Zvi D. Gellis, PhD. University of Pennsylvania
Stanley G. McCracken, PhD, University of Chicago.
This review of the research literature on late life depressive disorders was undertaken to determine the extent of the problem and the effectiveness of various psychosocial and pharmacological treatments. The term effectiveness is defined here as producing or capable of producing a desired effect in a controlled study (Level A evidence). The review consists of systematic reviews, meta-analyses, other reviews of the literature, experimental, quasi-experimental designs, and case studies with older adults (65+) as participants, reported in English language peer-reviewed journals. Keyword terms included the following: aged, aging, elderly, geri*, older adult, senior, depressed, depression, mood disorder, intervention, treatment, and randomized controlled trials. We conducted searches in the following electronic databases: PubMed (1980-2007), PsycINFO (1972-2007), Ageline (1978-2007), Social Work Abstracts (1977-2006/December), and Social Sciences Abstracts (1983-2007). Google Scholar was also searched using November-February 2008 as the time range to identify recent publications that would not have been cited or indexed. Relevant journals were hand searched to identify recent publications that would not have been cited or indexed. Unpublished literature was not included.
This review addresses the epidemiology, prevalence, suicide risk, comorbidity, and evidence-based treatments for depression in late life, focusing on empirical research with community-based and institutionalized older adults. This review specifically examines depressive disorders since they frequently occur in older adults. The aim is to highlight critical themes of depression in late life that are pertinent for social work practitioners, researchers, educators, and policy analysts, as they confront the challenge of shaping and delivering services to an aging population in the coming decades. If social workers are to respond to the continuing demographic shift, they must be knowledgeable in evidence-based treatments for depression in older adults (Gellis & Reid, 2004).
Depression is a frequent cause of psychological distress in later life and significantly decreases quality of life (Blazer, 2002; Doraiswamy, Khan, Donahue, & Richard, 2002; Gellis, 2006). As the U.S. population continues to grow older, the necessity for social work to provide assistance with mental health needs associated with later life will be critical. This will become especially apparent between the years 2015 and 2030, when older adults (65 years+) will account for 20% of the total population, up from 13% in 2000 (U.S. Bureau of the Census, 2000). Another concern is that less than 3% of older adults seek mental health care in the U.S. (Gellis, 2006). Added to this trend is the increasing proportion of minority older adults, including African-American, Latino, and Asian-Americans (Arean et al., 2005; Gellis & Taguchi, 2003; Harada & Kim, 1995), who tend to experience more obstacles than Caucasians do in accessing mental health services. Due to theses trends, strategic planning to meet the call for geriatric mental health services is imperative. Therefore, it is critical for social work practitioners to understand and intervene in mental health problems of aging since the social work profession is the largest provider of mental health services in the U.S.
Depressive disorders in older adults are relatively prevalent (Administration on Aging, 2001; Baldwin, 2002). Inadequate recognition and treatment of depression at the individual level has important implications for the use of social, medical, and mental health services, and for the allocation of health care resources (Birrer & Vemuri, 2004; Powers, Thompson, Futterman, & Gallagher-Thompson, 2002). The provision of mental health care to older adults involves a unique set of barriers to human service providers. Older adults may be fearful of seeking psychological treatment or acknowledging that they have an emotional problem due to stigma. They may worry that if they identify themselves as in need of mental health services, they may jeopardize their health care and insurance. They also fear loss of financial security and independence, embarrassment, isolation, or being declared incompetent. Service access barriers, including limited financial resources, language barriers, and a lack of culturally-sensitive programs, are other reasons for not seeking treatment. Sometimes, due to fragmented mental health services or gaps in services, older adults do not receive appropriate care when they do seek help. Financial constraints of managed care are increasingly restricting the time spent with clients, forcing mental health concerns to compete with comorbid medical conditions. Primary care physicians often report feeling too pressured for time to investigate mental health problems in older people (Glasser & Gravdal, 1997). Given the inseparability of mental and general health in later life, this trend is of concern. Likewise, there is a critical shortage of professional staff trained in the geriatric mental health field to meet this looming public health crisis.
Chronic medical conditions are common in older adults and frequently co-occur with mental disorders such as depression and anxiety disorders. Mental health problems in later life demand extra attention to minimize their effects on disability and the quality of life. Medically ill older adults experience more depressive symptoms, more anxiety, less self-esteem, and lower ability to control many aspects of their lives than older adults without disease experience. Given the effects on daily functioning of depression, anxiety, cognitive decline, and physical illness in older adults, understanding geriatric mental health problems and utilizing efficacious treatments assumes great importance.
According to the Surgeon General’s Mental Health Report, depression in older adults leads to physical, mental, and social dysfunction (United States Department of Health and Human Services [USDHHS], 1999). Depression is a serious and prevalent medical illness in older adults (Bruce et al., 2002; Gellis, 2006). The prevalence estimates of major depression in community elderly samples are low, ranging from 1% to 4% overall, with a higher prevalence among women than men. The prevalence rate for dysthymia is about 2% although for minor depression estimates are higher, ranging from 4% to 13%, with the same pattern of distribution across gender, race, and ethnicity (Blazer, 2002; Beekman et al., 1995). There are no significant racial or ethnic differences in prevalence rates for depression (Beekman, Copeland, & Prince, 1999; Steffens et al., 2000; Zalaquett & Stens, 2006). There is some suggestion that rates are higher for Hispanic elderly though further investigation is warranted. In one study, 25% of Latino-Americans scored above criterion on a well-validated depression screening measure (Gonzales, Haan, & Hinton, 2001).
In comparison to the general older population, estimates for major depression in medically ill elderly are higher, ranging from 10% to 12% with an additional 23% experiencing significant depressive symptoms (Koenig, Meador, Cohen, & Blazer, 1988). In home health care, estimates of 13.5 % for major depression and 27.5% for significant depressive symptoms were found (Bruce et al., 2002; Gellis, 2006). Rates of clinically significant depressive symptoms among medically ill elderly range from 10 to 43% (Williams-Russo, Sharrock, Mattis, Szatrowski, & Charlson, 1995; Peterson, Williams-Russo, Charlson, & Myers, 1996; Steffens et al., 2000). In fact, depression is twice as prevalent in home health care as in primary care; it is persistent, intermittent, and is associated with medical illness, pain, and disability (Lyness, Niculescu, Tu, Reynolds, & Caine, 2006).
In long-term care settings, prevalence rates for major depression can range from 6% to 24% (Blazer, 2002) and clinically significant depressive symptoms range from 12% to 50% (Hendrie et al., 1995; Hyer, Carpenter, Bishmann, & Wu, 2005; Mojtabai & Olfson, 2004; Parmelee, Katz, & Lawton, 1989; Payne et al., 2002). Depression is underdetected in long-term care facilities and if detected, is inadequately treated (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Brown, Lapane, & Luisi, 2002).
The prognosis of depression can often be poor. A meta-analysis of depression outcomes at 24 months estimated that only 33% of older patients were well, 33% were depressed, 13% were hospitalized, and 21% had died (Cole, Bellavance, & Mansour, 1999). Depression is also an independent predictor of overall poor treatment compliance and may exacerbate other common chronic medical conditions in older adults (DiMatteo, Lepper, & Croghan, 2000). Moreover, late life depression slows recovery rates from illnesses and surgeries and is associated with increased mortality (Beekman et al., 1999; Unützer et al., 2002).
In summary, evidence is clear that late life depression is one of the most common mental disorders to present in primary care and home health care settings (Bruce et al., 2002; Gellis, 2006; Gellis, McGinty, Horowitz, Bruce, & Misener, 2007; Lyness, King, Cox, Yoediono, & Caine, 1999; Reynolds & Kupfer, 1999). Nearly 5 million of the 31 million Americans over 65 suffer from clinically significant depressive syndromes.
The consequences of depression in later life are potentially serious. Depressive disorders can be persistent (Unützer et al., 1997, 1999), intermittent and/or recurrent (Little et al., 1998), and result in significant physical and psychological co-morbidity and functional impairment (Coyne, Fechner-Bates, & Schwenk, 1994; Katon et al., 1994) that negatively influence the course of depression (Sherbourne & Wells, 1997).
Cole and Dendukuri (2003) completed a systematic review of risk factors for depression in community-dwelling elderly that involved a qualitative and quantitative synthesis of the data. They examined 20 studies and identified key risk factors that included female gender, sleep disturbance, disability level, prior history of depression, and bereavement.
Depression with physical illness increases levels of functional disability (Alexopoulos et al., 1996; Proctor et al., 2003), use of health services (Beekman, Deeg, Braam, Smit, & Van Tilburg, 1997; Saravay, Pollack, Steinberg, Weinsched, & Habert, 1996), and health care costs (Callahan, Kesterson, & Tierney, 1997; Manning & Wells, 1992; Simon, VonKorff, & Barlow, 1995), particularly among older adults (Unützer et al., 1997). It also delays or inhibits physical recovery (Covinsky, Fortinsky, Palmer, Kresvic, & Landefeld, 1997; Katz, 1996). Common medical illnesses known to be associated with depression include heart disease, stroke, hypertension, diabetes, cancer, and osteoarthritis.
Late onset, unipolar depression is characteristic suicide victims in later life (Conwell et al., 1996, Henriksson et al., 1995). Older suicide victims often have had late onset undetected or untreated depressions, although typically they have had contact with their primary care provider prior to their death (Conwell, 1994; Van Casteren, Van der Veken, Tafforeau, & Van Oyen, 1993), presumably reflecting high rates of comorbid illness (Barnow & Linden, 2000; Conwell et al., 1996) and/or fears of dependency or pain (Duberstein, 1995). Taken altogether, these findings support the importance of treatment of depression in late life.
Suicide is almost twice as frequent in the elderly as in the general population (Conwell, Duberstein, & Caine, 2002). The elderly account for 20% of all suicides, yet they make up only 13% of the population (Hoyert, Kung, & Smith, 2005; Pearson & Brown, 2000). Some of the most common demographic correlates of suicide are older age, male gender, white race, and unmarried status (Peters, Kochanek, & Murphy, 1998). Late onset depression is a serious risk factor for suicidal ideation (Conwell et al., 1996; Lebowitz et al., 1997; Raue, Meyers, Rowe, Hao, & Bruce, 2007). Late onset, unipolar depression is characteristic of suicides in later life (Conwell et al., 1996, Henriksson et al., 1995).
