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Research Articles

Recommendations for Treating Depression in


Community-Based Older Adults
Lesley E. Steinman, MPH, John T. Frederick, MD, Thomas Prohaska, PhD, William A. Satariano, PhD,
Sharon Dornberg-Lee, LCSW, Rita Fisher, MSW, Pearl Beth Graub, MSSW, Katherine Leith, PhD,
Kay Presby, MPH, Joseph Sharkey, PhD, Susan Snyder, MS, David Turner, MEd, Nancy Wilson, MA,
Lisa Yagoda, MSW, Jurgen Unutzer, MD, Mark Snowden, MD, for the Late Life Depression Special Interest
Project (SIP) Panelists
Objective:

To present recommendations for community-based treatment of late-life depression to


public health and aging networks.

Methods:

An expert panel of mental health and public health researchers and community-based
practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness
from a systematic literature review of articles published through 2005.

Results:

The expert panel strongly recommended depression care managementmodeled interventions delivered at home or at primary care clinics. The panel recommended individual
cognitive behavioral therapy. Interventions not recommended as primary treatments for
late-life depression included education and skills training, comprehensive geriatric health
evaluation programs, exercise, and physical rehabilitation/occupational therapy. There
was insufficient evidence for making recommendations for several intervention categories,
including group psychotherapy and psychotherapies other than cognitive behavioral
therapy.

Conclusions: This interdisciplinary expert panel determined that recommended interventions should be
disseminated throughout the public health and aging networks, while acknowledging the
challenges and obstacles involved. Interventions that were not recommended or had
insufficient evidence often did not treat depression primarily and/or did not include a
clinically depressed sample while attempting to establish efficacy. These interventions may
provide other benefits, but should not be presumed to effectively treat depression by
themselves. Panelists also identified primary prevention of depression as a much understudied area. These findings should aid individual clinicians as well as public health
decision makers in the delivery of population-based mental health services in diverse
community settings.
(Am J Prev Med 2007;33(3):175181) 2007 American Journal of Preventive Medicine

Introduction

epression is common among older adults, affecting almost 7 million Americans aged 65 and
older.1,2 In 1999, a landmark U.S. Surgeon
Generals report on mental health found that 8% to
From the Department of Health Services, University of Washington
School of Public Health and Community Medicine (Steinman),
Department of Psychiatry and Behavioral Sciences, University of
Washington School of Medicine (Frederick, Unutzer, Snowden), and
Senior Services of Seattle/King County (Snyder), Seattle, Washington; Division of Community Health Sciences, University of Illinois at
Chicago School of Public Health (Prohaska), Council for Jewish
Elderly (Dornberg-Lee), and Council for Jewish Elderly Adult Day
Service Center (Fisher), Chicago, Illinois; Division of Community
Health and Human Development, University of California at Berkeley
School of Public Health (Satariano), Berkeley, California; Long Term
Care, Philadelphia Corporation for Aging (Graub), Philadelphia,

20% of older adults in the community, and up to 37%


in primary care settings, suffer from depressive symptoms.3 Unfortunately, many of these older adults receive
no or inadequate treatment,4 6 and this under-diagnosis
and under-treatment of depression represents a serious
public health problem.7 Preventing and treating late-life
Pennsylvania; College of Social Work, University of South Carolina
School of Social Work (Leith), Columbia, South Carolina; Michigan
Department of Community Health (Presby), Lansing, Michigan;
Department of Social and Behavioral Health, Texas A&M Health
Science Center School of Rural Public Health (Sharkey), College
Station, Texas; Salt Lake County Aging Services (Turner), Salt Lake
City, Utah; Department of Geriatrics, Baylor College of Medicine
(Wilson), Houston, Texas; and National Association of Social Workers (Yagoda), Washington, DC
Address correspondence and reprint requests to: Mark Snowden,
MD, University of Washington, Box 359911, Seattle WA 98104.
E-mail: snowden@u.washington.edu.

Am J Prev Med 2007;33(3)


2007 American Journal of Preventive Medicine Published by Elsevier Inc.

0749-3797/07/$see front matter


doi:10.1016/j.amepre.2007.04.034

175

depression is also of significant public health importance because depression can increase symptom burden of other comorbid conditions (e.g., heart disease),
disability, healthcare utilization, and mortality from
suicide and cardiac disease.8 12
Community-based medical and social services settings (vs traditional mental health clinics), offer important opportunities for recognition and intervention of
depression in older adults, since many depressed older
adults typically present in these environments. Although a broad array of effective interventions exists
for depression, there is no clear consensus on effective
treatments to be recommended for community-based
older adults specifically. This project aimed to identify
effective interventions and to develop recommendations based on consensus from a panel of experts from
public health, epidemiology, social services, and primary care.

