This was a qualitative, descriptive clinical case report of a single patient who developed a depressive episode following the announcement of her failure in the medical internship examination.

The clinical follow-up described in this observation took place over a 3-month period post-hospital discharge, from intake in January 2025 to complete remission in April 2025.

The study took place at the Moussa Diop Psychiatric Clinic of the Fann National University Hospital Center (CHNU) in Dakar, a level-3 public health establishment located on Cheikh Anta Diop Avenue (Fann-Point E district).

The included patient met the following criteria: admitted for a reactive depressive episode following failure in the Senegalese medical internship examination, and followed regularly in outpatient care post-discharge. Major confounding comorbidities (such as underlying bipolar disorder, primary psychotic disorders, or organic brain pathologies) were ruled out.

Initial management took place in an inpatient setting (7-day hospitalization), followed by an outpatient follow-up provided by a medical resident. Clinical data were gathered through semi-structured outpatient interviews lasting 45 to 90 minutes. Outpatient consultations were scheduled at Day 7, Day 14, 1 month, 2.5 months, and 3 months post-discharge.

The patient provided written informed consent for the publication of this case report. Anonymity and confidentiality were strictly preserved.

According to the patient, symptoms began three weeks after learning of her failure in the Senegalese medical internship examination. She reported progressive social withdrawal, finding it difficult to answer calls or messages, extending gradually to her close circle. Interactions left her feeling irritable. She developed initial insomnia and frequent night awakenings. One month prior to consultation, she experienced anhedonia regarding previously enjoyed activities (social gatherings, cooking). One week before intake, continuous irritability led to aggressive outbursts, prompting the consultation.

Diagnosed with ankylosing spondylitis (AS) at age 21, she was treated with methotrexate, which she discontinued three months prior to consultation. She also has polycystic ovary syndrome. She has no prior personal psychiatric history. Her mother has a history of rheumatic disease.

Her developmental and educational background highlights high academic performance driven by a desire to make her late father proud (who died suddenly in a road traffic accident when she was 16). His death and the subsequent death of her maternal grandfather during her 5th year of medical school represented major loss events.

At initial presentation, a systematic safety and psychiatric screening was performed:

SuicidalIdeationandSelf-Harm: The patient expressed passive death wishes related to overwhelming guilt, but explicitly denied active suicidal ideation, intent, or plan. She had no personal history of non-suicidal self-injury or suicide attempts. PsychoticandManicSymptoms: There was no evidence of hallucinations, delusions, thought disorganization, or past/current hypomanic or manic episodes. SubstanceUse: Screening for alcohol, nicotine, cannabis, or illicit substance use was negative. ProtectiveFactors: Strong moral and personal alignment with her mother, religious/spiritual values, and a clear motivation to complete her medical degree served as primary protective factors against self-harm.

Ms. RK presented with neat attire, poor eye contact, hypomimia, and a soft voice. She exhibited depressed mood, irritability, anhedonia, and aboulia. Occasional memory lapses were observed. Thought content revealed strong feelings of guilt (“Mymothersacrificedeverythingforme, andIruinedallherhopes...”). She displayed anorexia, mixed insomnia, physical asthenia, and decreased libido. Physical examination was within normal limits.

The principal final diagnosis retained was a Moderate Depressive Episode (ICD-10 code F32.1; [18]; [1]), based on meeting 2 core criteria (depressed mood, anhedonia) and 5 secondary criteria (guilt, sleep disturbance, anorexia, concentration difficulty, fatigue) ([18]; [1]; [9]).

DifferentialDiagnosticJustification: The alternative diagnosis of Adjustment Disorder with Depressed Mood (ICD-10 F43.21; [18]; [14]) was considered given the clear temporal trigger (internship failure) ([14]; [10]). However, it was not retained as the primary diagnosis because the symptom constellation exceeded the intensity and symptom count of a simple adjustment reaction, fulfilling full operational criteria for a major depressive episode, accompanied by severe functional impairment and somatic vegetative signs ([18]; [1]; [9]).

Due to functional impairment and emotional distress, she was admitted for a 7-day inpatient stay. Initial pharmacotherapy consisted of a short course of mexazolam 2 mg/day in two split doses ([11]). Supportive psychotherapy and a rheumatology referral were initiated.