In the U.S., older white males age (85+) have the highest suicide completion rates (65 per 100,000), exceeding adolescent rates (16.6 per 100,000) (U.S. Dept. of Health and Human Services, 2003). This is over six times the rate of all age-adjusted suicides (Peters et al., 1998). Older men (80+) take their own lives at four to six times the rate of older women (Scocco & de Leo, 2002). Rates of depression among elderly suicide victims have been estimated at approximately 80% (Conwell et al., 1996; Plutchik, Botsis, Weiner, & Kennedy, 1996). Depression, comorbid anxiety, substance abuse, isolation, loneliness, lack of social supports, and declining physical health are some of the risk factors for suicide among older adults (Conwell et al., 2002). Retrospective studies identified that greater than 70% of older suicide victims had had contact with their primary care provider within 3 months prior to their death (Conwell, Olsen, Caine, & Flannery, 1991; Conwell, 1994; Diekstra & van Egmond, 1989; Frierson, 1991; Uncapher, 2000). In these studies, the majority of older patients had late onset undetected or untreated depressive symptoms, likely reflecting high rates of comorbid illness and/or fears of pain or dependency on others (Duberstein, 1995).
During the past decade, efforts to improve detection and treatment of geriatric depression in health care settings have led to lowered suicide rates (Brown, Bruce, & Pearson, 2001; Lish et al., 1996). One recent large multisite randomized trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) enrolled patients who met criteria for major depression, dysthymic disorder, or minor depression and observed them for a period of 2 years through acute, continuation, and maintenance phases of treatment (Bruce & Pearson, 1999; Alexopoulos et al., 2005). The experimental intervention was implemented by depression care managers who monitored psychopathology, treatment adherence, response, and side effects at predetermined times. Patients were offered antidepressant medications and/or interpersonal psychotherapy, an evidence-based intervention. The usual primary care condition included primary care physicians who were notified in writing of the patient’s depression diagnosis and informed when the study guidelines indicated suicide risk in individual patients. Physicians received a videotape and printed material on geriatric depression and treatment guidelines. The PROSPECT trial demonstrated that elderly patients receiving a depression care management intervention had less severe depressive symptoms and greater remission rates at 4, 8, and 12 months than did patients receiving usual primary care (Bruce et al., 2004).
Psychosocial interventions have been demonstrated to be effective among older adults, particularly those who reject medication due to unpleasant side effects or who are coping with low social support or stressful situations (Choi & Morrow-Howell, 2007; Gellis, 2006; Klausner & Alexopoulos, 1999). Evidence-based approaches such as structured problem-solving (PST) cognitive-behavioral (CBT), and interpersonal (IPT) therapies are effective intervention alternatives or adjuncts to medication treatment (Gath & Mynors-Wallis, 1997; Gellis, McGinty, Horowitz, et al., 2007; Gerson, Belin, Kaufman, Mintz, & Jarvik, 1999; Hegel, Barrett, Cornell, & Oxman, 2002; Jacobson & Hollon, 1996; De Rubeis, Gelfand, Tang, & Simons, 1999; Schulberg, Pilkonis, & Houck, 1998). These interventions are considered Level A evidence due to demonstrated outcome effectiveness in numerous randomized trials. (See Chapter 1. Introduction for description of Levels of Evidence.)
Some evidence indicates that psychosocial interventions alone are effective with older populations, including minorities (Coulehan, Schulberg, Block, Madonia, & Rodriguez, 1997; Mossey, Knott, Higgins, & Talerico, 1996; Munoz, et. al., 1995). Cognitive therapies, including PST, are particularly promising (McCusker, Cole, Keller, Bellavance, & Berard, 1998; Nezu, 2004; Robinson et al., 1995) among older men and women of diverse ethnic backgrounds (Gil et al., 1996). Patient attitudes and preference for type of treatment has been shown to affect acceptance of and adherence to the prescribed treatment for depression (Schulberg, Magruder, & deGruy, 1996), and the majority of primary care patients prefer counseling over medication (Brody, Khaliq, & Thompson, 1997; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001).
PST interventions for depression by non-medical mental health practitioners have also demonstrated effectiveness for homebound, frail, medically ill populations (Gellis, McGinty, Horowitz, et al., 2007; Mynors-Wallis et al., 1997) (Level A). Adjunct written educational materials for patients and family members have been shown to improve medication adherence and clinical outcomes (Robinson et al., 1997). Gellis, McGinty, Horowitz, and colleagues (2007) found robust effects in treating geriatric depression using 6 sessions of PST. Other researchers found similar effects using 12 sessions of PST (Arean et al., 1993). Some studies have found that 6 sessions of PST are as effective as pharmacotherapy among ambulatory primary care patients with minor and major depression (Hegel et al., 2002; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995), are modestly effective with older adults with minor depression (Mossey, 1997), and lead to greater improvement in self-reported social adjustment (Mynors-Wallis et al., 1995). PST can also be used by therapists of different theoretical orientations (Arean et al., 1993; Gellis, McGinty, Tierney, et al., 2007; Mynors-Wallis, Gath, Davies, Gray, & Barbour, 1997).
Literature reviews on the effect of CBT on late-life depression noted that CBT was at least as or more efficacious than pharmacotherapy and other forms of psychotherapy such as IPT, brief insight-oriented therapy, PST, and reminiscence therapy (Arean & Cook, 2002; Cuijpers, van Straten, & Smit, 2006; Laidlaw, 2001; Pinquart & Soerensen, 2001; Zalaquett & Stens, 2006) (Level A). The positive outcomes for CBT were detected in both clinician-rated depression (e.g., the Hamilton Depression Rating Scale [HDRS]) and self-rated depression scales (e.g., the Beck Depression Inventory [BDI]), and shown equally in individual and group therapy. The reviews also found that therapeutic gains were maintained in some groups of older adults for a period of 6 months or longer (Laidlaw, 2001).
A review of the efficacy of several therapies evaluated in randomized trials (12 studies of CBT, 6 studies of behavior therapy, 5 studies of reminiscence and life review, 4 studies of PST, 3 studies of IPT, and 5 studies of other therapies) found that the different treatments had moderate to substantial effects on reducing depression in older adults with no clear evidence that one type of treatment was more effective than another (Cuijpers et al., 2006; Laidlaw, 2001) (Level A).
Among low-income older adults with Major Depressive Disorder (MDD) or dysthymia, cognitive behavioral group therapy (CBGT) augmented with clinical case management and clinical case management alone led to greater improvements in depressive symptoms 12 months after treatment, compared to CBGT alone (Areán, Gum, & McCulloch, 2003). In a study of low-income older primary care patients with MDD, Spanish-speaking and English-speaking patients responded equally well to CBT alone versus case management alone (Miranda, Azocar, & Organista, 2003). Interestingly, CBT with supplemental case management was associated with greater improvement in symptoms and functioning than CBT alone for Spanish speakers, but the combination was less effective for those whose first-language was English. These two studies suggest that combined case management and CBT may have more efficacy than CBT alone for persons in low-income and/or certain minority group.
IPT, another evidence-based intervention for late life depression, focuses on the depressed person’s relationships and conflicts with family and friends (Hinrichsen, 1999; Miller at al., 2001) (Level A). The overall purpose is to improve communication in those relationships and to develop or enhance the social support network of the identified depressed patient (Weissman & Markowitz, 1994). Several meta-analytic reviews provide findings of the efficacy of IPT for depression (de Melo, de Jesus, Bacaltchuk, Verdeli, & Neugebauer, 2005; Parker, Parker, Brotchie, & Stuart, 2006; Thase et al., 1997; Weston & Morrison, 2001). IPT was found to be somewhat better than waitlist control and placebo conditions with a reduction in depression symptoms (de Melo et al., 2005) and significantly better than standard clinical management (Elkin et al., 1989; Reynolds et al., 1999). Studies examining combined treatment of IPT and medication documented a reduction of depressive symptoms, compared to either alone (Frank et al., 1990; Reynolds et al., 1999).
Numerous studies support the notion that depression interventions can shorten the time to recovery (Cuijpers, van Straten, & Smit, 2006; Gotlib & Hammen, 2002; Zalaquett & Stens, 2006). The recommended overall treatment of choice for late life depression is a combination of psychotherapy and antidepressant medication. Psychoeducation counseling and regular monitoring are recommended for clinically significant depressive symptoms that last for less than 2 weeks. If symptoms persist, then a combined approach of medication and talk therapy is recommended (Blazer, 2002).
Antidepressants are widely used for the treatment of moderate to severe depression in older adults. Based on several literature reviews of pharmacologic treatment for geriatric depression, antidepressants are safe treatments for depressed older adults (Barkin, Schwer, & Barkin, 2000; Mamdani, Parikh, Austin, & Upshur, 2000; Salzman, Wong, & Wright, 2002; Solai, Mulsant, & Pollock, 2001) (Level A). Almost all antidepressant medications are equally effective for treating major depression (Blazer, Hybel, Simensick, & Harbin, 2000; Salzman et al., 2002). Antidepressants not only shorten the duration of depressive episodes but also decrease the remission rates from depressive disorders. Yet, as older adults are prescribed numerous medications for other medical diseases, the likelihood of self-medication, multiple drug use, drug-drug interactions, and unpleasant side effects increases. In addition, certain medications (e.g., antihypertensives) may actually induce depressive symptoms in later life (Govoni, Racchi, Mascero, Zamboin, & Ferini-Strambi, 2001).
During the past two decades, there have been over 30 randomized placebo-controlled clinical trials as well as many comparative trials (das Gupta, 1998; Salzman et al., 2002) documenting the efficacy and safety of antidepressant medications (tricyclics and selective serotonin reuptake inhibitors [SSRIs]) for older adults with depression. One trial in relatively old medically ill patients involved randomizing nortriptyline and placebo (Katz, Parmelee, Beaston-Wimmer, & Smith, 1994). This trial generally showed the efficacy of nortriptyline but with side effects including orthostatic hypotension. Thus, although nortriptyline is effective with older adults (Reynolds, Frank, Perel, Mazumdar, & Kupfer, 1995), it may have intolerable side effects for some. One large efficacy study of fluoxetine showed efficacy but with a relatively low response rate (Tollefson et al., 1994). Another study demonstrated that fluoxetine was equally effective as nortriptyline but with fewer cardiovascular side effects among a sample of late middle-aged and older adults with co-existing cardiovascular disease (Roose et al., 1997). Since the SSRIs appear to be as effective as the older tricyclic antidepressants, their use in treatment in late life depression may result in improved outcomes due to their lower side effect profile (Schneider, 1996). Naturalistic studies have shown that medically ill older adults have more adverse effects to trycyclics than to SSRIs (Cole, Elie, McCusker, Bellavance, & Mansour, 2001; Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001) and that increased use of SSRIs in primary care has become common (Crystal, Sambamoorthi, Walkup, & Akincigil, 2003). Due to fewer side effects than found with other medications, SSRIs are now frequently the first line of medical treatment.
