I did average 1 or 2 tylenol 3's per day for back pain from an injury I sustained on my job. I have been told repeatedly that this is not a cause of brain damage and that your opiate receptors may build up a tolerance but will not cause permanent brain damage. Alas it is in the past. I do have one other concern. I watch the television show law and order and I have found it very difficult to follow...The other day I was following an episode and then I couldn't remember the names of people they were talkign about and I got completely lost as to who did what etc. Does that mean that I have damage because it wasn't only this one episode it was many! But i've asked my parents and they can't follow the show half the time too.
Expert:  Daniel Nelson, MD replied 9 years ago.


I have never watched Law & Order, although I have been at locations very briefly where it was playing on TV at the time I was present. I really didn't pay much attention to it, except that I recognised an actor (Jeremy Sisto) from the now retired HBO series "Six Feet Under" ... he played the character of Billy Chenowith.

I would not label anyone with brain damage for not recalling characters in a television show. It's not how we would test this hypothesis. As I have mentioned, the gold standard, if you are truly concerned about this, is to undergo serial cognitive and behavioural testing and specialised memory assessments that are stadardised and adjusted for confounding or conflicting variables.

Did you try any of the brain exercise links I posted earlier? I love those things. I recently tested my reaction time to a box that flashes on the screen when I was freshly awake and alert, and again after two nights without sleep following intense work covering for colleagues who were sick or needed me in for backup. At around the 58 hour mark of being awake continuously, here are my results, each an average of 10 successive attempts each:

Freshly Awake Reaction Time: 230 ms
Sleep Deprived Reaction Time: 312 ms

Customer: replied 9 years ago.
I did try the response time game. My best was 250ms. Thanks once again. I just wanted to confirm that you believe when you take everything I said into account that you would not expect brain damage from that correct? IT wold almost be impossible from what I did? there has to be another explanation of why I am having difficulty or perceived difficulty.
Expert:  Daniel Nelson, MD replied 9 years ago.
HiCustomer I do not believe you to have brain damage, nor do I think that taking into account everything you have told me that I would expect there to be any. The other explanation we discussed are the multiple other factors that are likely contributing to your perceived memory concerns, like depression, OCD, and what I perceive to be very high anxiety. The occasional codeine containing analgesic can temporarily affect memory, but is not going to cause brain damage. Alcohol has already been discussed with you as well ... no brain damage in the mild to moderate amounts you ingest, and nothing from the Zoloft. I wish I could put you more at ease, but I believe you are not suffering from any brain damage.
Customer: replied 9 years ago.
Hi I took one of the IQ test on one of the sites you gave me and it took me a lot longer than the alotted time and I scored low too! says my IQ is 88...but the questions were really hard and it says that you may not be familiar with these types of questions...I remember taking an IQ test a couple years ago and getting I don't have much to worry about right? it doesn't really mean anything
Expert:  Daniel Nelson, MD replied 9 years ago.
These aren't the STANDARDISED Cognitive and Behavioural Tests that I was referring to for serial testing, evaluation, and longitudinal progress monitoring; rather, you may have come across a brain exercise website that posted an IQ test. I don't consider these valid medical testing sites, but rather a place to go and clear out my cobwebs once in a while. You're correct, it doesn't mean very much coming from the web other than being a place to practise some fun activities. Have fun with them but don't take them to heart.
Daniel Nelson, MD and 3 other Health Specialists are ready to help you
Customer: replied 9 years ago.
Dr. you have done an amazing job at explaining things to me. I greatly appreciate it. I have one last question . If zoloft is not working for me anymore and that is an IF (as it could cause memory issues...there is only anecdotal evidence of this at this time) are there other drugs that may be better for me ? ie. less effects on memory or atleast less perceived effects?
Expert:  Daniel Nelson, MD replied 9 years ago.

I don't know of any that are better, per se. A Psychiatrist will be much better versed on the comparative studies. What I have seen listed in recent literature reviews were "Meta Analyses" showing that SSRI's have replaced clomimpramine as first line therapy for OCD. They have the ancillary benefit of being antidepressants, too, of course, but the doses to treat OCD are generally higher than the doses to treat depression. There have been no head-to-head studies addressing the cognitive/memory concerns that you have. The newest SSRI's, like Lexapro and Cymbalta, have not been indicated for use in OCD, yet.

Prozac (fluoxetine) is commonly used to treat OCD and depression, and in one of the meta analyses it was no better than Luvox (fluvoxamine). A nice ancillary benefit to Prozac is that it has a very long elimination half-life in the body, and once it's stopped, it generally auto-tapers itself out of the body without withdrawal symptoms.

Customer: replied 9 years ago.
Do we know that codeine does not interact with zoloft? The reason I ask is because if difficulties with the SSRI's are just surfacing then that shows that we don't fully understand how they how can we say that they don't interact with codeine? I know this is very paranoid but that's what I have to deal with everyday!
Expert:  Daniel Nelson, MD replied 9 years ago.
Sure they can interact ... somnolence is a side effect of both codeine and Zoloft, so the two together can make you more tired, just like the known interaction of alcohol and Zoloft. I wouldn't go so far as to say the difficulties associated with SSRI's are just surfacing, we have known of many issues for a long time. We do understand pretty well their mechanism of action and how they work. There will always be ongoing experience with medications that sheds new light on interactions and contraindications ... however anecdotal evidence is perhaps the weakest form of evidence in the scientific community. Reliability on studies tells us that large-scale, randomised, placebo-controlled, double-blinded, prospective studies are the most trusted form. Everything else is a distant second.
Customer: replied 9 years ago.
In addition to the moderate alcohol consumption that I talked about I did on occasion...I can't put a number on it over the years have larger amounts 6 -8 drinks over the night.. that would not change your answer with regard to brain wasn't like that was everyday....maybe once per month sometimes twice per month...but usually once per month
Expert:  Daniel Nelson, MD replied 9 years ago.