Methods
In the first stage of this project, a panel of 14 academics in
public health and geriatric depression systematically reviewed
3543 peer-reviewed studies published from 1967 to 2005 to
identify effective interventions for treating depression in
non-institutionalized older adults. The panel operationalized
depression as either a clinical DSM-IV13 depression diagnosis (e.g., major depression, dysthymia) or as a symptom
severity score from a standardized assessment instrument.
The literature review considered all study designs, including
both interventions that target depression as their main outcome and as a secondary outcome (e.g., an aquatics class for
arthritic older adults that also measures changes in depression). Search terms of electronic article databases included
both multifaceted interventions (e.g., IMPACT14) and standalone treatments (e.g., cognitive behavioral therapy15). Results from this review are detailed in an accompanying article
in this issue.16 In the second stage, a newly formed expert
panel of researchers and community-based practitioners
made recommendations for interventions demonstrating effectiveness in community-based settings and judged as feasible and appropriate for community-based dissemination. This
stage is unique because it included front-line practitioners
intimately familiar with the challenges of program planning
and implementation. This panel prioritized effective interventions for dissemination, commented on feasibility, identified promising interventions for further research, and recognized interventions to be discontinued based on lack of
effectiveness. This paper describes the second panels work.
The second expert panelists were identified from referrals
from public health and aging network contacts around the
country. Eight members represented researchers in depression,
public health, and epidemiology, providing knowledge in conducting depression and public health research (e.g., appropriate study methodology). Six panelists were community-based
practitioners in social services, adult day care, nursing, senior
centers, and primary care, offering practical expertise in
available settings, population, and resources (e.g., staffing,
training, funding) for implementing programs.

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This panel was charged with making recommendations to


the public health and aging networks on previously reviewed
interventions. Community was defined to include a variety
of settings serving older adults to meet people where they are
and further increase the applicability of the recommendations. In making recommendations, the panel characterized
the reviewed interventions as strongly recommended, recommended, not recommended, or having insufficient evidence.
These categories were based on the Task Force on Community Preventive Services Community Guide ;17 however, the
Guides explicit criteria to differentiate categories were not
used because of limited available studies. Panel members thus
assigned these categorizations based on their professional
experience and the existing evidence on feasibility (e.g.,
personnel, training, cost, duration) of delivery in communitybased settings, strength of the evidence of effectiveness
(including appropriateness and quality of the study design for
treating depression and the number of available studies), and
potential population impact with community-based older
adults. The fourth category, insufficient evidence, was created
to categorize programs with adequate evidence to rate efficacy but without sufficient data to judge effectiveness in
community-based settings.
The process for making recommendations was as follows:
The 14-member panel reviewed results from the systematic
literature review, including summarized data and evidence
ratings on interventions reviewed by the first panel. A metaanalysis was not conducted due to low number of studies and
high variation in study design and outcome measures. Next,
the panel convened at a 1-day in-person meeting to discuss
strengths and limitations of each intervention, considering
the nature of the scientific evidence, study population, and
feasibility. After each discussion, members voted for one of four
recommendation categories. Consensus comprised agreement
among at least 12 panelists. Panelists also provided key points
and caveats for each recommendation based on populations
studied, feasibility issues, and other factors to consider when
applying recommendations.
During the recommendation process, several changes were
made to the grouping of interventions by the first panel. The
second panel eliminated the overarching individual psychotherapy category and instead considered each type of psychotherapy separately (e.g., psychodynamic, cognitive
behavioral). Also, because it was nearly impossible to
determine whether antidepressant treatment studies were
performed in community settings, antidepressants were not
evaluated as a separate intervention. Other reviews describe
effectiveness of antidepressants in older adults.18 20

Results
A summary of the recommendations is provided in
Table 1. Further details on the programs and points to
consider are provided in the following section. Consensus was reached for all recommendations.

