Assess kratom as a psychoactive substance with mu-opioid receptor activity that can cause dependence and withdrawal, and evaluate its temporal relationship to the depressive symptoms.

Kratom (Mitragyna speciosa) acts on mu-opioid receptors at higher doses and has stimulant-like effects at lower doses. It can cause dependence, withdrawal symptoms similar to opioid withdrawal, and may be masking or complicating the depression picture. The depressive symptoms may represent: independent MDD with concurrent kratom use, kratom-induced mood effects, or kratom withdrawal between doses. The temporal relationship is essential. Determine the dose, frequency, and timeline relative to mood symptom onset. Screen for opioid withdrawal symptoms if the patient has missed doses. Standard UDS does not detect kratom (mitragynine) — specialized testing is required if confirmation is needed.

Kratom is classified as a dietary supplement and does not have psychoactive properties relevant to the psychiatric evaluation or treatment plan.

Kratom is psychoactive, acts on opioid receptors, and causes dependence and withdrawal. Its classification as a supplement does not make it clinically irrelevant.

Recommend he continue kratom as a natural alternative to antidepressants, since plant-based mood support may reduce the need for prescription pharmacotherapy.

Recommending continued use of an unregulated opioid-receptor agonist as an antidepressant alternative is inappropriate and potentially dangerous given dependence risk.

Report the patient to the DEA, since kratom is a federally controlled substance and daily use constitutes illegal drug activity requiring mandatory reporting.

Kratom is not federally scheduled (jurisdiction varies); some states and localities have restricted it. There is no universal reporting obligation, and this mischaracterization would damage the therapeutic alliance.