Depression

While it is natural to feel low or sad at times, people with depression usually experience these feelings for longer and with greater intensity. [1] Depression is the most common mental health condition among older adults. [2] However, older adults are the population least likely to seek mental health treatment, [3] with less than half of those impacted receiving treatment. [2] 

Depression is markedly higher among people living in residential aged care compared to those living in the community. [4, 5] It is estimated that between 35 and 49 per cent of people living in residential aged care would meet the criteria for a diagnosis of depression. [6, 7] Depression is a manageable condition and symptoms can be improved or managed through therapy and/or medication. [4] However, when residents are recognised as being depressed, they are often prescribed medication only (usually antidepressants). [4] 

Depression also often coincides with dementia, with approximately 25% of people living with dementia having a depression diagnosis. [8] 

This evidence theme on depression is a summary of one of the key topics identified by a scoping review of mental health and wellbeing in aged care research. If you need more information on this topic, try using the PubMed search below.

Prevalence and risk factors

Some reviews focused on the prevalence and risk factors for depression, particularly in residential aged care. Depression in residential aged care is relatively common and has been under-recognised and inadequately treated. [9] Why depression is so common among people living in residential aged care is somewhat unclear and requires further research. [10] However, some of the most consistently identified risk factors include:

• Younger age [10, 11]
• Cognitive impairment [10]
• Functional impairment (including visual and hearing impairment). [10] 

Detecting depression among older adults

Two reviews focused on tools for detecting depression in older adults. These were both conducted in residential aged care populations. [12, 13] These tools aim to detect depressive symptoms or disorders that may warrant further assessment with a clinician. [13] Some tools are designed to be administered by a mental health professional. However, some can be administered by aged care staff. [13]

One review concluded that it is not possible to identify the single best screening tool for detecting depression in residential aged care, as the tool selection should ideally be guided by the needs of the facility and the residents. [12] There are many tools that have been used to detect depression among people living in residential aged care, such as:

• The Geriatric Depression Scale (GDS)
• The Cornell Scale for Depression in Dementia (CSDD)
• The Depression Rating Scale (DRS)
• The Mood Questionnaire (PHQ-9, modified)
• Center for Epidemiological Studies Depression Rating Scale (CES-D). [12, 13]

For more information about mental health screening tools, see this evidence theme. 

When screening for depression, it is important to distinguish between persons with and without dementia, as some tools may be inappropriate for individuals living with dementia (e.g., self-rated tools or tools that take a long time to administer). 
Furthermore, multiple studies evaluating depression detection tools have not considered the suitability of their questions and approaches for people from diverse backgrounds including different races, gender, ethnicity, or ages. More evidence is needed about who these screening tools may work for. [12]

Fifteen reviews identified some of the most common approaches in treating depression among older adults. Pharmacological treatment (such as antidepressant medications) is frequently used to treat depression among individuals living in residential aged care. [14]. However, medications often have unwanted side effects, and how well they work is not well understood. [9, 14, 15] More research is needed to examine whether antidepressant medications may be beneficial, and who they may be most beneficial for.

Some non-pharmacological approaches appeared to be relatively consistent in reducing depression. These approaches include:

• Life review  [9]
• Exercise and physical activity  [9, 16-19]
• Psychotherapy (including cognitive behavioural therapy and internet-delivered therapy)  [5, 9, 16, 19-23]
• Music-based approaches [19] 
• Psychoeducational and rehabilitation interventions (this category included a variety of interventions delivered in individual or group settings such as self-worth therapy, pleasant activities, and video conferences with relatives). [16]

The impact of some approaches on depression was more inconclusive. This is because some studies reported benefits of the approach, while others did not. Approaches with mixed findings include:

• Reminiscence and life story work  [5, 9, 16, 18, 19, 22, 24-26]
• Social robots [27]
• Pet therapy [9, 16]
• Horticulture and gardening. [16]

Some studies focused on staff interventions including training or mentoring. These interventions improved staff understanding and knowledge, empathy shown toward residents, and rapport between staff and residents. However, it was unclear if these interventions improved depression outcomes for older adults. [5] 

The reviews highlighted concerns about the methods used in some studies. This reduces the degree of confidence we may have when making conclusions about depression in aged care. For example: 

• Who was responsible for administering the approaches was not always made clear in the reviews or the original studies. 
• Some studies only had a small number of participants. [9, 19, 22] 
• The way researchers conducted the studies was not always clear. [5] 
• Studies varied widely in who the participants were, and how depression was measured, making it difficult to come to strong conclusions. [9] 
• Some studies were unclear about whether the participants had been formally diagnosed with depression. [9] 
• Few studies included follow-up measures, so it is unclear how long the effects may last. [5] 
• Some studies reported that staff were not always supportive of some interventions, and more research is needed to understand this further and provide potential solutions. [2] 
• More research is needed regarding the link between depression and the transition from living at home into a residential aged care facility, which appears to be a particularly vulnerable time. [5] 

• Gain more knowledge around signs of depression. 
• Learn more about how to approach a conversation about mental health with someone you may be worried about. 
• Refer or escalate concerns you may have about the psychological wellbeing of an individual to a supervisor or manager. 

• Provide routine mental health checks for people in its care. 
• Consider employing or contracting someone with psychological expertise into the organisation. 
• Provide regular staff training about recognising and responding to mental health concerns among the people they support. 
• Implement regular case conferences for individuals who have mental health conditions or for whom staff have concerns. The individual and their family should also be involved.   
• Support and encourage staff to approach management with any concerns about individuals’ psychological wellbeing. 