Recent attention has been given to minor (also known as subthreshold or subsyndromal) depressive disorders, though there is a dearth of research on this topic (Lyness et al., 2006; Koenig, Vandermeer, Chamber, Burr-Crutchfield, & Johnson, 2006). Various names and definitions for subthreshold depression have been given as well as duration and cutoff thresholds. One literature review summed up the definition of minor depression as a set of symptoms that do not meet the full criteria for a specific depressive disorder, yet are associated with clinically significant impairment (Pincus, Davis, & McQueen, 1999). Minor depression is generally defined as the presence of at least two but fewer than five depressive symptoms including depressed mood or anhedonia during the same 2-week period with no history of major depressive episode or dysthymia but with clinically significant impairment (American Psychiatric Association, 1994).
Minor depression is a common type of depressive disorder in older adults (Lyness et al., 2006; Oxman & Sengupta, 2002) and is observed more often than major depression in numerous settings (Charney et al., 2003; Lavretsky & Kumar, 2002; Judd, Schettler, & Akiskal, 2002). Minor depression rates ranges from 10% to 30% in older community-dwelling adults (Hybels & Blazer, 2003) and approximately 5% to 9% in primary care patients (Lyness et al., 1999). Minor depression has been found to be associated with an increased risk for mortality in older men and to have a relatively high prevalence in some ethnic groups (Penninx et al., 1999). This subthreshold disorder is common in older minorities in primary care. As many as 15% of older Latinos, 12% of older Asian-Americans, and 10% of older African Americans meet criteria for minor depression (Arean & Alvidrez, 2001).
A recent systematic review of adults and older adults diagnosed with minor depression found remission rates in the range of 46% to 71% after 3-6 years (Hermens et al., 2004). Two studies reported that 62% of adults and older adults still had minor depression at the 5-month follow-up evaluation, whereas 16% had persistent or recurrent minor depression at the 1-year follow-up (Broadhead, Blazer, George, & Tse, 1990; Penninx et al., 1999). At 1 year, 12.7% of the adults originally with a diagnosis of minor depression developed major depression (Broadhead et al., 1990). Research has been mixed in terms of the evidence on mortality, functional impairment, and prognosis of minor depression in older adults.
CPT, IPT, and PST models appear to be promising treatments for older adults with minor depression (Rowe & Rapaport, 2006) (Level B). However, the research literature is less clear about these therapies efficacies for minor depression than for major depression, because of the dearth of treatment studies, particularly among older adults. One randomized clinical trial reported that a 6-week problem solving therapy program for minor depression in medically ill elderly significantly reduced depressive symptoms and increased personal problem solving abilities, compared to an education control (Gellis, McGinty, Tierney, et al., 2007) (Level B). Due to the heterogeneity of the few studies on minor depression, results need to be interpreted with caution. The next important challenge for practitioners and researchers is to develop agreement on the clinical definition of minor depression, and on how to diagnose and treat it in older adults, particularly with concurrent medical problems.
Social workers are likely to encounter older adults in many areas of clinical practice. Therefore, it is essential for social workers to recognize geriatric mental health problems and to provide referrals and appropriate treatment. Screening for the detection of depressive disorders involves the use of easily administered inexpensive procedures to identify older adults who may be experiencing mental health problems. The goal of screening is early identification and thus prevention through early intervention. This is critical since depression, for example, is a treatable mental health disorder with the potential for positive outcomes over time. Some criteria that social workers can use to justify mental health screening for depression in older adults include the following:
The evidence provided herein clearly shows that the prevalence of depression among older adults is frequent enough and causes sufficiently serious health and social consequences to warrant screening. For depression, valid cost-effective procedures for screening exist, and treatments are effective.
Social workers can play a critical role in increasing the proportion of depressed older adults who obtain treatment. Since comorbidity of depression with health, bereavement, and other social problems is typical in the elderly, social workers are likely to encounter older adults with mental health needs in many community settings (e.g., home health care, community work, social services, senior centers, health clinics). If a depressive disorder is suspected, the social worker can screen the older person, using one of several screening tests that are readily available (detailed in Table 3.1).
The standardized rating scales mentioned above assess for the presence and severity of depressive symptoms in community-based and long-term care settings. Furthermore, both long-term care staff and family members can provide additional valuable information on elderly residents.
Screening involves obtaining the person’s agreement to be screened, explaining the purpose for the screening, and administering and scoring the screening tool as instructions direct. If the screen results is positive, initial treatment referrals for further diagnostic assessment to the older person’s primary care physician for possible psychotherapy and antidepressant medication should be made. The social worker is in a unique position to (a) identify resources if financial barriers exist, (b) address stigma through psychoeducation, and (c) encourage client follow through with the referral.
The provision of evidence-based mental health care to older adults poses a unique set of challenges to social work providers. Barriers to the provision of care exist at the direct practice and agency levels. Social workers should consider state-of-the-art evidence-based interventions for geriatric depression. Effective intervention options for mental health problems in later life include psychotropic medication and psychosocial interventions (CBT, PST, IPT).
Treatment protocols for late life depression are typically time-limited psychotherapeutic interventions. For depression, interventions generally range from 6 to 20 sessions, each lasting about an hour (Gellis, McGinty, Horowitz, et al., 2007; Hegel et al., 2002; Nezu, 2004; Nezu & Nezu, 2001). The goal of brief interventions is to treat the problem, specifically, changing the behavior of individuals who are experiencing mental health problems in later life. These psychosocial interventions include assessment and direct feedback, contracting, and goal setting, cognitive and behavioral techniques, and the use of written and educational materials. Unfortunately, little evidence is available on culturally appropriate mental health treatments for older adults.
Current depression management in primary care is suboptimal; yet, depression is prevalent at rates of 5 to 9% of the older population (Freudenstein, Jagger, Arthur, & Donner-Banzhoff, 2001). Much effort has been expended trying to improve the psychiatric skills of primary care physicians but with only modest effects (Lin et al., 1997; Rihmer, Rutz, & Pihlgren, 1995). Integration of specialty mental health care within primary care and system of care enhancements, such as “collaborative or integrative care” are found to be more effective than usual primary care alone (Meyers, 1996; Schulberg et al., 1998; Gilbody, Whitty, Grimshaw, & Thomas, 2003 (Level A). Collaborative care approaches are multifaceted intervention packages that involve nurses, social workers or depression care managers and vary in content and intensity (Katon et al., 1999; Swindle et al., 2003). These interventions often aim to increase knowledge about depression (psychoeducation), improve adherence to antidepressant medication, improve physician-patient communication, and decrease depressive symptoms (Unützer et al., 2001; Von Korff & Goldberg, 2001). One of the challenges is in understanding which components are critical determinants of effectiveness in reducing depressive symptoms.
A systematic review of 21 studies on educational and organizational interventions to improve depression management in primary care settings found positive results (Gilbody et al., 2003). Intervention components that were found effective included enhanced nurse depression care manager role, clinician education, and improvement in communication between primary care and psychiatry liaison. However, simple documentation alone of practice guidelines and educational strategies were generally ineffective.
A recent systematic review of 22 studies on PST was undertaken to determine the effectiveness of PST on reducing depressive symptoms in noninstitutionalized adults aged 18 years and older (Gellis & Kenaley, 2007). Four studies (Ciechanowski et al., 2004; Doorenbos et al., 2005; Katon et al., 2004; Unützer et al., 2003) employed a multi-faceted intervention (Level A). The IMPACT intervention included access for up to 12 months to a depression care manager, education, care management, and a choice of either medication support or PST (Unützer et al., 2002). The Pathways case management intervention (Katon et al., 2004) included enhanced education and support combined with antidepressant medication treatment by the primary care physician, or a PST intervention delivered in primary care. The PEARLS (Program to Encourage Active, Rewarding Lives for Seniors) intervention included PST, social and physical activation, and recommendations to patients’ physicians regarding antidepressant medications (Ciechanowski et al., 2004). Doorenbos and colleagues (2005) administered a multi-modal intervention that included problem-solving strategies, self-care management, information and decision-making, counseling and support, and communication with primary care providers. The studies found that combined use of PST and antidepressant treatment had favorable depression outcomes compared with PST alone.
Another systematic review found 34 studies of multifaceted collaborative care interventions with outcome data on depressive symptoms and 28 studies on antidepressant medication use (Bower, Gilbody, Richards, Fletcher, & Sutton, 2006). Positive effects were found on both antidepressant use and depressive symptom reduction. The studies found no variables that predicted variation in antidepressant medication use. Nonetheless, several key predictors of positive depressive symptom outcomes were found, including mental health training background of staff, systematic identification of patients, and continuous depression specialist supervision. This suggests that depression care managers have valuable expertise and experience in working with depressed patients. Additionally, these positive outcomes are associated with the managers’ technical expertise such as knowledge of evidence-based psychosocial treatments and psychotropic medications, and their ability to work effectively in collaboration with other health care providers.
Blanchard and colleagues (1994) randomly allocated 96 older primary care patients with depression to either the community nurse depression care management or usual primary care practitioner. Assessments 3 months later found that the depression care management group showed improved depression scores compared with the control group of patients treated by their primary care physician.
Callahan and his group (1994) conducted a clinical trial to study physician-targeted interventions to facilitate compliance with recommended standards of care for late-life depression. Significant improvement in depression or disability severity among intervention patients was not demonstrated despite the informational support provided to their physicians. Flaherty and colleagues (1998) found that a collaborative management home care intervention for depression resulted in lower hospitalization rates (23.5%) compared to a historical control group (40.6%). A randomized controlled trial with blind follow-up evaluation 6 months after recruitment found that psychogeriatric team home care versus usual primary care improved depressive outcomes for 58% versus 25% of people 65 and over (Banerjee, Shamash, Macdonald, & Mann, 1996).
Another randomized controlled trial examined whether a decision support system in comparison to usual primary care improves outcomes for patients with depression (Dobscha et al., 2006). The depression decision support team, which consisted of a psychiatrist and nurse, provided individual patient educational contact and depression monitoring with feedback to clinicians over the course of 12 months. Findings demonstrated improved depression scores in both groups, but the decision support intervention did not generate sustained improvements in depression severity or health-related quality of life compared with usual primary care (Dobscha et al., 2006).
