About 5% to 15% of community-dwelling older adults (i.e., adults aged 60 years or older) suffer from depression (1), which is associated with functional impairment (2-5), high health care costs (6,7), and possibly increased mortality rates through suicide and complications of cardiac disease (2-5,8,9). Recent data suggest that treatment can reduce not only depression but also the secondary symptoms such as pain and improve health-related quality of life (7-10). Whether treatment also reduces health care costs is unclear.

In light of the increasing burden of, and suboptimal treatment for, depression and the extensive scientific literature on treating and preventing depression (1,11), several major public health organizations designated depression as a major public health concern. For example, a key objective of Healthy People 2010 is to reduce the proportion of adults with disabilities who report symptoms of depression and are less active because of those symptoms (12). In addition, the Task Force on Community Preventive Services endorsed depression as a topic for a systematic literature review to identify effective treatments (13). In this article, we report on a recent special interest project called Defining the Public Health Role in Depression in Older Adults (Depression in Older Adults project), which was supported by the Centers for Disease Control and Prevention (CDC) through the Prevention Research Centers' Healthy Aging Network (PRC–HAN).

During the first stage of this project, an expert panel of 14 academics in public health or geriatrics (including two of the authors: MS, JF) systematically reviewed published, peer-reviewed studies to learn about successful interventions for depression among noninstitutionalized older adults. Panel members (who were recommended by CDC or PRC–HAN) reviewed all studies of interventions with the primary objective of reducing depression or interventions that had other primary objectives but evaluated depression as a secondary outcome (e.g., a study of participants in an aquatics class for elderly people with arthritis, after which researchers measured not only changes in participants' mobility but also changes in symptoms of depression).

The panel established the following eligibility criteria for studies to be included in our review: 1) the mean age of study subjects should be 60 years or older; 2) the number of subjects should be 25 or more; 3) subjects should not be institutionalized; 4) study criteria for determining whether participants were depressed were based either on a clinical diagnosis (e.g., major depression, dysthymia) or on a symptom-severity score from a standardized assessment instrument, and 5) the study report must clearly describe replicable interventions.

After the review was complete, the panel determined whether the study data were adequate to rate the intervention's effectiveness. When the data were adequate, panel members rated each intervention as effective, of mixed effectiveness, or ineffective. These determinations were based on the quality of the studies. Quality was based on, for example, dropout rates, adequacy of statistical analyses, and magnitude of study participants' response to the interventions. Full details about the criteria used to determine the adequacy of the data, effectiveness of the intervention, and quality of the studies are published elsewhere (14).

For the second stage of the Depression in Older Adults project, the panel was restructured: six of the original members left, and six community health care providers were added. This stage of the project is unique because the panel reviewing the literature and recommending interventions included not only researchers but practitioners familiar with the challenges of planning and implementing interventions. This second panel reviewed the list of interventions found through the literature review and recommended or strongly recommended certain of those interventions for treating late-life depression among community-dwelling older adults to healthy-aging experts and public health professionals. In selecting which interventions to recommend or strongly recommend, the panel considered not only their effectiveness but the feasibility and appropriateness of implementing them at the community level. The panel also suggested further research on promising interventions. The study methods and citations for reviewed studies are published elsewhere (14,15).

A total of 97 intervention studies met the panel's criteria for inclusion and were grouped into 24 intervention categories (Table). At the end of this two-stage project, the researcher-practitioner expert panel strongly recommended interventions based on the depression care management (DCM) model and recommended cognitive behavioral therapy (CBT) as treatment for depression in older adults. DCM was supported by eight randomized clinical trials (RCTs) with more than 3000 study subjects. These subjects experienced greater reductions in symptoms of depression, higher remission rates, and more improvement in health-related quality of life than did people in the control group who were given whatever care their physicians deemed appropriate. In addition, the DCM subjects often reported greater satisfaction with their care than did subjects given usual care. The review also found six RCT studies involving CBT. Typically researchers found that those given CBT treatment had significant improvement in their depression symptoms after less than 1 year. Further details on the reviewed studies and on interventions that are not recommended or that provided insufficient evidence are in the Table.

Several groups of experts recognize DCM and CBT as proven treatments for depression in many older adults (22,23), yet numerous obstacles prevent these interventions from being used by public health and healthy aging programs. Next we describe several efforts to implement the recommended evidence-based depression interventions in various communities.

Two points from the review warrant further discussion. First, the panel did not find sufficient evidence from community-based studies to make any recommendations for therapies to deal with grief or prevent suicide. By excluding articles on studies that were based in academic settings, we may have amplified the problem of insufficient evidence. However, excluding these articles was consistent with the community-based focus of our review. Given the multiple losses experienced by older adults and the high suicide rate for older adults in the United States (27), more research is needed in these areas. Second, many of the reviewed interventions targeted primarily other conditions or outcomes (e.g., increases in physical therapy, training in certain skills) and measured depression levels only as a secondary outcome. These interventions did improve the targeted outcomes but did not alleviate depression. Therefore, although depression is a comorbid condition in many patients, it is an independent contributor to suffering and requires direct treatment.

Many real-world challenges to implementing the recommended depression interventions are also challenges for other areas of public health. These are acquiring adequate funds to set up and manage programs well, overcoming barriers to training staff in the intervention techniques, ensuring that people who need the service have access to it, ensuring staff fidelity to established protocols, and having adequate support to evaluate outcomes. Reducing the stigma attached to having mental health problems is one means of improving access to care, especially for older adults with depression. One advantage of the models for managing depression that we reviewed is that they can be made available in primary care clinics or in the home, places without any stigma attached to them.

In summary, several interventions are effective for treating depression in older adults and were deemed appropriate by an expert panel for community-based implementation. Many challenges remain, but overcoming these is an important public health priority. Partnerships among researchers, health care providers, and policy makers will be necessary to overcome the funding and training obstacles that block implementation of treatment programs for older adults. As shown by research studies (7-10) and stated by the President's New Freedom Commission on Mental Health, good emotional health is necessary for good physical health (28).