Case Presentation Mr. A, a 34-year-old man, came to our outpatient clinic for treatment of a major depressive episode. His history was also notable for polysubstance abuse and dependence in sustained remission, with prior abuse of alcohol, LSD, and other hallucinogens and prior dependence on marijuana, cocaine, opiates, and Ecstasy (MDMA [3,4-methylenedioxymethamphetamine]). He began using alcohol at age 9, marijuana at age 12, cocaine at age 13, opiates at age 20, and Ecstasy at age 21. He had a history of depressive symptoms 6 years earlier in the context of active substance dependence and chronic back pain but had no other prior psychiatric diagnosis or treatment. One year before presentation to our clinic, he had been smoking cocaine daily, using Ecstasy several days a week, and consuming two to 10 alcoholic drinks daily but reported no depressive symptoms. After consuming cocaine, Ecstasy, oxycodone, and methadone at a party, he became aggressive and was brought to an emergency room. There, he ingested all of his remaining methadone to prevent it from being discovered. He reported no suicidal intentions surrounding this ingestion. He became unresponsive, hypoxic, and hypotensive. Mr. A was resuscitated and then stabilized in an intensive care unit over 4 days. After this overdose, Mr. A became acutely depressed. He endorsed a depressed mood, anhedonia, low energy, difficulties concentrating and remembering, feelings of hopelessness and guilt, poor self-esteem, social isolation, increased sleep, and a 20-lb weight gain over the ensuing year. He reported the disappearance of drug cravings and remained abstinent from all recreational drugs