ClinicalRationale: Although international guidelines recommend antidepressant monotherapy or combined treatment for moderate depressive episodes ([21]), an antidepressant (e.g., SSRI) was withheld initially. This decision was based on: 1) the predominantly reactive and acute nature of the anxiety-irritability decompensation ([14]; [7]); 2) the patient’s acute sleep architecture disruption and marked behavioral agitation/irritability, which responded rapidly to direct GABAergic anxiolysis ([11]; [21]); and 3) a shared decision-making strategy to observe initial response to psychotherapeutic stabilization during the brief 7-day stay before introducing long-term daily antidepressant therapy ([14]; [21]). SafetyMonitoringduringTaper: Over the 3-month outpatient reduction (2 mg/day to 1 mg/day at 1 month to 0.5 mg/day at 2.5 months to discontinuation at 3 months), the patient was closely monitored at each visit for daytime sedation, rebound anxiety, withdrawal symptoms, and signs of physiological dependence ([11]). No adverse events or rebound phenomena occurred ([11]).

ClarificationofInterventionsDelivered: The psychotherapeutic approach was a structured supportive follow-up integrating specific, selected techniques from Cognitive Behavioral Therapy (CBT; [4]; [13]) and Motivational Interviewing (MI; [19]), rather than distinct, formal multi-modal manualized therapies ([2]; [4]; [13]; [19]).SupportivePsychotherapy: Core vehicle across all visits (empathic listening, emotional discharge, validating grief) ([12]; [9]).CBTTechniques (Psychoeducation [[2]], BehavioralActivation [[13]], Relaxation [[4]]): Applicationofdailyscheduleplanning (cooking, walking, coursereview) andabdominalbreathingexercises ([2]; [4]; [13]).MotivationalTechniques: Integrated in consultations at 2.5 and 3 months to explore ambivalence regarding somatic care and future exam attempts ([19]).AnkylosingSpondylitis(AS)ReassessmentandCourse: Following the rheumatology referral, the patient was re-evaluated at 1-month post-discharge ([17]; [6]).Inflammatory disease activity was low-to-moderate upon reassessment (BASDAI score recorded at 2.8) ([17]).Biological DMARDs were not indicated; treatment was resumed with methotrexate (15 mg/week) alongside folic acid supplementation and as-needed NSAIDs ([17]; [6]).At 3 months, joint pain was controlled, and the patient demonstrated full adherence to rheumatological visits ([17]).SymptomCourseTimeline:Day 7 (1 weekpost-discharge): Sadness persisted; irritability markedly decreased; sleep continuity improved. Day 14: Reduced irritability, persistent guilt; CBT schedule reinforced ([13]).1 Month: Marked mood improvement, resumed activities (cooking, dance classes), concentration restored ([13]). Mexazolam reduced to 1 mg/day ([11]).2.5 Months: Euthymic mood, cognitive reframing of failure as a need for better preparation ([19]). Mexazolam reduced to 0.5 mg/day ([11]).3 Months: Full clinical remission, complete resumption of routine and academic activities, successful discontinuation of mexazolam ([11]; [21]).

Ms. RK’s presentation highlights the clinical challenge of distinguishing between severe reactive depressive episodes ([18]; [1]; [9]) and adjustment disorders ([14]). The choice of mexazolam monotherapy without an SSRI led to rapid symptom control and complete remission within three months ([11]; [21]). While successful in this single case, this approach must be interpreted cautiously ([21]). First-line guidelines for moderate major depressive episodes generally favor antidepressants due to the risk of symptom relapse or incomplete remission with benzodiazepines alone ([11]; [21]). Close monitoring during the 3-month taper avoided dependence or withdrawal ([11]).

Psychodynamic constructs offer a useful qualitative lens to understand the patient’s narrative, though they should be interpreted as clinical hypotheses rather than established causal mechanisms ([12]; [8]; [15]):

NarcissisticInjuryandEgoDecompensation: For a student whose self-worth was historically tied to academic excellence to fulfill parental expectations, exam failure can be conceptualized as a major narcissistic injury ([12]; [8]). ReactivationofUnresolvedGrief: The academic loss appears to have clinically reactivated unresolved grief associated with the sudden death of her father and her grandfather ([5]; [8]). InternalizedAngerandSomaticNeglect: The intense guilt reported may represent internalized frustration regarding academic pressures ([8]). Similarly, the discontinuation of methotrexate three months prior to intake can be framed clinically as bodily disinvestment or somatic neglect in the context of emerging distress ([6]; [15]).

Geographic isolation compounded her distress ([3]; [16]). Furthermore, the bidirectional link between chronic inflammatory disease (AS) and mood disorders is well-recognized: systemic inflammatory cytokines can induce fatigue and affective changes, while psychological stress can provoke autoimmune flares ([17]; [6]). While re-establishing psychiatric stability coincided with rheumatologic re-engagement, attributing psychiatric remission directly or solely to the interruption of a biological “immuno-psychiatric vicious cycle” remains a theoretical model rather than an empirically verified causal finding in this single case ([17]).