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Excerpt: Prevention of Mental Health Problems: Depression and Anxiety

Executive Summary

The prevention of substance abuse and mental health problems within the
aging population has been recognized as a national priority. The
Substance Abuse and Mental Health Services Administration's *Older
Americans Substance Abuse and Mental Health Technical Assistance Center*
(TAC) is committed to serving as a leading resource for the prevention
and early intervention of late-life substance use and mental health
problems. Despite the substantial prevalence and adverse consequences of
substance use and mental health problems in older persons and the
considerable knowledge related to preventing these problems,
evidence-based prevention and early intervention services are not widely
available nor promoted for this at-risk population. Given financial
restrictions facing many health care systems, guidance is needed to
direct limited available resources toward the provision of programs that
have proven effectiveness. To support this effort, the TAC has reviewed
the best available evidence supporting programs that target the
prevention and early intervention of substance abuse and mental health
problems in older adults.

The purpose of this review is to highlight prevention and early
intervention programs that have proven effectiveness. This report
identifies the demographic imperative for addressing late-life substance
use and mental health problems, describes the current terminology of
prevention programs and practices, provides a comprehensive review of
the published evidence base for the prevention and early intervention of
geriatric substance abuse and mental health problems based on the
empirical evidence, and describes dissemination and implementation
issues that align with state needs and priorities.

Five specific areas are addressed. These include the prevention and
early intervention of alcohol misuse, medication misuse, depression and
anxiety, suicide, and co-occurring substance abuse and mental health
problems among older adults. This review provides a comprehensive
examination of prevention programs in these areas that have been
published through September 2005.

## Alcohol Misuse

-   Brief interventions can reduce alcohol misuse and hazardous drinking
    among older adults. Specifically, structured brief interventions and
    brief advice in health care settings have shown to be effective at
    reducing alcohol consumption in this population.

-   Little evidence is available regarding universal prevention programs
    targeted at the prevention or reduction of alcohol misuse among
    older adults. Some health education programs have demonstrated
    increased knowledge among older adults about hazardous alcohol use.

-   Recently developed screening and assessment instruments show promise
    as useful tools to improve identification of older at-risk drinkers
    and enhance clinician interactions to prevent or reduce alcohol
    misuse.

## Medication Misuse

-   Computer-based health education tools designed for older adults have
    shown gains in knowledge and self-efficacy regarding potential drug
    interactions, as well as improvements in self-medication behaviors.

-   Clinical trials on early interventions with older adults who are at
    increased risk for medication misuse have had mixed results.
    Nonetheless, interventions with patients prior to hospital
    discharge, interventions targeted at changing provider prescription
    patterns, and home-based medication reviews show some promise to
    prevent medication misuse.

## Depression and Anxiety

-   A moderate amount of evidence supports the effectiveness of problem
    solving therapy (PST) and exercise in preventing the onset or
    worsening of depression. In addition, targeted outreach is effective
    in engaging isolated and vulnerable older adults in mental health
    care.

-   More research is needed to determine whether other potentially
    effective strategies are effective in preventing depression,
    including: life review, reminiscence therapy, educational classes
    for older adults and providers, and mind-body wellness.

-   Minimal evidence supports prevention programs focused on late-life
    anxiety.

## Suicide

-   Supportive interventions that include screening for depression,
    psychoeducation, and group-based activities have been associated
    with reduced rates of completed suicide among older adults.

-   Telephone-based supportive interventions have also been associated
    with a reduction in the rate of completed suicide.

-   Protocol-driven treatment of depression delivered by a care manager
    has been associated with reduced suicidal ideation.

## Co-occurring Disorders

-   Concurrent treatment of substance abuse and depression may be
    effective in reducing alcohol use and improving depressive symptoms.

-   The evaluation and treatment of co-occurring substance use and
    mental health problems among older adults is an under-studied area.

This report highlights the evidence base for the prevention and early
intervention of substance use disorders and mental illness in older
adults. Of note, the field of prevention is far less developed than our
understanding of the diagnosis and treatment of substance abuse and
mental disorders in late-life. In particular, comparatively few
scientific efforts have focused on preventive measures, the early
identification of and intervention with high-risk individuals, and the
promotion of optimal health regarding substance abuse and mental health
concerns in late adulthood. However, this summary of the current
evidence base provides direction for both providers and consumers
regarding substance abuse and mental health prevention and early
intervention services. This information can be useful in planning and
implementing effective programs and practices, while also underscoring
future directions for research and evaluation.