In a multi-site randomized controlled trial, researchers investigated if “Quality Improvement (QI)” programs in managed care practices for depressed primary care patients could improve patient care and health outcomes (Bower et al., 2006). They found that patients in QI (n = 913) and usual care (n = 443) clinics did not differ significantly at baseline in service use or quality of life. At 6 months, 50.9% of QI patients and 39.7% of controls were in counseling or were using antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs. 50.1%; P = .006). When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care and mental health outcomes of depressed patients improved over a year, while medical visits did not increase overall (Bower et al., 2006).
Home care services are essential to maintaining elders with disability in the community and reducing their hospitalization and nursing home use. Yet, knowledge on specific treatments for depressive disorders is limited (Brown, Kaiser, & Gellis, in press; Bruce et al., 2002; Gellis, McGinty, Horowitz, et al., 2007; Gellis, McGinty, Tierney, et al., 2007). Compared with the general elderly population, home care recipients are older, more socially isolated, more likely to be women, and more likely to have high rates of physical illness, disability, and depression (Banerjee, 1993).
The Weill Cornell Institute of Geriatric Psychiatry estimated the prevalence of current DSM-IV major depression at 13.5% in a probability sample (N=539) of older (age > 65) new patients from a home care agency (Bruce et al., 2002). These researchers found that depression was highly prevalent, and characterized by symptoms and various conditions (functional disability, cognitive impairment, and comorbid vascular disease) associated with poor outcomes (Alexopoulos et al., 1996). New York researchers at the SUNY Center for Mental Health and Aging have estimated a prevalence of clinically significant depressive symptoms at 27.5% in a probability sample (N=618) of older (age > 65) community-dwelling elderly (Gellis, 2006). However, few elderly receive appropriate treatment of depression. For instance, in two studies only 21% (Brown, McAvay, Raue, & Moses, 2003) and 16% (Banerjee et al., 1996) received treatment.
The older client, treating physician, and health care organizational factors interact to impede the detection and treatment of depression, particularly among older adults (Klinkman, 1997; Meyers, 1996; Schulberg et al., 1996). From a biopsychosocial framework, the complexity of depression is reflected by variability in onset, presentation, and course, as well as functional disability, negative life events, and medical comorbidity. The heterogeneity of depression coupled with physical and cognitive impairment, social vulnerabilities, and various medical conditions prevalent in health care makes it more difficult for accurate assessment, diagnosis, and treatment in the elderly population. Older primary care patients are less likely than younger patients to voluntarily report affective symptoms of depression (Lyness et al., 1995). They are more likely to ascribe symptoms of depression to a physical illness (Knauper & Wittchen, 1994). Depressed older adults of various ethnic backgrounds are less likely to use specialty care and more likely to use the general health care system (Brown et al., 1995; Unützer et al., 1997).
To date, only two intervention studies have examined geriatric depression in home health care. A recent randomized controlled trial in home care tested the effectiveness of home-delivered PST (PST-HC) for depression in medically ill elderly over a 6-month period (Gellis, McGinty, Horowitz, et al., 2007) (Level A). Data suggested significant reductions in depression scores at post-baseline, 3 months, and 6 months, relative to the usual care condition. This suggests that the effects of treatment were maintained over a 6-month period post-baseline. Older patients also reported higher quality of life and problem-solving ability, compared to usual care patients (Gellis, McGinty, Horowitz, et al., 2007). Few studies have investigated the use of PST for minor depression (two to four depressive symptoms with one symptom being depressed mood or anhedonia) in older adults and none in home health care. Recently, one randomized trial of brief PST was found to decrease symptoms of minor depression in older home care patients post-treatment, and the decrease was maintained over a 6-month period (Gellis, McGinty, Tierney, et al., 2007) (Level A). Homebound elderly participants in the PST group were also more satisfied with treatment than those in the control group were.
Leading researchers have pointed out the need for future studies to address critical questions about the feasibility, generalizability, and cost of treatment for depressive disorders in home health care (Bruce et al., 2002; Gellis, McGinty, Horowitz, et al., 2007; Gellis, McGinty, Tierney, et al., 2007; Katon et al., 1997; Schulberg et al., 1996); the use of brief intervention models by non-physicians (Brown & Schulberg, 1998); the management of detected patients (Coyne, Schwenk, & Fechner-Bates, 1995), and the ways to improve access to care among ethnically diverse and low-income populations (Miranda et al., 2003).
Few studies have examined depressive disorders among older adults in assisted living facilities (ALF). A recent study attempted to obtain estimates of depression and related factors, and of treatment rates for 196 ALF residents recruited from 22 facilities in Maryland (Watson et al., 2006). Most residents were widows. Results found that the majority met criteria for dementia (68%), and that 24% of the participants met the cutoff score for depression on the Cornell Scale for Depression in Dementia. Almost half (43%) of those depressed were receiving some type of antidepressant medication, while 57% of those depressed had not been referred to nor were they receiving psychiatric services. Based on the data from this study, the rate of depression among ALF residents are apparently high, and depression is often undetected or inadequately treated.
Researchers examined a large data set of assisted living residents (N=2,078 residents aged 65 and older) in 193 assisted living facilities (Watson, Garrett, Sloane, Gruber-Baldini, & Zimmerman, 2003). The purpose of the study was to determine the prevalence of depression, to examine resident characteristics associated with depressive symptoms, and finally, to investigate the relationship between depressive symptoms and nursing home placement and mortality. They found relationships between depression and cognitive impairment, agitation, recent hospitalization, dependence on others for more than three activities of daily living, psychosis, and social withdrawal. At the 1-year follow-up investigation, 370 depressed residents had been transferred to a nursing home, and 250 residents with severe depressive symptoms had died. Assisted-living residents appear to have significant rates of depression and depressive symptoms; yet, their conditions are undetected or undertreated. This setting is suitable for introducing new models of geriatric mental health service delivery to reduce the psychological burden on older residents.
A randomized trial in Australia examined the effectiveness of a population-based, multifaceted shared-care intervention for late life depression in 220 depressed residential care residents in one large residential facility (Llwellyn-Jones et al., 2001). All participants were cognitively intact and met the criteria for depressive symptoms on the geriatric depression scale The shared-care intervention included 1) multidisciplinary consultation and collaboration, 2) training general practitioners and care staff to detect depression, and 3) management of depression. More specifically, the intervention sought to provide depression-related health education and activity programs for residents, to increase the detection rate of depression by care staff, to get elderly people to accept that depression is treatable, and to provide accessible treatment programs in residential care. Results found that the experimental condition had reduced depressive scores as compared to a usual care control condition at the 9.5 month follow-up point. However, generalizability to other residential facilities is difficult, and the intervention needs further descriptive detail and refinement (Level B).
One small study examined factors that contributed to depressive symptomology in 57 ALF residents (Cummings, 2002). The study reported that almost 20% of residents reported dissatisfaction in their lives and exhibited depression symptoms. A critical variable in mediating depressive symptoms was perceived social support.
In the U.S. approximately 5% of older adults reside in long-term care facilities at any given time. Prevalence rates of depression in long-term care vary depending on study definitions and measures used. For elderly patients with major depression, rates range from 6% to 24% in nursing homes (Blazer, 2002). Prevalence estimates for minor depression and dysthymia are even higher and range from 30% to 50% in the majority of studies; and for subthreshold clinically significant depressive symptoms, the range is 35% to 45% (Hyer et al., 2005).
Researchers estimated the incidence, prevalence, and outcomes of depression in 201 long-term care residents with dementia (Payne et al., 2002). Participants who were mostly white women were given a neuropsychiatric interview and were observed for 1 year. At 6 months post-admission, 15% of the original women were still depressed, and at 12 months only 7.5% were depressed. The annual cumulative likelihood of depression over 1 year for the total group was 26.4%. The authors concluded that a significant proportion of long-term care elderly with dementia had depression. With rapid screening, accurate diagnosis, and appropriate treatment, reduction in depression symptoms is a likely outcome.
Research has demonstrated high rates of depressive symptoms among older people, particularly those with cognitive impairment and those in residential care. One study examined the prevalence of depression among older people with cognitive impairment and the extent to which depression among these individuals had previously been detected (McCabe et al., 2006). Findings regarding the prevalence of depression among older people with cognitive impairment indicated that 17.7% met criteria for a diagnosis of MDD, based on a structured clinical interview (SCID), whereas another 38.9% had clinically significant depressive symptoms. Individuals with moderate cognitive impairment were more likely to present with MDD than were those with mild cognitive impairment. Furthermore, there was an increased prevalence of depression among dementia suffers. There was a larger proportion of major depression among residents with moderate to severe cognitive impairment than among those with mild cognitive impairment or normal cognitive function.
Depression is a frequently comorbid condition with dementia with estimates at 30% (Evers et al., 2002; Teri & Wagner, 1992). This makes the detection and assessment of depression challenging for the clinician. A recent study focused on specific factors that might contribute to nursing home placement by examining the detection and course of coexisting dementia and depression (CDD) in elderly patients as compared with patients with either disorder alone (Kales et al., 2005). This was a 1-year prospective study comparing outcomes among 82 elderly male veterans receiving inpatient and outpatient treatment. Subjects were recruited and reassessed at 3, 6, and 12 months after baseline. This study found lower rates of depression detection by treating (i.e., non-study) physicians in CDD patients. Only 35% of the CDD group had been correctly diagnosed and had received adequate treatment. The CDD group had significantly higher levels of functional impairment when compared to the dementia-only group. The CDD subjects used nursing home care at significantly higher rates. The investigators concluded that undetected, untreated, or inadequately treated depression may result in higher rates of nursing home placement in patients with dementia due to an increase in functional disability.
Many long-term care residents present with signs and symptoms that overlap with depression (for example, anhedonia, irritability, flat affect) (Gauthier, 2003). Studies also indicate that depression is a risk factor for dementia (Alexopoulos, Meyers, Young, Mattis, & Kakuma, 1993; Lichtenberg & Mast, 2003). Therefore, consensus practice guidelines recommend that caregivers and other reliable informants be interviewed on behalf of an individual with moderate to severe dementia (American Geriatrics Society & American Association of Geriatric Psychiatry, 2003). Attention also needs to be paid to the biopsychosocial factors during assessment to obtain a clear picture of the patient. Assertive outpatient and community-based treatment of depression may also improve the course of coexisting dementia and depression and lengthen the time the patient can remain at home before nursing home placement.
Smalbrugge and colleagues (2005) examined the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among 333 nursing home patients in the Netherlands. Using a diagnostic research interview, they estimated the prevalence of major depression at 17.1%, anxiety at 4.8%, and comorbid anxiety and depression at 5.1%. The prevalence of depressive disorders (both major and minor) was 22.2%, and of anxiety was 9.9%. The researchers concluded that the comorbidity of anxiety and depression is most prevalent in more severely depressed and anxious nursing home patients.
