Review and special article
Community-Based Treatment of Late Life Depression: An Expert Panel–Informed Literature Review

https://doi.org/10.1016/j.amepre.2007.04.035Get rights and content

Objectives

To present findings from an expert panel–informed literature review on community-based treatment of late-life depression.

Methods

A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions.

Results

A total of 3543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions.

Conclusions

While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

Introduction

Research has characterized the prevalence rates, associated comorbidities, and adverse health effects of depression in older adults. Estimates of the prevalence of major depression range from 1% to 4%, and the estimated prevalence of subsyndromal depression among older adults is 8% to 16%.1 Depression frequently accompanies and complicates chronic medical conditions such as ischemic heart disease, diabetes, and stroke, and it is associated with functional impairment and disability.2, 3, 4, 5, 6 Depression in older adults has also been linked to increased healthcare costs.7, 8 Finally, depression may increase mortality rates through suicide and complications of cardiac disease.2, 3, 4, 6, 9, 10

Effective treatment of depression not only lowers depressive symptoms, it also reduces suicidal thoughts and improves functioning, quality of life, and physical symptoms (e.g., pain associated with chronic conditions).11, 12, 13, 14 Although studies suggest that effective treatments exist for late-life depression, older adults often receive suboptimal treatment.11, 12, 13, 14 Dissemination of evidence-based research findings to clinical and community practice and to the broader public health audiences has been difficult. Furthermore, changing behaviors of healthcare providers is a complex task. The increasing pace of research, coupled with rising healthcare costs, has led to the use of systematic literature reviews and evidence-based recommendations to promote improved healthcare practices. The mental health literature has no shortage of reviews and consensus statements for depression in older adults,15 yet their focus is mainly on treatment efficacy as opposed to applicability and feasibility in community settings.16, 17, 18 Applying systematic reviews plus evidence-based expert consensus recommendations to public health has been a recent phenomenon.19

This paper results from a systematic literature review, conducted with oversight and participation of a multidisciplinary expert panel, focused on identifying interventions applicable to and feasible in community-based settings. The purpose was to identify effective interventions for addressing depression in community-based older adults, particularly those strategies that could be delivered through public health and social service agencies. The results of our review process are intended to be of interest to individual clinicians and decision makers involved in the delivery of population-based mental health services in diverse community settings.20

Section snippets

Methods

Methods for this systematic literature review were based on those developed for the Guide to Community Preventive Services (Guide).21, 22 The Guide uses systematic reviews of the scientific literature to create evidence-based recommendations on population-based and public health interventions. The first step in this project involved assembling a multidisciplinary review panel of 14 experts in public health services and geriatric depression.

Results

The initial literature search produced 3543 articles with publication dates from 1967 to October 2005. Articles with insufficient information in the abstract to exclude or include them were read in their entirety (Level 2 screening) to determine if inclusion criteria were met (Figure 2). A total of 174 articles met the selection criteria, 121 of which investigated interventions (the remaining studies examined screening instruments). Given the small number of studies for each specific type of

Interventions Rated as Effective

Depression care management was the only intervention rated as effective by the expert panel. DCM produced statistically significant results across both home- and clinic-based models in eight different RCTs with the largest number of participants among reviewed interventions. Of note, the intervention is multifaceted in nature, suggesting that treatment of depression in community-based older adults requires more resources, effort, and coordination among treatment providers than might otherwise

Conclusion

This review identified DCM as an effective community-based treatment for late life depression based on sufficient strength of the evidence and quality of the data. None of the other intervention categories had adequate data or evidence to warrant this rating. Ratings were not given to interventions for which insufficient data existed, and the lack of a rating should not be interpreted to mean that such interventions are ineffective. In general, studies that did not actively recruit depressed

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