A 34-Year-Old Man With Depression, Heavy Drinking, and a Recent Family Suicide

Do not make abstinence a precondition. Requiring sobriety before treating depression is a common and harmful delay; both conditions should be treated concurrently, and each worsens the other.

Medication

• Sertraline 50 mg daily is a sound first choice: efficacy in comorbid depression and alcohol use, a benign interaction profile, and a manageable discontinuation syndrome.
• Avoid bupropion - it lowers the seizure threshold, and a heavy daily drinker carries withdrawal-related seizure risk.
• Avoid tricyclics - dangerous in overdose in a patient with elevated suicide risk.
• Mirtazapine has trial evidence in comorbid depression and alcohol use and helps sleep, but sedation and weight gain make it a second-line choice rather than a first.
• Naltrexone 50 mg daily is a strong add-on for reducing heavy drinking. His ALT of 62 is well under three times the upper limit; naltrexone is contraindicated in acute hepatitis or liver failure, not mild transaminase elevation - but recheck liver enzymes at baseline and in 4–6 weeks. Acamprosate is the alternative if his renal function is normal.

Non-drug treatment

• Combined CBT addressing both mood and drinking is more effective than either alone; refer for therapy and, given the quantity he describes, to an intensive outpatient program if he is willing.
• Sleep is his stated reason for drinking. Address it directly - CBT for insomnia rather than a sedative, which would be a second dependency.

Risk factors are stacked here: male sex, active moderate-severe depression, heavy alcohol use (impulsivity and disinhibition), a father who died by suicide, and a recent major loss. Family history of suicide is one of the more robust predictors we have.

Ask directly and specifically

• Ideation, plan, intent, rehearsals, prior attempts, and access to means. His denial of ideation must be followed by questions about passive death wish and about what keeps him safe.
• Ask what he would do if things got worse. A patient with a plan and means is a different disposition than one without.

Means restriction

• The rifle at his brother's house is the actionable item. Ask that it be stored by someone else for now, or at minimum that ammunition be stored separately and elsewhere. Means restriction is one of the few interventions with strong evidence for reducing suicide deaths, and it is easier to negotiate than a general "be safe."

Concrete plan

• Same-day safety plan with crisis numbers (988 in the US), a named support person, and an agreement about when to go to the emergency department.
• Prescribe a small quantity - a 2-week supply - and schedule follow-up within 1–2 weeks rather than 6.
• Document the risk assessment, the reasoning, and the shared plan; document the firearms conversation specifically.

Estimate the risk

• He drinks roughly 35–40 standard drinks per week with daily use, which is enough to produce dependence in some patients, but he has no history of withdrawal symptoms, seizures, or blackouts, and no morning drinking is described. That puts him at low, not zero, risk.
• Withdrawal follows a predictable timeline: tremor, sweats, anxiety, and insomnia at 6–24 hours; seizures at 12–48 hours; delirium tremens at 48–96 hours. Because he drives for a living, untreated withdrawal is an occupational and public safety issue as well as a medical one.

Advise, don't simply forbid

• Do not tell him to quit abruptly without a plan. Offer a structured reduction with a follow-up call in 2–3 days and clear instructions to seek emergency care for tremor, vomiting, confusion, fever, or hallucinations.
• If he develops symptoms, symptom-triggered benzodiazepines are appropriate in a monitored setting - but not prescribed casually to a depressed patient who drives.
• Thiamine and folate supplementation during any reduction; counsel on hydration and nutrition.
• Use a brief motivational-interviewing frame rather than confrontation: his own stated link between drinking and sleep is the lever. Ask permission before advising, and elicit his own reasons for cutting back.
• Deliver the message about driving and alcohol plainly, and note that his CDL or employment may be at stake - this is often a stronger motivator than health.
• Reassess AUDIT-C and liver enzymes at 4–6 weeks alongside his mood.