The research literature on interventions for depression in older adults residing in long-term care is sparse and deficient. Several reviews offer insights into specific psychosocial interventions for depression in long-term care (Hartz & Splain, 1997; Molinari, 2000; Norris, Molinari, & Ogland-Hand, 2003). Yet, there are limitations to the literature. First, most research studies have focused on depressive symptoms and not on specific disorders. Second, the diverse study samples of elderly makes it difficult to compare across studies. Third, the majority of studies lack a description of intervention protocols or manuals, making it difficult to understand, analyze, or replicate their treatment components. Finally, the inconsistency of follow-up evaluations across studies provides further barriers to determining long-term effects.
One randomized trial examined a control-relevant intervention versus a waitlist control for major and minor depression among 31 cognitively intact nursing home residents (Rosen et al., 1997) (Level B). The treatment group participants took part in planned activities that were held for 1- to 2-hour periods, twice a day, 5 days a week over the course of 8 weeks. The emphasis of the program varied over the 8 weeks of the intervention (socialization, weekly activity schedule, assertiveness, trips). Of the 31 participants, 14 (45%) were deemed Responders, and 17 (55%) were non-responders. None of the 11 patients on the waitlist were judged to be responders. Non-responders were depressed nursing home residents who perceived their environment as lacking in cohesiveness and support. Limitations of the study included the failure to establish the validity of the categorical assessments made by the clinical staff of the nursing home, and the study did not control for the concurrent use of psychotropic medications.
Another randomized trial compared an individual 8-week life review treatment with friendly visiting as the control on depressive symptoms in 201 nursing home residents (Haight, Michel, & Hendrix, 1998) (Level B). Results demonstrated that BDI scores were lower in the treatment group than in the control group at the 1-year follow-up examination. In a small pilot study, Hyer and colleagues (1990) compared the effectiveness of a 12-week group psychotherapy, in a cognitive behavioral format, to usual care in a small sample of 22 residents. At post-treatment, depression scores had decreased in the treatment group but not in the control group.
Researchers have recommended a combined approach to depression treatment including behavioral interventions and antidepressants (Lyketsos & Olin, 2002) (Level B). They have suggested psychosocial intervention as an initial treatment step and the introduction of medication in more severe forms of depression. For example, a randomized controlled trial by Teri and colleagues (1997) investigated two psychosocial interventions for depression in Alzheimer’s patients living with their caregivers in the community. All participants met diagnostic criteria for major (n=54) or minor (n=18) depression. Seventy-two patient-caregiver dyads were randomly assigned to one of four groups and assessed at pre-, post-, and 6-months follow-up intervals by interviewer’s blinded to treatment assignment. The group conditions included (1) behavior therapy-pleasant events (BT-PE), (2) behavior therapy-problem solving (BT-PS), (3) typical care control (TCC), and (4) wait-list control (WLC). They found that patients in both behavioral treatments showed significant improvement. Caregivers in each behavioral group showed significant improvement. In contrast, caregivers in the other two conditions did not.
A few psychosocial interventions such as group and individual behavioral therapies show some potential but require further investigation, improved study design, and clear intervention protocols for duplication and treatment component analysis.
Administration on Aging. (2001). Profile of Older Americans. Washington, DC: U.S. Department of Health and Human Services.
Alexopoulos, G., Abrams, R., Young, R., & Shamoian, C. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23(3), 271-284.
Alexopoulos, G., Katz, I., Bruce, M., Heo, T, Ten Have, T., Raue, P., et al. (2005). Remission in depressed geriatric primary care patients: a report from the PROSPECT study. American Journal of Psychiatry, 162(4), 718-724.
Alexopoulos, G., Meyers, B., Young, R., Mattis, S., & Kakuma, T. (1993). The course of geriatric depression with “reversible dementia”: a controlled study. American Journal of Psychiatry, 150, 1693-1699.
Alexopoulos, G., Vrontou, C., Kakuma, T., Meyers, B. S., Young, R. C., Klausner, E., et al. (1996). Disability in geriatric depression. American Journal of Psychiatry, 153, 877-885.
American Geriatrics Society & The American Association for Geriatric Psychiatry. (2003). Consensus statement on improving the quality of mental health in U. S. nursing homes: Management of depression and behavioral symptoms associated with dementia. Journal of the American Geriatric Society, 51, 1287-1298.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders DSM-IV (4th ed.). Arlington, VA: American Psychiatric Press.
Areán, A., & Alvidrez, J. (2001). Prevalence of mental disorder, subsyndromal disorder and service use in older disadvantaged medical patients. Interpersonal Journal of Psychiatry in Medicine, 31(1), 9-24.
Areán, P., Ayalon, L., Hunkeler, E., Lin, E., Tang, L., Harpole, L., et al. (2005). Improving depression care for older minority patients in primary care. Medical Care, 43(4), 381-390.
Areán, P., & Cook, B. (2002). Psychotherapy and combined psychotherapy pharmacotherapy for late life depression. Society of Biological Psychiatry, 52, 293-303.
Areán, P., Gum A., & McCulloch C. (2003). Treatment of depression in low-income older adults. Psychology and Aging, 20, 601-609.
Areán, P., Perri, M., Nezu, A., Schein, R., Christopher, F., & Joseph, T. (1993). Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. Journal of Consulting and Clinical Psychology, 61, 1003-1010.
Baldwin, R. C. (2002). Research into depressive disorder in later life: Who is doing what? A literature search from 1998-2001. International Psychogeriatrics, 14, 335-346.
Banerjee, S. (1993). Prevalence and recognition of psychiatric disorder in the elderly clients of a community care service. International Journal of Geriatric Psychiatry, 8, 125-131.
Banerjee, S., Shamash, K., Macdonald, A. J. D., & Mann, A. H. (1996). Randomised controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home. British Medical Journal, 313, 1058-1061.
Barkin, R., Schwer, W., & Barkin, S. (2000). Recognition and management of depression in primary care: A focus on the elderly. A pharmacotherapeutic overview of selection process among the traditional and new antidepressants. American Journal of Therapeutics, 7, 205-226.
Barnow, S., & Linden, M. (2000). Epidemiology and psychiatric morbidity of suicidal ideation among the elderly. Crisis, 21, 171-180.
Beck, A. T. & Beck, R. W. (1972). Screening depressed patients in family practice. A rapid technic. Postgraduate Medicine, 52(6), 81-85.
Beekman, A., Copeland, J., & Prince, M. (1999). Review of community prevalence of depression in later life. British Journal of Psychiatry, 174, 307-311.
Beekman, A. T., Deeg, D. J., Braam, A. W., Smit, J. H., & VanTilburg, W. (1997). Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychological Medicine, 27, 1397-1409.
Beekman, A., Deeg, D., van Tilburg, T., Smit, J., Hooijer, C., & van Tilburg, W. (1995). Major and minor depression in later life: a study of prevalence and risk factors. Journal of Affective Disorders, 36(1-2), 65-75.
Birrer, R. B., & Vemuri, S. P. (2004). Depression in later life: A diagnostic and therapeutic challenge. American Family Physician, 69(10), 2375-2382.
Blazer, D. (2002). Depression in late life (3rd ed.). New York: Springer Publishing.
Blazer, D., Hybel, C., Simensick, E., & Harbin, J. (2000). Marked difference in antidepressant use by race in an elderly community sample: 1986-1996. American Journal of Psychiatry, 157, 1085-1094.
Bower, P., Gilbody, S., Richards, D., Fletcher, J., & Sutton, A. (2006). Collaborative care for depression in primary care. British Journal of Psychiatry, 189, 484-493.
Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P., Adey, M. B., Rose, T. L. (1982). Screening tests for geriatric depression. Clinical Gerontologist 1: 37-44.
Broadhead, W. E., Blazer, D. G., George, L. K., & Tse, C. K. (1990). Depression, disability days, and days lost from work in a prospective epidemiologic survey. Journal of the American Medical Association, 264(19), 2524–2528.
Brody, D. S., Khaliq, A., & Thompson, T. (1997). Patient’s perspectives on the management of emotional distress in primary care settings. Journal of General and Internal Medicine, 12, 403-406.
Brown, C., & Schulberg, H. C. (1998). Diagnosis and treatment of depression in primary medical care practice. Journal of Clinical Psychology, 54(3), 303-314.
Brown, E. L., Kaiser, R. M., & Gellis, Z. D. (in press). Screening and assessment of late life depression in home health care: Issues and challenges. Annals of Long-Term Care: Clinical Care and Aging.
Brown E. L., McAvay, G., Raue, P., Moses, S., & Bruce M. L. (2003). Recognition of depression in the elderly receiving homecare services. Psychiatric Services, 54(2), 208-213.
Brown, G., Bruce, M., & Pearson, J. (2001). High-risk management guidelines for elderly suicidal patients in primary care settings. International Journal of Geriatric Psychiatry, 16(6), 593-601.
Brown, M., Lapane, K., & Luisi, A. (2002). The management of depression in older nursing home residents. Journal of the American Geriatrics Society, 50, 69-76.
Brown, S., Salive, M., Guralnik, J., Pahor, M., Chapman, D., & Blazer, D. (1995). Antidepressant use in the elderly: Association with demographic characteristics, health-related factors, and health care utilization. Journal of Clinical Epidemiology, 48, 445-453.
Bruce, M., McAvay, G., Raue, P., Brown, E., Meyers, B., Keohane, D., et al. (2002). Major depression in elderly home health care patients. American Journal of Psychiatry, 159, 1367-1374.
Bruce, M., & Pearson, J. (1999). Designing an intervention to prevent suicide. Dialogues in Clinical Neuroscience, 1, 100-112.
Bruce, M., Ten Have, T., Reynolds, C., Katz, I., Schulberg, H., Mulsant, B., et al. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. Journal of the American Medical Association, 291(9), 1081-1091.
Callahan, C., Hendrie, H., Dittus, R., Brater, D., Hui, S., & Tierney, W. (1994). Improving treatment of late life depression in primary care: A randomized clinical trial. Journal of the American Geriatrics Society, 42, 839-846.
Callahan, C., Kesterson, J., & Tierney, W. (1997). Association of symptoms of depression with diagnostic test charges among older adults. Annals Internal Medicine, 126, 426-432.
Charney, D., Reynolds, C., Lewis, L., Lebowitz, B., Sunderland, T., Alexopoulos, G., et al. (2003). Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Archives of General Psychiatry, 60(7), 664-667.
Choi, N., & Morrow-Howell, N. (2007). Low-income older adult’s acceptance of depression treatments: Examination of within-group differences. Aging and Mental Health, 11(4), 423-433.
Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., et al. (2004). Community-integrated home-based depression treatment in older adults. Journal of the American Medical Association, 291, 1569-1577.
Cole, M., Bellavance, F., & Mansour, A. (1999). Prognosis of depression in elderly community and primary care populations: A systematic review and meta-analysis. American Journal of Psychiatry, 156, 1182-1189.
Cole, M., & Dendukuri, N. (2003). Risk factors for depression among elderly community subjects: A systematic review and meta-analysis. American Journal of Psychiatry, 160(6), 1147-1156.
Cole M., Elie, L., McCusker, J., Bellavance, F., & Mansour, A. (2001). Feasibility and effectiveness of treatments for post-stroke depression elderly inpatients: a systematic review. Journal of Geriatric Psychiatry and Neurology, 14, 37-41.
Conwell, Y. (1992). Suicide in the elderly. In L. Scneider, C. Reynolds, B. Lebowitz, & A. Friedhoff (Eds.), Diagnosis and treatment of depression in late life: Results of the NIH Consensus Development Conference (pp. 397-418). Washington, DC: American Psychiatric Press.
Conwell, Y. (1994). Suicide and aging: lessons from the nursing home. Crisis, 15(4), 153-158.
Conwell, Y., Duberstein, P., & Caine, E. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193-204.
Conwell, Y., Duberstein, P., Cox, C., Herrmann, J., Forbes, N., & Caine, E. (1996). Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. American Journal of Psychiatry, 153(8), 1001-1008.
Conwell, Y., Olsen, K., Caine, E., & Flannery, C. (1991). Suicide in later life: psychological autopsy findings. International Psychogeriatrics, 3(1), 59-66.
Coulehan, J., Schulberg, H., Block, M., Madonia, M., & Rodriguez, E. (1997). Treating depressed primary care patients improves their physical, mental, and social functioning. Archives of Internal Medicine, 157, 1113-1120.
Covinsky, K., Fortinsky, R., Palmer, R., Kresevic, D., & Landefeld, C. (1997). Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Annals of Internal Medicine, 126, 417-425.
Coyne, J., Fechner-Bates S., & Schwenk, T. (1994). Prevalence, nature, and comorbidity of depressive disorders in primary care. General Hospital Psychiatry, 16, 267-276.
Coyne, J., Schwenk, T., & Fechner-Bates, S. (1995). Nondetection of depression by primary care physicians reconsidered. General Hospital Psychiatry, 17, 3-12.
Crystal, S., Sambamoorthi, U., Walkup, J., & Akincigil, A. (2003). Diagnosis and treatment of depression in the elderly Medicare population: Predictors, disparities, and trends. Journal of the American Geriatrics Society, 51, 1718-1728.
Cuijpers P., van Straten A., & Smit F. (2006). Psychological treatment of late-life depression: A meta-analysis of randomized controlled trials. International Journal of Geriatric Psychiatry, 21, 1139-1149.
Cummings, S. (2002). Predictors of psychological well-being among assisted-living residents. Health & Social Work, 27(4), 293-302.
Das Gupta, K. (1998). Treatment of depression in elderly patients: Recent advances. Archives of Family Medicine, 7, 274-280.
de Melo, M., de Jesus, M., Bacaltchuk, J., Verdeli, H., & Neugebauer, R. (2005). A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. European Archives of Psychiatry and Clinical Neurosciences, 255, 75-82.
DeRubeis, R., Gelfand, L., Tang, T., & Simons, A. (1999). Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. American Journal of Psychiatry, 156, 1007-1013.
Diekstra, R., & van Egmond, M. (1989). Suicide and attempted suicide in general practice. Acta Psychiatrica Scandinavica, 79(3), 268-275.
DiMatteo, M., Lepper, H., & Croghan, T. (2000). Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160(14), 2101-2107.
Dobscha, S., Corson, K., Hickam, D. Perrin, N., Kraemer, D., & Gerrity, M. (2006). Depression decision support in primary care: a cluster randomized trial. Annals of Internal Medicine, 145(7), 477-487.
Doorenbos, A., Given, B., Given, C., Verbitsky, N., Cimprich, B., & McCorkle, R. (2005). Reducing symptom limitations: a cognitive behavioral intervention randomized trial. Psycho-Oncology, 14, 574-584.
Doraiswamya, P., Khanb, Z., Donahuec, R., & Richard, N. (2002). The spectrum of quality-of-life impairments in recurrent geriatric depression. The Journals of Gerontology Series: Biological Sciences and Medical Sciences, 57, 134-137.
Duberstein, P. R. (1995). Openness to experience and completed suicide across the second half of life. International Psychogeriatrics, 7, 183-198.
Elkin, L., Shea, T., Watkins, J., Imber, S., Sotsky, S., Collins, J., et al. (1989). National Institute of Mental Health treatment of depression collaborative research program. Archives of General Psychiatry, 46, 971-982.
Evers, M., Samuels, S., Lantz, M., Khan, K., Brickman, A., & Marin, D. (2002). The prevalence, diagnosis and treatment of depression in dementia patients in chronic care facilities in the last six months of life. International Journal of Geriatric Psychiatry, 17(5), 464-472.
Flaherty, J., McBride, M., Marzouk, S., Miller, D., Chien, N., Hanchett, M., et al. (1998). Decreasing hospitalization rates for older home care patients with symptoms of depression. Journal of the American Geriatrics Society, 46, 31-38.
Frank, E., Kupfer, D., Perel, J., Cornes, C., Jarrett, D., Mallinger, A., et al. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093-1099.
Freudenstein, U., Jagger, C., Arthur, A., & Donner-Banzhoff, N. (2001). Treatments for late life depression in primary care: A systematic review. Family Practice, 18(3), 321-327.
Frierson, R. (1991). Suicide attempts by the old and the very old. Archives of Internal Medicine, 151(1), 141-144.
Gath, D., & Mynors-Wallis, L. (1997). Problem-solving treatment in primary care. In D. Clark & C. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 415-431). New York: Oxford University Press.
Gauthier, S. (2003). Clinical aspects. In A. C. Juillerat, M. Van Der Linden, & R. Mulligan (Eds.), The clinical management of early Alzheimer's disease: A handbook (pp. 21-34). Mahwah, NJ: Lawrence Erlbaum.
Gellis, Z. D. (2006). Mental health and emotional disorders among older adults. In B. Berkman (Ed.), Oxford handbook of social work in health and aging (pp. 129-139). New York: Oxford University Press.
Gellis, Z. D., & Kenaley, B. (2008). Problem solving therapy for depression in adults: A systematic review. Research on Social Work Practice, 18, 117-131.
Gellis, Z. D., McGinty, J., Horowitz, A., Bruce, M., & Misener, E. (2007). Problem solving therapy for late life depression in home care elderly: A randomized controlled trial. American Journal of Geriatric Psychiatry, 15(11), 968-978.
Gellis, Z. D., McGinty, J. Tierney, L., Burton, J., Jordan, C., Misener, E., et al., (2007). Randomized controlled trial of problem-solving therapy for minor depression in home care. Research on Social Work Practice. Advance online publication. Retrieved November 27, 2007. doi 10.1177/1049731507309821.
Gellis, Z. D., & Reid, W. J. (2004). Strengthening evidence-based practice. Brief Treatment and Crisis Intervention Journal, 4, 155-165.
Gellis, Z. D., & Taguchi, A. (2003). Depression and health status among community-dwelling Japanese American elderly. Clinical Gerontologist, 27, 23-38.
Gerson, S., Belin, T. R., Kaufman, A., Mintz, J., & Jarvik, L. (1999). Pharmacological and psychological treatments for depressed older patients: A meta-analysis and overview of recent findings. Harvard Review of Psychiatry, 7(1), 1-28.
Gil, K., Wilson, J., Edens, J., Webster, D., Abrams, M., Orringer, E., et al. (1996). Effects of cognitive coping skills training on coping strategies and experimental pain sensitivity in African American adults with sickle cell disease. Health Psychology, 15(1), 3-10.
Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care. Journal of the American Medical Association, 289(23), 3145-3151.
Glasser, M., & Gravdal, J. A. (1997). Assessment and treatment of geriatric depression in primary care settings. Archives of Family Medicine, 6, 433-438.
González, H., Haan, M., & Hinton, L. (2001). Acculturation and the prevalence of depression in older Mexican Americans: Baseline results of the Sacramento area Latino study on aging. Journal of the American Geriatrics Society, 49, 948-953.
Gotlib, I., & Hammen, C. (Eds.). (2002). Handbook of depression. New York: Guilford.
Govoni, S., Racchi, M., Mascero, E., Zamboin, M., & Ferri-Strambi, L. (2001). Extrapyramidal symptoms and antidepressant drugs neuropharmacological aspects of frequent interaction in the elderly. Molecular Psychiatry, 6, 134-142.
Haight, B., Michel, Y., & Hendrix, S. (1998). Life review: Preventing despair in newly relocated nursing home residents, short- and long-term effects. International Journal of Aging & Human Development, 47(2), 119-142.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-61.
Harada, N., & Kim, L. (1995). Use of mental health services by older Asian and Pacific Islander Americans. In D. Padgett (Ed.), Handbook on ethnicity, aging and mental health (pp. 185-202). Westport, CT: Greenwood Press.
Hartz, G., & Splain, D. (1997). Psychosocial intervention in long-term care: An advanced guide. New York: Haworth Press.
Hegel, M., Barrett, J., Cornell, J., & Oxman, T. (2002). Predictors of response to problem-solving treatment of depression in primary care. Behavior Therapy, 33(4), 511-527.
Hendrie, H., Callahan, C., Levitt, E., Hui, S., Musick, B., Austrom, M., et al. (1995). Prevalence rates of major depressive disorders: The effects of varying the diagnostic criteria in an older primary care population. American Journal of Geriatric Psychiatry, 5, 119-131.
Henriksson, M., Marttunen, M., Isometsä, E., Heikkinen, M., Aro, H., Kuoppasalmi, K., et al. (1995). Mental disorders in elderly suicide. International Psychogeriatrics, 7, 275-286.
Hermens, M., van Hout, H., Terluin, B., van der Windt, D., Beekman, A., van Dyck, R., et al. (2004). The prognosis of minor depression in the general population: a systematic review. General Hospital Psychiatry, 26(6), 453-462.
Hinrichsen, G. (1999). Treating older adults with interpersonal psychotherapy for depression. Journal of Clinical Psychology, 55(8), 949-960.
Hoyert, D., Kung, H., & Smith, B. (2005). Deaths: preliminary data for 2003. National Vital Statistics Reports, 53(15), 1-48.