We discussed earlier that alcohol has neurotoxic affects in and of itself when present in quantities that exceed some arbitrary threshhold. We don't know what that threshhold is, but it is generally accepted that 1 to 2 ounces per day is okay. Binge drinking, on the other hand, clearly is not. I am not sure what type of drinks you are mentioning here, but 6-8 drinks could be 6-8 ounces of alcohol as hard liquor, or it could be 3-4 ounces of alcohol as beer. In either case, this value is too much and will injure neurons ... how many and to what extent we don't know, but this amount exceeds the threshhold and would likely damage more neurons than our normal rate of age-related neuron loss. See the following NIH link on this topic:

I still feel that if you have done this at a rate of only once per month, that you haven't done excessive harm, but I would advise that you absolutely stop the binge-type drinking, from a purely medical and physiological standpoint. Make sure you don't drive if you do drink this amount, using the assumption that we metabolise 1 ounce of alcohol per hour. You mentioned "over the night," which reassures me that you are likely spreading your drinks out ... this causes less of the binging peak alcohol levels that are concerning for alcohol-related brain injury. I still advise against this amount, even once per month and spread out over longer periods. Alcohol has an accumulative effect.

In light of alcohol use, I do believe that B-vitamin supplementation (including and especially thiamine) and folic acid (folate) are reasonable things to take. Given your infrequent but more heavy drink ingestion once or twice a month, you are still in a much better position than others who drink more often and in large amounts. From the outset, however, I have made it evident that alcohol is a neurotoxin, and with such overwhelming fear of brain damage as you seem to display, it would seem you would likewise have an overwhelming desire to minimise anything that could insult and injure the brain.

Kindest Regards,

Customer: replied 9 years ago.
Thanks. I have another couple questions and I will not ask anymore because I have already asked too many but I am going to the dr. to get help(maybe increase the dose of the med). I would appreciate if you could answer these. I would not have done any more harm to my brain by drinking and being on zoloft than someone who was not on zoloft though?. That is really what I am getting at. Also sometimes I would take tylenol 3 after drinking...i would however wait 1 hour per drink (i took it for a headache) there really wasn't much of an interaction. Once in a while I may have almost had all the alcohol cleared out of my blood but not quite and taken codeine...but the alcohol would have been very low at that point. Also I have gone the other way...where I have taken tylenol with codeine and then after 6 hours usually had a couple drinks...But on occasion it was 4 or 5 hours only which means that the codeine would not be fully eliminated. Its not like I did this all the time...this still would not cause brain damage.?
Expert:  Daniel Nelson, MD replied 9 years ago.

Zoloft is not causative of "brain damage" based on any evidence that I am aware of to-date. Alcohol is the neurotoxin ... the more that is binged, the greater the potential for neuron damage. Zoloft, to the best of my knowledge, does not add to the neurotoxicity of alcohol. Tylenol with codeine is not additive or associated with brain damage, to the best of my knowledge, in the presence of alcohol, any more than the alcohol neurotoxicity alone. Alcohol neurotoxicity is seen with higher blood alcohol levels, especially those considered to be binges.

Kindest Regards,

Customer: replied 9 years ago.
Dr. Nelson...sometimes the moderate drinking that I did was over a short period of an hour or less....2 or 3 drinks...would that cause any additional neurotoxicity beyond what alcohol normally causes.
I saw my psychiatrist yesterday and she thinks that my ocd/depression may have been undertreated all these years...she wants me to eventually get up to 300mg zoloft...I am willing to try it...she thinks my mind will be unburdened and my memory may actually improve because my brain won't be cluttered with ruminations constantly
Expert:  Daniel Nelson, MD replied 9 years ago.

HiCustomer Alcohol's ability to injure neurons is dose-dependent, so the higher the dose (the number of drinks) per unit time, the more neurotoxicity the alcohol will have. I do notice significant characteristics of the OCD/Depression peaking through during our discussion ... mostly the OCD and anxiety over aspects concerning brain damage. I can sense you want/need of reassurance from many differrent sources online, not just here. It's almost taking over your entire thought process, and is concerning to me. At the same time, I commend you strongly on your excellent insight and apparent desire to do well for yourself and your health. As with your Psychiatrist, I believe that your memory concerns are more due to the multiple factors of combined OCD, Depression, and Anxiety. I recommend trying to abstain from alcohol use, as well.

Kindest Regards,

Customer: replied 9 years ago.
Hello I was wondering if you could answer a follow up question for me. I realized that the definition of binge drinking is 5 or more drinks on a single occasion for men over the period of 2 hours or less...I have done something like this many times...what i described as moderate drinking may have been more like this because many times I would have 3 drinks over 1+ hours or so wouldn't that be more like binge drinking...I would often have a moderate AMOUNT of alcohol but over a short i could feel buzzed ...but it lasted for a short time. Could this increase the risk of synergistic brain damage with zoloft? Also what about serotonin syndrome from zoloft and alcohol. I was told that this is unlikely as alcohol increases serotonin so little...what about the times where I had large quantities of alcohol...only a few times in my this why Dr. Gould said that if i repeated that many times brain damage was a real issue? What he said was it based on the purely neurotoxic effects of alcohol at that high level...or a combination of zoloft alcohol serotonin syndrome synergy?