solved

O.M. Winters, a 46-year-old white minister, was referred to the psychiatry outpatient department by his primary care doctor for ongoing depressive symptoms and opioid misuse in the setting of chronic right knee pain.
Mr. Winters injured his right knee playing basketball 17 months earlier; his mother gave him several tablets of hydrocodone-acetaminophen that she had for back pain, and he found this helpful. When he ran out of the pills and his pain persisted, he went to the emergency room. He was given a 1-month supply of hydrocodone-acetaminophen. He took the pills as prescribed for 1 month, and his pain resolved.
After stopping the pills, however, Mr. Winters began to experience a recurrence of the pain in his knee. He saw an orthopedist and was given another 1-month supply of hydrocodone-acetaminophen. This time, however, he needed to take more than prescribed to ease the pain. He also felt dysphoric and “achy” when he abstained from taking the medication and began to experience a “craving” for more opioids. He returned to the orthopedist, who referred him to a pain specialist. Mr. Winters was too embarrassed to go to the pain specialist. However, because of the pain, dysphoria, and muscle aches when he stopped the medication and his “enjoyment of the high”, he began to frequent emergency rooms to receive more opioids. He would often lie about the timing and nature of his right knee pain, and even stole pills from his mother on two occasions. He endorsed low mood, especially when contemplating the impact of opioids on his life but denied any other mood or neurovegetative symptoms.
Mr. Winters had a history of two lifetime major depressive episodes that were treated successfully with escitalopram by his primary care doctor. He also had a history of an alcohol use disorder when he was in his 20s. He managed to quit using alcohol on his own after a family intervention. He currently smokes two packs of cigarettes daily. He had been married to his wife for 20 years, and they had two school-age children. He had been a minister in his church for 15 years. Results of a recent physical examination and laboratory testing performed by his primary care physician had been within normal limits.
On mental status examination, Mr. Winters was cooperative and did not exhibit any psychomotor abnormalities. He answered most questions briefly, often simply saying “yes” or “no.” Speech was of a normal rate and tone, without tangentiality or circumstantiality. He reported that his mood was “lousy,” and his affect was dysphoric and constricted. He denied symptoms of paranoia or hallucinations. He denied any thoughts of harming himself or others. Memory, both recent and remote, was grossly intact.
2a. What would be the most likely diagnoses for Mr. Winters given his history and presentation?
2b. What medications would you initiate for Mr. Winters? Briefly discuss the rationale for your choice of med(s).

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