Prevention of Mental Health Problems

One in five older adults has a significant mental disorder, including
more than 16 percent with a primary psychiatric illness and 3 percent
with dementia complicated by psychiatric symptoms.^1^ Depression and
anxiety disorders are among the most common mental health problems in
older persons and affect approximately 3-7 percent and 11 percent of the
general older adult population, respectively.^2^ The prevalence of other
mental health disorders such as schizophrenia and bipolar disorder is
much lower (less than 1%), although these disorders impart significant
functional impairments in older persons. As with substance abuse, the
prevalence of these disorders is heightened among persons receiving
health care in the primary care system, in outpatient mental health
settings, and in nursing homes.^3,4^

This review focuses on the universal, selective, and indicated
prevention of the most common mental health problems in older adults. We
specifically address the most prevalent conditions (mood and anxiety
disorders) and suicide. Similar to the mental health *treatment*
literature, most *prevention* programs target depressive symptoms and do
not address late-life anxiety or other mental health conditions.
Programs that target the reduction of depressive symptoms also heavily
inform our reviews of suicide prevention. We specifically excluded the
prevention of cognitive disorders, such as dementia, as this area
includes a relatively large, rapidly growing, and complex research
literature that is outside the scope of this review. The exclusion of
dementia is based on the premise that the prevention and treatment of
cognitive impairment disorders are most commonly addressed outside of
the mental health care system and are, thus, less pertinent to state and
local substance abuse and mental health care service providers and
administrators.

## Depression and Anxiety

Risk factors for late-life depression have been identified through a
systematic review of the research literature and a longitudinal study.
In a review of 20 studies, Cole and Dendukuri^5^ noted that bereavement,
sleep disturbance, disability, prior depression and female gender were
all significant predictors of depression. Risk factors for depression
have also been identified through a survey of older persons living in
the community. Using data collected from two questionnaires administered
5 years apart to 1,947 older adults, Strawbridge and colleagues^6^ noted
that older adults who were more likely to be depressed included those
with low and medium physical activity, physical disability or mobility
impairment, one or more chronic conditions, fewer than three close
friends or relatives, and those who were somewhat satisfied or not
satisfied with friendships.^6^ Several of these risk factors may be
mitigated by preventive efforts, including programs that attend to
persons that are currently suffering from depression or that have a
history of recurrent depression, undertreated conditions that commonly
precipitate depression, vascular disease, functional impairment, and
nutritional deficiencies.^7^

Several search strategies were used to identify programs addressing the
prevention and early intervention of late-life depression or anxiety.
The PubMed, PsychInfo, CINAHL, Ageline, Social Services Abstracts, and
ERIC databases were used to identify published literature using the
search terms: depression, minor depression, sub-syndromal depression,
anxiety, and prevention. Other search strategies were also employed,
including searches conducted through Google and federal grant databases.

The following section describes the evidence supporting prevention and
early intervention programs for late-life depression and anxiety. In
overview, there are several substantive differences in the evidence base
for prevention compared to early intervention for depression and anxiety
in older adults. The research literature describing the prevention of
depression is relatively small and is largely focused on health
promotion and positive aging and includes programs such as exercise,
life review, reminiscence therapy, educational classes, and mind-body
wellness. Much of this literature is based on the reduction of known
risk factors for depression. In contrast, much of the literature on
early interventions for depression reflects research findings on the
treatment of minor depression or sub-syndromal depression. Early
intervention strategies include problem-solving therapy, interpersonal
counseling, exercise, nurse case management, and caregiver training. Of
note, Cole and Dendukuri^8^ recently conducted a systematic review of
controlled trials of time-limited brief (less than 12 weeks)
interventions to prevent depression. They identified several brief
interventions that have the potential to prevent depression in older
people (these trials are included within Table 2). Finally, there is
little available information to guide the prevention of late-life
anxiety.^9^ Table 1 and Table 2 provide an overview of prevention and
early intervention programs for late-life mental illness. In addition,
these studies are reviewed within the text.

## Univers**a**l Prevention Programs

#### *Exercise*

Physical activity has been shown to be a protective factor against the
development of depression.^6^ In addition, findings from at least two
programs show that exercise can help prevent depression in older adults.
Wallace and colleagues^10^ evaluated a multi-component intervention
wherein participants received a 30- to 60-minute visit at a senior
center with a registered nurse to review risk factors for disability,
develop a targeted health promotion plan, and introduce a supervised
exercise program. This visit focused on current exercise habits, alcohol
and tobacco use, dietary habits, and home safety issues. The nurse
contacted subjects by telephone to review progress toward goals,
motivate continued behavior change, and identify problems with
compliance. The exercise program was conducted in groups of 10-15 older
adults led by a trained exercise instructor. Each 60-minute exercise
session occurred at the senior center and consisted of 10 minutes of
warm up, 15-20 minutes of strength training, 20 minutes of
walking/aerobic activity, and a flexibility and cool-down phase. As
shown in Table 1, positive outcomes included improved health functioning
and a reduction in depressive symptoms. A second study conducted by
Penninx and colleagues^11^ evaluated the effectiveness of exercise in
preventing depression in older adults with osteoarthritis. They compared
a 3-month facility-based aerobic or resistance exercise program to a
control group receiving education on arthritis management. The aerobic
exercise program consisted of an indoor walking program that was
conducted under the supervision of an exercise leader and that was
scheduled three times per week for 1 hour. Each session had 10 minutes
of warm up and cool down including flexibility stretches and 40 minutes
of walking at an intensity equivalent to 50-70 percent of the heart rate
reserve. The resistance exercise program included three 1-hour sessions
per week. Each session consisted of a 10-minute warm up and cool down
and 40 minutes of repetitions of various upper and lower body exercises
using dumbbells and cuff weights, with weights increased in a stepwise
fashion. The aerobic and resistance exercise programs were each followed
by a 14-month home exercise program with support and supervision from an
exercise leader. Evaluation of these programs found that aerobic
exercise, but not resistance exercise, significantly reduced depressive
symptoms. Together, these findings complement research showing that
exercise is an effective treatment for late-life depression^12^ and
identify benefits of exercise in preventing depressive symptomatology in
non-depressed older adults.