Depression Care Management, Home or Primary


Care Clinic: Strongly Recommended
Depression care management (DCM), or collaborative
care management, entails a systematic team approach

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Table 1. Recommendations for community-based


treatment of late-life depression from the combined
researcher/practitioner Late-Life Depression Expert
Panel
Intervention

Recommendation

Depression care management,


home or primary care clinic
Individual CBT
Group psychotherapy for
depression
Individual psychotherapy for
depression: other therapies
(except CBT)
Individual psychotherapy for
overall mental health care
Education and/or skills training
Geriatric health evaluation and
management, home or clinic
Exercise not targeting depression
Rehabilitation and occupational
therapy

Strongly recommended
Recommended
Insufficient evidence
Insufficient evidence
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended

Note: Reviewed interventions are categorized as strongly recommended, recommended, not recommended, or as having insufficient
evidence. These categorizations are based on the feasibility (e.g.,
personnel, training, cost, duration) of delivery in community-based
settings, the strength of the evidence of effectiveness (including the
appropriateness and quality of the study design for treating depression and the number of available studies), and the potential population impact with community-based older adults. Insufficient evidence
categorizes those programs that had adequate evidence to rate
efficacy, but did not have sufficient data to judge effectiveness in
community-based settings. Fourteen expert panel members voted for
one of the four recommendation categories; consensus was defined
by agreement among at least 12 members.
CBT, cognitive behavioral therapy.

to treating depression in older adults. Common elements of DCM include active identification of depressed persons with a validated screening instrument,
measurement-based care (psychotherapies and/or antidepressants used according to evidence-based guidelines, with repeated assessment using a validated
screening instrument to identify treatment responders
and nonresponders and adjust treatment accordingly),
and a trained social worker, nurse, or other practitioner
(sometimes called a depression care manager) who
facilitates patient education, outcomes tracking, and
support/delivery of the evidence-based treatments prescribed by a primary care provider in consultation with
a psychiatrist. The goal is to improve low rates of
engagement in and adherence to depression treatment, and to improve recognition and treatment for
nonresponders to initial treatments. In the clinic, a
depression care manager works with the patients
primary care provider, a consulting psychiatrist, and
other healthcare personnel to deliver the intervention. Clinic-based management takes advantage of a
service delivery platform that older adults already access regularly.2123 At-home interventions involve home
visits by the depression care manager, working with
similar teams as in clinics.
September 2007

Depression care management programs in the primary care setting14,24 are strongly recommended for
older adults. The two large, well-executed randomized
control trial (RCT) studies showed significantly greater
reduction of depression symptoms, improvement in
quality of life, and satisfaction with care for older adults
with major depression and dysthymia than primary care
as usual, although not for individuals with minor depression. The panel also strongly recommended homebased DCM for older adults with minor depression and
dysthymia since five of six reviewed RCTs demonstrated
significant improvement in treatment subjects depression symptoms and quality of life beyond outcomes
seen with usual care controls.2529

Individual Cognitive Behavior Therapy:


Recommended
The panel found six CBT studies with sufficient evidence for separate evaluation. CBT is a psychotherapy
focusing on current symptoms of depression and patterns of thoughts and behaviors that exacerbate or,
when used, can reduce depression.15 Typically, it entails weekly therapy sessions plus daily practice exercises
to assist older adults in applying CBT skills within their
everyday environment. This intervention includes several key components: cognitive restructuring, behavioral activation, and problem-solving skills. The reviewed studies primarily used masters-level trained
therapists to deliver the intervention who received
regular supervision and consultation from a doctorallevel professional.
Individual CBT is recommended for treating depression in older adults. Significant improvement in depressive symptoms was mainly found during a short-term
follow-up period (1 year). Other one-on-one psychotherapies were not found to have sufficient evidence
and were reclassified as individual psychotherapies,
other therapies.

Individual Psychotherapy, Other Therapies


(Besides CBT): Insufficient Evidence
Psychotherapy is a therapeutic approach to treating
depression that requires formal training, supervision,
and consultation to maintain treatment fidelity. Lessformal education and skills training programs were not
considered psychotherapy; however, these programs
may be substituted (inappropriately) in limited-resource
community-based settings. Other therapies identified
by the review included cognitive, brief relational/insight, brief psychodynamic, self-management, reminiscence, bibliotherapy, and problem-solving therapy for
primary care. They involved a range of settings, duration, dosage, and personnel (although trained masterslevel clinicians with supervision were typical). Since the
numbers of reviewed studies and sample sizes were
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177

small, the panel found insufficient evidence for making


recommendations.

Group Psychotherapy: Insufficient Evidence


As with individual psychotherapies, this category comprised a range of therapies: group cognitive behavioral,
psychodynamic, cognitive, integrative reminiscence,
and instrumental reminiscence therapy. Given small
sample sizes and lack of study replication, the panel
found insufficient evidence for making recommendations for treating depression in community-dwelling
older adults.