1. healthdirect. Depression [Internet]. 2020 [cited 2023 Jun 29]. Available from: https://www.healthdirect.gov.au/depression.
2. Christensen LF, Moller AM, Hansen JP, Nielsen CT, Gildberg FA. Patients' and providers' experiences with video consultations used in the treatment of older patients with unipolar depression: A systematic review. J Psychiatr Ment Health Nurs. 2020;27(3):258-71.
3. Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J, et al. The mental health of Australians 2: Report on the 2007 National Survey of Mental Health and Wellbeing. 2009.
4. Bhar S. Reducing depression in nursing homes requires more than just antidepressants [Internet]. 2015 [cited 2023 Jun 29]. Available from: https://theconversation.com/reducing-depression-in-nursing-homes-requires-more-than-just-antidepressants-38970.
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6. Beyond Blue. Our work with older adults [Internet]. n.d. [cited 2023 Jun 29]. Available from: https://www.beyondblue.org.au/about-us/about-our-work/older-adults-program.
7. Australian Institute of Health and Welfare. Older Australians [Internet]. 2021 [cited 2023 Jun 29]. Available from: https://www.aihw.gov.au/reports/older-people/older-australians/contents/health/health-selected-conditions#Mental%20health.
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9. Simning A, Simons KV. Treatment of depression in nursing home residents without significant cognitive impairment: A systematic review. Int. Psychogeriatr. 2017;29(2):209-26.
10. Chau R, Kissane DW, Davison TE. Risk factors for depression in long-term care: A systematic review. Clinical Gerontologist: Aging Ment Health. 2019;42(3):224-37.
11. Fornaro M, Solmi M, Stubbs B, Veronese N, Monaco F, Novello S, et al. Prevalence and correlates of major depressive disorder, bipolar disorder and schizophrenia among nursing home residents without dementia: Systematic review and meta-analysis. BJPsych. 2020;216(1):6-15.
12. Azulai A, Walsh CA. Screening for Geriatric Depression in Residential Care Facilities: A Systematic Narrative Review. J. Gerontol. Soc. Work. 2015;58(1):20-45.
13. Mele B, Watt J, Wu P, Azeem F, Lew G, Holroyd–Leduc J, et al. Detecting depression in persons living in long-term care: A systematic review and meta-analysis of diagnostic test accuracy studies. Age Ageing. 2022;51(3):1-12.
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15. Boyce RD, Hanlon JT, Karp JF, Kloke J, Saleh A, Handler SM. A review of the effectiveness of antidepressant medications for depressed nursing home residents. JAMDA. 2012;13(4):326-31.
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17. Daryanti Saragih I, Yang YP, Saragih IS, Batubara SO, Lin CJ. Effects of resistance bands exercise for frail older adults: A systematic review and meta‐analysis of randomised controlled studies. J. Clin. Nurs. 2022;31(1-2):43-61.
18. Gill BK, Cant R, Lam L, Cooper S, Lou VWQ. Non-pharmacological depression therapies for older Chinese adults: A systematic review & meta-analysis. Arch Gerontol Geriatr. 2020;88.
19. Chen Y-j, Li X-x, Pan B, Wang B, Jing G-z, Liu Q-q, et al. Non-pharmacological interventions for older adults with depressive symptoms: A network meta-analysis of 35 randomized controlled trials. Aging Ment Health. 2021;25(5):773-86.
20. Zhang A, Kong D, Jiang L, Sun F, Dunkle RE, Liu C. Understanding the Effectiveness of Psychosocial Services for Anxiety and Depression in Chinese Older Adults: A Systematic Review and Meta-Analysis of Controlled Trials. Gerontologist. 2020;60(1):e76-e92.
21. Harerimana B, Forchuk C, O'Regan T. The use of technology for mental healthcare delivery among older adults with depressive symptoms: A systematic literature review. Int. J. Ment. Health Nurs. 2019;28(3):657-70.
22. Cody RA, Drysdale K. The effects of psychotherapy on reducing depression in residential aged care: A meta-analytic review. Clinical Gerontologist: Aging Ment Health. 2013;36(1):46-69.
23. Xiang X, Wu S, Zuverink A, Tomasino KN, An R, Himle JA. Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: A systematic review and meta-analysis. Aging Ment Health. 2020;24(8):1196-206.
24. Syed Elias SM, Neville C, Scott T. The effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults in long-term care: A systematic review. Geriatr Nurs. 2015;36(5):372-80.
25. Franck L, Molyneux N, Parkinson L, Franck L. Systematic review of interventions addressing social isolation and depression in aged care clients. Qual Life Res. 2016;25(6):1395-407.
26. de Assunção Gil IM, dos Santos Costa PJ, Batista Cardoso DF, de Oliveira Parola VS, Malgorzata Bobrowicz-Campos E, de Lurdes Ferreira de Almeida M, et al. The effectiveness of reminiscence in cognition, depressive symptoms, and quality of life in elderly people in the community: A systematic review. Rev. Enferm. Ref. 2018;4(19):147-58.
27. Chen S-C, Jones C, Moyle W. Social robots for depression in older adults: A systematic review. J. Nurs. Scholarsh. 2018;50(6):612-22.