Hybels, C., & Blazer, D. (2003). Epidemiology of late life mental disorders. Clinical Geriatric Medicine, 19, 663-696.
Hyer, L., Carpenter, B., Bishmann, D., & Wu, H. S. (2005). Depression in Long-Term Care. Clinical Psychology: Science and Practice, 12(3), 280-299.
Hyer, L., Swanson, G., Lefkowitz, R., Hillesland, D., Davis, H., & Woods, M. G. (1990). The application of the cognitive behavioral model to two older stressor groups. Clinical Gerontologist, 9(3/4), 145-190.
Jacobson, J., & Hollon, S. (1996). Cognitive-behavior therapy versus pharmacotherapy; now that the jury’s returned its verdict, it’s time to present the rest of the evidence. Journal of Consulting and Clinical Psychology, 64, 74-80.
Judd, L., Schettler, P., & Akiskal, H. (2002). The prevalence, clinical relevance, and public health significance of subthreshold depressions. Psychiatric Clinics of North America, 25(4), 685-698.
Kales, H., Chen, P., Blow, F., Welsh, D., & Mellow, A. (2005). Rates of clinical depression diagnosis, functional impairment, and nursing home placement in coexisting dementia and depression. American Journal of Geriatric Psychiatry, 13(6), 441-449.
Katon, W., Lin, E., von Korff, M., Bush, T., Walker, E., Simon G., et al. (1994). The predictors of persistence of depression in primary care. Journal of Affective Disorders, 31(20), 81-90.
Katon, W., Von Korff, M., Lin, E., Simon, G., Ludman, E., Russo, J., et al. (2004). A randomized trial of collaborative care in patients with diabetes and depression. Archives of General Psychiatry, 61, 1042-1049.
Katon, W., Von Korff, M., Lin, E., Simon, G., Walker, E., Bush, T., et al. (1997). Collaborative management to achieve depression treatment guidelines. Journal of Clinical Psychiatry, 58 (Suppl), 20-23.
Katon, W., Von Korff, M., Lin, E., Simon, G., Walker, E., Unützer, J., et al. (1999). Stepped collaborative care for primary care patients with persistent symptoms of depression: A randomized trial. Archives of General Psychiatry, 56(12), 1109-1115.
Katz, I. (1996). On the inseparability of mental and physical health in aged persons: Lessons from depression and medical comorbidity. American Journal of Geriatric Psychiatry, 4, 1-16.
Katz, I., Parmelee, P., Beaston-Wimmer, P., & Smith, B. (1994). Association of antidepressants and other medications with mortality in the residential-care elderly. Journal of Geriatric Psychiatry and Neurology, 7(4), 221-226.
Klausner, E., & Alexopoulos, G. (1999). The future of psychosocial treatments for elderly patients. Psychiatric Services, 50, 1198-1204.
Klinkman, M. (1997). Competing demands in psychosocial care; a model for the identification and treatment of depressive disorders in primary care. General Hospital Psychiatry, 19, 98-111.
Knauper, B., & Wittchen, H. (1994). Diagnosing major depression in the elderly: Evidence for response bias in standardized diagnostic interviews? Journal of Psychiatric Research, 28, 147-164.
Koenig, H., Meador, K., Cohen, H., & Blazer, D. (1988). Depression in elderly hospitalized patients with medical illness. Archives of Internal Medicine, 148(9), 1929-1936.
Koenig, H., Vandermeer, J., Chambers, A., Burr-Crutchfield, L., & Johnson, J. (2006). Minor depression and physical outcome trajectories in heart failure and pulmonary disease. Journal of Nervous and Mental Disease, 194(3), 209-217.
Kroenke, K., & Spitzer. R. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509-515.
Laidlaw K. (2001). Empirical review of cognitive therapy for late life depression: Does research evidence suggest adaptations are necessary for cognitive therapy with older adults? Clinical Psychology and Psychotherapy, 8, 1-14.
Landreville, P., Landry, J., Baillargeon, L., Guerette, A., & Matteau, E. (2001). Older adults' acceptance of psychological and pharmacological treatments for depression. Journals of Gerontology, 56B(5), 285-291.
Lavretsky, H., & Kumar, A. (2002). Clinically significant non-major depression: old concepts, new insights. American Journal of Geriatric Psychiatry, 10(3), 239-255.
Lebowitz, B., Pearson, J., Schneider, L., Reynolds III, C., Alexopoulos, G., Bruce, M., et al. (1997). Diagnosis and treatment of depression in late life: Consensus statement update. Journal of the American Medical Association, 278(14), 1186-1190.
Lichtenberg, P., & Mast, B. (2003). Psychological and nonpharmacological aspects of depression in dementia. In P. Lichtenberg, D. Murman, & A. Mellow (Eds.), Handbook of dementia: Psychological, neurological and psychiatric perspectives (pp. 309-334). Hoboken, NJ: Wiley.
Lin, E., Katon, W., Simon, G., VonKorff, M., Bush, T., Rutter, C., et al. (1997). Achieving guidelines for the treatment of depression in primary care: Is physician education enough? Medical Care, 35, 831-842.
Lish, J., Zimmerman, M., Farber, N., Lush, D., Kuzma, M., & Plescia, G. (1996). Suicide screening in a primary care setting in a Veterans' Affairs medical setting. Psychosomatics, 37, 413-424.
Little, J., Reynolds, C., Dew, M., Frank, E., Begley, A., Miller, M., et al. (1998). How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 155, 1035-1038.
Llwellyn-Jones, R., Baikie, K., Castell, S., Andrews, C., Baikie, A., Pond, C., et al. (2001). How to help depressed older people living in residential care: a multifaceted shared-care intervention for late-life depression. International Psychogeriatrics, 13(4), 477-492.
Lyketsos, C., & Olin, J. (2002). Depression in Alzheimer's disease: overview and treatment. Biological Psychiatry, 52(3), 243-252.
Lyness, J., Cox, C., Curry, J., Conwell, Y., King, D., & Caine, E. (1995). Older age and the underreporting of depressive symptoms. Journal of the American Geriatrics Society, 43, 216-221.
Lyness, J., King, D., Cox, C., Yoediono, Z., & Caine, E. (1999). The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. Journal of the American Geriatric Society, 47(6), 647-652.
Lyness, J. M., Niculescu, A., Tu, X., Reynolds, C., & Caine, E. (2006). The relationship of medical comorbidity and depression in older, primary care patients. Psychosomatics, 47, 435-439.
Mamdani, M., Parikh, S., Austin, P., & Upshur, R. (2000). Use of Antidepressants Among Elderly Subjects: Trends and Contributing Factors. American Journal of Psychiatry, 157, 360-367.
Manning, W., & Wells, K. (1992). The effects of psychological distress and psychological well-being on use of medical services. Medical Care, 30(6), 541-553.
McCabe, M., Davison, T., Mellor, D., George, K., Moore, K., & Ski, C. (2006). Depression among older people with cognitive impairment: prevalence and detection. International Journal of Geriatric Psychiatry, 21(7), 633-644.
McCusker, J., Cole, M., Keller, E., Bellavance, F., & Berard A. (1998). Effectiveness of treatments of depression in older ambulatory patients. Archives of Internal Medicine, 158, 705-712.
Meyers, B. (1996). Psychiatric interventions to improve primary care diagnosis and treatment of depression. American Journal of Geriatric Psychiatry, 4(suppl), S91-S95.
Miller, M., Cornes, C., Frank, E., Ehrenpreis, L., Silberman, R., Schlernitzauer, M., et al. (2001). Interpersonal psychotherapy for late-life depression: Past, present, and future. Journal of Psychotherapy Practice & Research 10, 231-238.
Miranda, J., Azocar, F., & Organista, K. (2003). Treatment of depression among impoverished primary care patients from ethnic minority groups. Psychiatric Services, 54, 219-225.
Mojtabai, R., & Olfson, M. (2004) Major depression in community-dwelling middle-aged and older adults: Prevalence and 2- and 4 year follow-up symptoms. Psychological Medicine, 34(4), 623-634.
Molinari, V. (Ed.). (2000). Professional psychology in long term care: A comprehensive guide. New York: Hatherleigh Press.
Mossey, J. (1997). Subdysthymic depression and the medically ill elderly. In R. Rubenstein & M. Powell (Eds.), Depression in long term and residential care: Advances in research and treatment (pp. 55-74). New York, NY: Sage.
Mossey, J., Knott, K., Higgins, M., & Talerico, K. (1996). Effectiveness of a psychosocial intervention, interpersonal counseling for subdysthymic depression in medically ill elderly. Journals of Gerontology, 51A(4), M172-M178.
Munoz, R., Ying, Y., Bernal, G., Perez-Stable, E., Sorensen, J. L., Hargreaves, W. A., et al. (1995). Prevention of depression in primary care patients: A randomized control trial. American Journal of Community Psychology, 23(2), 199-222.
Mynors-Wallis, L. M., Gath, D., Davies, I., Gray, A., & Barbour, F. (1997). Randomized controlled trial and cost analysis of problem-solving treatment given by community nurses for emotional disorders in primary care. British Journal of Psychiatry, 170, 113-119.
Mynors-Wallis, L., Gath, D., Lloyd-Thomas, A., & Tomlinson, D. (1995). Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. British Medical Journal, 310, 441-445.
Nezu, A. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35, 1-33.
Nezu, A., & Nezu, C. (2001). Problem solving therapy. Journal of Psychotherapy Integration, 11(2), 187-205.
Norris, M., Molinari, V., & Ogland-Hand, S. (Eds.). (2003). Emerging trends in psychological practice in long-term care. New York: Haworth Press.
Oxman, T., & Sengupta, A. (2002). Treatment of minor depression. American Journal of Geriatric Psychiatry, 10(3), 256-264.
Parmelee, P., Katz, I., & Lawton, M. (1989). Depression among institutionalized aged: Assessment and prevalence estimation. Journal of Gerontology, 44(1), 22-29.
Parker, G., Parker, I., Brotchie, H., & Stuart, S. (2006). Interpersonal psychotherapy for depression? The need to define its ecological niche. Journal of Affective Disorders, 95, 1-11.
Payne, J., Sheppard, J., Steinberg, M., Warren, A., Baker, A., Steele, C., et al. (2002). Incidence, prevalence, and outcomes of depression in residents of a long-term care facility with dementia. International Journal of Geriatric Psychiatry, 17(3), 247-253.
Pearson, J., & Brown, G. (2000). Suicide prevention in late life: directions for science and practice. Clinical Psychology Review, 20(6), 685-705.