Interventions Not Recommended


Several interventions had sufficient evidence but were
not recommended by the panel as specific treatments
for depression. These include individual psychotherapy
for overall mental health care (targeting mental health
in general, such as a mind body wellness program),
education and/or skills training (increasing knowledge
and skills in treating or preventing illness, e.g., classroombased chronic disease management), geriatric health
evaluation and management in the home or clinic
(comprehensive assessment of at-risk older adults for
case finding of common geriatric syndromes), exercise
not targeting depression (targeting other issues, such as
falls prevention and arthritic pain, with depression as a
secondary outcome), and rehabilitation or occupational therapy (focusing on daily-life and other specific
activities to treat a variety of illnesses). These interventions lacked evidence supporting their effectiveness
for reducing depression in community-based older
adults, although in several instances they improved
the targeted conditions (e.g., knee pain). Several
study design issues contributed to this conclusion,
including brief duration, failure to target depression as
a primary outcome, and the lack of clinically depressed
participants.

Discussion
This work addresses the urgent need for effective
prevention and treatment of depression in older adults.
More information can be found on our projects website.30 We strongly recommended home-based DCM for
people with minor depression or dysthymia; although
home-based DCM for major depression has not been
studied. DCM is also strongly recommended in primary
care settings for major depression and dysthymia, although it was not more effective than usual primary
care for minor depression. Primary care provides an
opportunity for reaching older adults since a majority
see a primary care provider and are opposed to specialty mental health clinics. Home-based care should be
made available via social service programs, as home178

bound elders are often unable to access clinic-based


care.
Understanding that community-based settings and resources vary, the essential elements of DCM are active
identification of depression, evidence- and measurementbased treatment and outcomes, a person trained to
support and deliver the treatment (depression care
manager), and a consulting psychiatrist. It is not
known whether the same outcomes can be achieved if
these DCM elements were changed, so fidelity to this
model is important until more research is available.
The panel emphasized the importance of consistently
using one of the evidence-based standardized instruments over time (e.g., Center for Epidemiological
Studies Scale [CES-D]31, 10-item CES-D-10,32 30-item
Geriatric Depression Scale [GDS],33 15-item GDS-15,34
2-item Patient Health Questionnaire [PHQ-2],35 and
Zung Self-Rating Depression Scale [ZSDS]36) to accurately identify depression and assess treatment outcomes. One recommended screen was not endorsed
over another given their different strengths in various
situations. The panel did not comment on antidepressants alone as a treatment; however, DCM includes
antidepressants with a focus on improving adherence
and adjustment of medications as needed.
Individual CBT is also recommended for communitybased older adults with a range of depression conditions. Strengths of CBT include its brevity, present-day
focus, flexibility to each persons needs, and availability
of treatment manuals and training materials to instruct
practitioners. As with DCM, the reviewed CBT studies
used a standardized approach important for treatment
fidelity. Unlike the DCM studies, most CBT research
used a masters-level therapist. A key take-home message for both of these recommended programs is that
effective interventions used specifically trained personnel using a standard, evidence-based approach.37

Implementation of Recommendations
Implementing recommended interventions depends
largely on available personnel, capacity, and financial
resources. Successful implementation requires trained
and supervised staff for delivery, which in turn requires
a funding and reimbursement structure that will cover
these services. Medicare and other insurers typically do
not cover care management unless it is provided by
physicians, psychologists, advanced registered nurse
practitioners or licensed clinical social workers, who are
typically more expensive than the care managers used
in the research studies. Other potential feasibility issues
include time available and comfort level for patient
provider communication around depression, stigma
about depression from practitioners and older adults,
and ageism by providers. It is also unclear if these
interventions will be effective and feasible in important
population subgroups often absent from study samples,

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including nonEnglish-speaking older adults, lowerincome people, people of color, the oldest-old (people
aged over 85), and those with significant cognitive
impairments (including dementia). A few reviewed
depression care management studies provided insight
into low-income,38 nonwhite,14 and old-old39 populations; however, further dissemination in these underserved populations is clearly needed.
Even without resources for delivering DCM and CBT,
community-based providers can play an important role
in identifying and linking people to recommended
treatments. Raising awareness that depression is common and treatable is an essential first step toward
reducing stigma and increasing comfort with talking
about depression in their communities. Practitioners
can be case finders through routine screening using
validated instruments within current programming (especially with at-risk populations). Note that proactive
identification is necessary but not sufficient for treating
depression; intervention and follow-up are required.
Effective linkages are also needed among community
organizations that identify potentially depressed older
adults and the agencies that treat them.
For policymakers and administrators, implementing
recommended programs is important for several reasons. Employing these interventions improves treatment outcomes and avoids costs of ineffective efforts,
thereby providing a better return on investment. If the
considerable sum already spent on depression treatment were earmarked for evidence-based interventions,
the same investment would likely provide substantially
greater outcomes. In some instances, effective depression treatment may also help improve other disease
outcomes (e.g., arthritis,40 diabetes41), augment quality
of life (e.g., in cancer patients42), and save money (e.g.,
with diabetics).43 Although few cost studies are available,
IMPACT was recently demonstrated as a high-value
intervention compared to other medical interventions;
the small outlay of $148/person (or $3/insured older
adult) provided huge benefits in depression improvement and other health and financial outcomes.44
Administrators can address financial concerns by
partnering with other agencies to share expensive
resources (e.g., psychiatrists time for supervision and
consultation).45 Policymakers should consider changing
reimbursement structures to pay for currently nonreimbursable personnel and services needed for effective
intervention delivery.46 In addition, public health and
aging agencies that have traditionally worked separately
should forge new partnerships for collaborative care including identification, outreach, and effective treatment.
Successful program implementation requires buy-in
and support from all levels of an organization, including front-line workers.47,48 Champions are also needed
to endorse a positive, proactive strategy for addressing
depression in older adults.48 For instance, a recent
report on feasibility of delivering a nurse-led, primary
September 2007

