Key themes in the psychology of depression include learned helplessness, impaired problem solving, distorted conflict resolution, and a tendency to ruminate negatively.3,4 Activation is used here to describe the process of reversing such mindsets or cognitive styles. Clinicians must be aware that dysfunctional mindsets may evolve in the individual with depression and also in those in contact with the patient, potentially reinforcing the patient’s negative cognitions. Activating the patient, their parents, teachers, and friends, if required, involves reflection on what led to the depression and what is required to find solutions. Activation here describes a shifting of mental orientation in the patient and others, from a sense of helplessness and inertia to one of action and solution. It is important to differentiate the use of the term activation in this context from the potential adverse effects of specific selective serotonin reuptake inhibitors (SSRIs).

A key aspect of STAU is case management. To develop and implement a management plan, the clinician needs to understand the components of case management and formulation, which include the following:

Although it can be helpful to think of assessment and treatment as separate, in reality elements of treatment are part of assessment, and assessment often continues during treatment.

A formulation includes (1) a summary of the presentation; (2) statements regarding diagnosis, severity, and differential diagnosis; (3) statements regarding risk; (4) statements of possible etiological, resilience, and protective factors; and (5) a decision about where and when to intervene based on a dialogue between the clinician and the patient and their parents. An understanding of what has helped as well as what makes things worse is crucial.

The treatment plan largely depends on the severity and complexity of the case (described in Chapters 1 and 3), which have treatment and prognostic significance.5,6,7,8 Severity may be indexed by the seriousness of functional impairment, the number of depressive symptoms, and the coexisting
disorders or problems complicating the presentation, along with the length of time the disorder was present before treatment.8,9,10 The presence of psychosis may indicate increased risk of bipolar disorder.6 Although severity is important, so is complexity. Certain co-occurring problems or disorders—such as hopelessness, major family conflict, current abuse or undisclosed previous abuse, obsessive compulsive disorder, anxiety, attention deficit hyperactivity disorder (ADHD), conduct disorder, persistent suicidal plans and behaviors6,9,10,11—can complicate assessment and treatment. Similarly, parental mental disorder, the level of family support, and the existence of a close confiding relationship12 have an impact on how treatment is delivered and probably on the chances of success.

Chapter 3 describes rating scales for the measurement of depressive symptoms13 and impairment in detail. A host of other potentially useful measures and questionnaires are available to assess family relationships, parental mental health, family stress, peer relationships, life events, adversities, and so forth, but their use may often not be feasible in routine clinical practice.

It needs to be emphasized that measures such as the Mood and Feelings Questionnaire (MFQ)14 are to be used as adjuncts to the face-to-face clinical assessment, not instead of it. Using a measure of impairment—for example, the Children’s Global Assessment Scale (CGAS)—alongside a depression rating scale such as the MFQ is particularly useful. For example, a severe episode typically has a CGAS rating of <41.15,16,17,18

Where the self-rating scores or individual items differ significantly from current face-to-face clinical assessment, the clinician should discuss the reasons with the patient. The review may lead either to a reevaluation of the clinical assessment or of the self-ratings. Self-report scales like the MFQ may reveal unsuspected levels of self-harm ideation or plans. To manage such disclosures, clinicians are advised where possible to administer the rating scale during the clinical interview and review the results with patients and their parents. Where questionnaires are sent out in advance and the completed scales received by mail, clinicians must have in place a care pathway to ensure they can act urgently if the questionnaire or rating scale indicates a high risk of self-harm.

Because depression is a major risk factor for completed suicide and nonsuicidal deliberate self-harm, often severity related, assessing and managing this risk is essential (described in detail in Chapters 3 and 15). In the authors’ experience, there are cases where the level of suicidality or self-harm is greater than and inconsistent with the severity of the depression (e.g., where unhappy, distressing family circumstances are driving the self-harming thoughts and behavior). Continued self-harm may be perceived as evidence of failure of treatment of the depression. This assumption, when incorrect, can lead to a vicious cycle of unhelpful inpatient admissions or use of complex medication regimes in the presence of mild or even minimal depressive symptoms. In such cases treatment should address the family relationships, for example through work with the family (see Chapter 10). As highlighted in Chapters 3 and 15, in rare circumstances, a depressed young person may pose a risk to others. Clinicians should be aware of their duty to disclose this risk.

Table 13.1 lists some risk factors and methods to address them. In addition, by helping all involved to understand the consequences of these risk factors, we provide psychoeducation and start relapse prevention work.