Penninx, B., Geerlings, S., Deeg, D., van Eijk, J., van Tilburg, W., & Beekman, A. (1999). Minor and major depression and the risk of death in older persons. Archives of General Psychiatry, 56, 889-895.
Peters, K., Kochanek, K., & Murphy, S. (1998). Deaths: final data for 1996. National Vital Statistics Report, 47(9), 1-100.
Peterson, J. C., Williams-Russo, P., Charlson, M. E., & Myers, B. (1996). Longitudinal course of new-onset depression after cardiac bypass surgery. International Journal of Psychiatry in Medicine, 26, 37-41.
Pincus, H., Davis, W., & McQueen, L. (1999). Subthreshold mental disorders: A review and synthesis of studies on minor depression and other brand names. British Journal of Psychiatry, 174, 288-296.
Pinquart, M., & Soerensen, S. (2001). How effective are psychotherapeutic and other psychosocial interventions with older adults? A meta-analysis. Journal of Mental Health and Aging, 7(2), 207-243.
Plutchik, R., Botsis, A., Weiner, M., & Kennedy, G. (1996). Clinical measurement of suicidality and coping in late life: A theory of countervailing forces. In G. Kennedy (Ed.). Suicide and depression in late life: Critical issues in treatment, research, and public policy. (pp. 83-102). Oxford, England: John Wiley & Sons.
Powers, D., Thompson, L., Futterman, A., & Gallagher-Thompson, D. (2002). Depression in later life: Epidemiology, assessment, impact, and treatment. In I. Gotlib & C. Hammen (Eds.), Handbook of depression (3rd ed., pp. 560-580). New York: Guilford Press.
Proctor, E., Morrow-Howell, N., Dore, P., Wentz, J., Rubin, E., Thompson, S., et al. (2003). Comorbid medical conditions among depressed elderly patients discharged home after acute psychiatric care. American Journal of Geriatric Psychiatry, 11(3), 329-338.
Radloff, L. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385-401.
Raue, P., Meyers, B., Rowe, J., Hao, M., & Bruce, M. (2007). Suicidal ideation among elderly homecare patients. International Journal of Geriatric Psychiatry, 22(1), 32-37.
Reynolds, C., Frank, E., Perel, J. Mazumdar, S., & Kupfer, D. (1995). Maintenance therapies for late life recurrent major depression: Research and review circa 1995. International Psychogeriatrics, 7(suppl), 27-40.
Reynolds, C., Frank, E., Perel, J., Imber, S., Cornes, C., Miller, M., et al. (1999). Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 281(1), 39-45.
Reynolds, C., & Kupfer, D. (1999). Depression and aging: A look to the future. Psychiatric Services, 50(9), 1167-1172.
Rihmer, Z., Rutz, W., & Pihlgren, H. (1995). Depression and suicide on Gotland: An intensive study of all suicides before and after a depression-training programme for general practitioners. Journal of Affective Disorders, 35, 147-152.
Robinson, P., Bush, T., VonKorff, M., Katon, W., Lin, W., Simon, G., et al. (1995). Primary care physician use of cognitive behavioral techniques with depressed patients. Journal of Family Practice, 40, 352-357.
Robinson, P., Katon, W., vonKorff, M., Bush, T., Simon, G., Lin, E. et al. (1997). The education of depressed primary care patients: What do patients think of interactive booklets and a video? Journal of Family Practice, 44, 562-571.
Roose, S., Glassman, A., Attia, E., Woodring, S., Giardina, E., & Bigger, T. (1997). Cardiovascular effects of fluoxetine, in depressed patients with heart disease. American Journal of Psychiatry, 155(5), 660-665.
Rosen, J., Rogers, J., Marin, R., Mulsant, B., Shahar, A., & Reynolds, C. (1997). Control-relevant intervention in the treatment of minor and major depression in a long-term care facility. American Journal of Geriatric Psychiatry, 5, 247-257.
Rowe, S. K., & Rapaport, M. H. (2006). Classification and treatment of subthreshold depression. Current Opinion in Psychiatry, 19(1), 9-13.
Salzman, C., Wong, E., & Wright, B. (2002). Drug and ECT treatment of depression in the elderly, 1996–2001: A literature review. Biological Psychiatry, 52(3), 265-284.
Saravay, S. M., Pollack, S., Steinberg, M. D., Weinsched, B., & Habert, M. (1996). Four-year follow-up of the influence of psychological comorbidity on medical rehospitalization. American Journal of Psychiatry, 153, 397-403.
Schneider, L. (1996). Pharmacological considerations in the treatment of late-life depression. American Journal of Geriatric Psychiatry, 4(suppl), S51-S65.
Schulberg, H. C., Magruder, K., & deGruy, F. (1996). Major depression in primary medical care practice: Research trends and future priorities. General Hospital Psychiatry, 18(6), 395-406.
Schulberg, H. C., Pilkonis, P., & Houck, P. (1998). The severity of major depression and choice of treatment in primary care practice. Journal of Consulting and Clinical Psychology, 66, 932-938.
Scocco, P., & de Leo, D. (2002). One-year prevalence of death thoughts, suicide ideation and behaviours in an elderly population. International Journal of Geriatric Psychiatry, 17(9), 842-846.
Sheikh, J., & Yesavage, J. (1986). Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clinical Gerontologist, 5, 165-172.
Sherbourne, C., & Wells, K. (1997). Course of depression in patients with comorbid anxiety disorders. Journal of Affective Disorders, 43(3), 245-250.
Simon, G. E., VonKorff, M., & Barlow, W. (1995). Health care costs of primary care patients with recognized depression. Archives of General Psychiatry, 52, 850-856.
Smallbrugge, M., Jongenelis, L., Pot, A., Beekman, A., & Eefsting, J. (2005). Comorbidity of depression and anxiety in nursing home patients. International Journal of Geriatric Psychiatry, 20(3), 218-226.
Solai, L. K., Mulsant, B., & Pollock, B. (2001). Selective serotonin reuptake inhibitors for late-life depression: A comparative review. Drugs & Aging, 18(5), 355-368.
Steer, R., Rismiller, D., & Beck, A. (2000). Use of Beck Depression Inventory-II with depressed geriatric patients. Behaviour Research and Therapy, 38, 311-318.
Steffens, D., Skoog, I., Norton, M., Hart, A., Tschanz, J., Plassman, B., et al. (2000). Prevalence of depression and its treatment in an elderly population: The Cache County study. Archives of General Psychiatry, 57(6), 601-607.
Swindle, R., Rao, J., Helmy, A., Plue, L., Zhou, X., Eckert, G., et al. (2003). Integrating clinical nurse specialists into the treatment of primary care patients with depression. International Journal of Psychiatry in Medicine, 33(1), 17-37.
Teresi, J., Abrams, R., Holmes, D., Ramirez, M., & Eimicke, J. (2001). Prevalence of depression and depression recognition in nursing homes. Social Psychiatry and Psychiatric Epidemiology, 36(12), 613-620.
Teri, L., & Wagner, A. (1992). Alzheimer's disease and depression. Journal of Consulting and Clinical Psychology, 60(3), 379-391.
Teri, L., Lodgosn, R., Uomoto, J., & McCurry, S. (1997). Behavioral treatment of depression in dementia patients: a controlled clinical trial. Journal of Gerontology B Psychological Sciences and Social Sciences, 52(4), 159-166.
Thase, M., Greenhouse, J., Frank, E., Reynolds, C. Pilkonis, P., Hurley K., et al. (1997). Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Archives of General Psychiatry, 54, 1009-1015.
Uncapher, H. (2000). Physicians are less likely to offer depression therapy to older suicidal patients than younger ones. Geriatrics, 55, 82.
Unützer, J., Katon, W., Callahan, C., Williams, J., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting. Journal of the American Medical Association, 288, 2836-2845.
Unützer, J., Katon, W., Callaghan, C., Williams, J., Hunkeler, E., Harpole, L., et al. (2003). Depression treatment in a sample of 1,801 depressed older adults in primary care. Journal of the American Geriatrics Society, 51(4), 505-514.
Unützer, J., Katon, W., Sullivan, M., & Miranda, J. (1999). Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness. The Millbank Quarterly, 77, 225-256.
Unützer, J., Patrick, D. L., Simon, G., Grembowski, D., Walker, E., Rutter, C. et al. (1997). Depressive symptoms and the cost of health services in HMO patients age 65 years and older: A 4-year prospective study. Journal of the American Medical Association, 277, 1618-1623.
Unützer, J., Rubenstein, L., Katon, W., Tang, L., Duan, N., Lagomasino, I., et al. (2001). Two-year effects of quality improvement programs on medication management for depression. Archives of General Psychiatry, 58(10), 935-942.
U.S. Bureau of the Census. (2000). Current Population Survey. Washington, DC: U.S. Government Printing Office, Author.
U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office, Author.
U.S. Department of Health and Human Services. (2003). New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub No. SMA-03-3832. Rockville, MD: Author.
Van Casteren, V., Van der Veken, J., Tafforeau, J., & Van Oyen, H. (1993). Suicide and attempted suicide reported by general practitioners in Belgium, 1990-1991. Acta Psychiatrica Scandinavica, 87, 451-455.
Von Korff, M., & Goldberg, D. (2001). Improving outcomes in depression. British Medical Journal, 323(7319), 948-949.
Watson, L., Garrett, J., Sloane, P., Gruber-Baldini, A., & Zimmerman, S. (2003). Depression in assisted living: Results from a four state study. American Journal of Geriatric Psychiatry, 11(5), 534-542.
Watson, L., Lehmann, S., Mayer, L., Samus, Q., Baker, A., Brandt, J., et al. (2006). Depression in assisted living is common and related to physical burden. American Journal of Geriatric Psychiatry, 14, 876-883.
Weissman, M., & Markowitz, J. (1994). Interpersonal psychotherapy: current status. Archives of General Psychiatry, 51, 599-606.
Weston, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875-899.
Williams-Russo, P., Sharrock, N. E., Mattis, S. Szatrowski, T. P., & Charlson, M. E. (1995). Cognitive effects after epidural vs. general anesthesia in older adults. A randomized trial. Journal of the American Medical Association, 274, 44-50.
Zalaquett, C., & Stens, A. (2006). Psychosocial treatments for major depression and dysthymia in older adults: A review of the research literature. Journal of Counseling and Development, 84, 192-201.
« Back to page Chapter 3 Review of the Literature on Depressive Disorders in Older Adults
CSWE Gero-Ed Center
A program of the Hartford Geriatric Social Work Initiative1701 Duke Street, Suite 200 Alexandria, VA 22314P: +1.703.683.8080 F: +1.703.683.8099 E: email@example.com