care based depression intervention found that support


from administrators, key stakeholders, and champions
was crucial to program success.48 An effective model
for diffusion of innovative treatments should be established to facilitate effective translation of evidencebased research into practice in diverse applied settings.49 Finally, the panel stressed addressing issues of
liability so that providers are adequately trained and
comfortable addressing depression, and have appropriate support and supervision.
The main strength of this consensus process was
incorporating community-based providers into a recommendation process focusing on scientific interventions. These providers offered essential input on what is
required for implementing these interventions in realworld settings. One limitation of this project was excluding interventions in academic settings, which often
used community-dwelling subjects. This study also focused on older adults only, and findings are not
generalizeable to other adult age groups.

Future Research
This project identified several areas for improving
future research. Targeting clinically depressed people,
looking at long-term outcomes (more than 1 year),
using an attention-control group, and reporting on
actual versus intended treatment intensity will improve
effectiveness research, including reviewed interventions that were not recommended or lacked sufficient
evidence for making recommendations. In addition,
most research is conducted in academic settings, which
may have more resources and less-diverse populations
than do community providers. Researchers and practitioners must partner to conduct effectiveness studies
that reflect the capacity of real-world settings (e.g.,
senior centers, area agencies on aging) to deliver
interventions. Further research is also needed for working with older adults who are less educated (affecting
literacy level), old-old, of color, less acculturated, and
who have cognitive and other disabilities; most studies
did not have diverse samples and/or excluded people
with cognitive or other impairments, so generalizability
of effectiveness with these populations is unknown.
Physical activity to treat depression in clinically depressed
older adults is also under-studied; effective physical activity interventions for community-based older adults exist,50
yet data are lacking that test these as a primary treatment
for depressed older adults. Lastly, additional research is
needed with DCM to assess effectiveness with various
depression diagnoses (namely, home-based DCM with
major depression and clinic-based DCM with minor depression) and with chronic medical comorbidities (e.g.,
dementia, chronic pain).51
Studies on primary prevention of depression in
community-based older adults were notably lacking in
the initial review, and therefore missing from this
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179

recommendation process. This is unfortunate since


prevention is our mandate as public health researchers
and practitioners. Some of the interventions identified
but not recommended may prevent depression, particularly when provided to populations at risk for depression (e.g., older adults with dementia, caregivers).
However, different design features including larger
sample sizes and longer durations are necessary for
research studies to effectively demonstrate prevention
outcomes. Recent research in the prevention of late-life
depression post-stroke or with age-related macular degeneration also offer important groundwork for prevention
research in the broader older adult population.52

Conclusion
This recommendation process identified DCM and
CBT for effective community-based treatment for latelife depression, based on their strength of evidence and
applicability in these settings. The panel felt that these
recommended programs should be disseminated
throughout public health and aging networks while
acknowledging the challenges and obstacles involved.
Other interventions were not recommended, often
because available studies did not target depressed subjects specifically or the number of depressed subjects
was small. While relatively few interventions were recommended, a large proportion of reviewed programs and
tools had insufficient data for rating their effectiveness or
for making recommendations. Clearly, current research
funding mechanisms must be changed to increase the
evidence base on this important public health issue.
This research was funded by the Centers for Disease Control
and Prevention (CDC) Healthy Aging Program through the
CDC Prevention Research Program Special Interest Project
grant (U48 DP000050, SIP-15-04) to the University of Washington Health Promotion Research Center. The authors also
wish to thank Lynda Anderson, PhD, Rosemarie Kobau,
MPH, Jason Lang, MPH, MS, and Jaya Rao, MD, MPH, for
their contributions to the expert panel.
No financial disclosures were reported by the authors of
this paper.

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