#### *Educational Classes*

Several educational programs were evaluated to determine their
effectiveness in preventing depression, including two that were directly
targeted at increasing knowledge of specific medical conditions. A
10-week arthritis education class was associated with significant
reductions in depressive symptoms compared to a control group at 1- and
2-year followup evaluations.^13^ Similarly, a 6-week diabetes education
class combined with a support group was associated with lower incidence
of depression at 2-year followup compared to a control group.^14^
Finally, classroom and home-based multi-component mind-body wellness
courses, including relaxation training, cognitive restructuring, problem
solving, communication, behavioral treatment for insomnia, nutrition,
and exercise, and instruction on mind-body relationships, were
associated with a reduction in depression and anxiety symptoms compared
to a control group.^9^

#### *Life Review*

Zauszniewski and colleagues^15^ examined the effectiveness of a focused
reflection reminiscence program in reducing negative emotions in older
adults living in retirement communities. The program, entitled
"Reflections for Seniors," included members of a retirement community
who met for 2 hours per week over a 6-week period. A similar life review
program evaluated by Haight and colleagues^16^ included nursing home
residents who met for 1 hour per week over a 6-week period. Both studies
found small effects on the reduction of depressive symptoms in older
adults.

#### *Screening and Assessment*

Early detection of depression and anxiety disorders among older adults
may be a useful strategy for identifying older adults who may benefit
from indicated prevention efforts (early intervention). Screening for
depression is recommended by the U.S. Preventive Services Task Force in
health care settings where providers are prepared to confirm an accurate
diagnosis and provide effective treatment and followup.^17^ However,
evidence suggests that screening alone may be associated with a lowering
of depression levels.^18^

A brief review of the literature suggests that several instruments have
been used to screen for depression (Geriatric Depression Scale:
GDS;^19,20^ Short Zung Scale Interview-Assisted Depression Scale;^21^
Patient Health Questionnaire-9: PHQ-9).^22,23^ Of note, the PHQ-9 has
been promoted as a practical depression screening instrument among
primary care settings.^24^ In addition, the Hopkins Symptom Checklist-25
is an effective method for identifying different categories of
depressive symptoms, including sub-threshold depression, minor
depression, and major depression.^25^ Preliminary research suggests that
the Center for Epidemiological Studies -- Depression (CES-D) scale can
be used to detect sub-threshold anxiety in older adults.^26^ In
addition, the Short Anxiety Screening Test (SAST)^21^ also has validity
in detecting anxiety disorders in older adults.

## Indicated and Selective Prevention Strategies (Early Intervention)

Estimates suggest that sub-threshold or minor depression is present in
8-16 percent of older adults residing in the community, 15-20 percent of
those receiving primary care services, 25-33 percent of older adults in
an acute care hospital, and up to 50 percent of older adults in
long-term care facilities.^3,4^ Moreover, the prevalence of anxiety
symptoms among older adults may be as high as 20 percent and diagnosable
anxiety disorders affect nearly 6 percent of older adults.^27^ While
this review identified several programs for the indicated and selective
prevention of geriatric depression, little information is available on
the prevention and early intervention of late-life anxiety.

#### *Targeted Outreach for Vulnerable Older Adults*

The Gatekeeper program was developed to train and encourage
non-traditional referral sources to identify and refer older adults
living in the community who are at risk for serious substance abuse and
mental health problems.^28-30^ Gatekeepers are the employees of local
businesses and community organizations who have contact with older
adults (e.g., letter carriers, police officers, bank tellers, landlords,
meter readers, and many others). The "gatekeeper" model has been
compared with traditional referral sources (e.g., medical providers,
family members, informal caregivers, or other concerned persons) to
determine its efficacy in identifying vulnerable older adults in need of
services.^28,29,31,32^ Studies of the Gatekeeper program have found
differences in individual characteristics between those referred by
gatekeepers and those referred by medical or other traditional sources.
Older adults (age 60+) referred by gatekeepers were significantly more
likely to live alone, were more often widowed or divorced, and were
significantly more likely to be affected by economic and social
isolation. These findings suggest that the gatekeeper model may uniquely
provide outreach to individuals who are less likely to access services
through conventional referral approaches. At the time of referral,
individuals referred by gatekeepers were also significantly less likely
to use needed services than individuals referred through traditional
sources, had similar service needs, and thus had a larger gap between
services needed and services received.^28,31,32^ At 1-year followup,
older persons referred from gatekeepers had no difference in service
utilization or out-of-home placements compared to individuals referred
by traditional sources.

[]{.mark}

A study conducted in urban senior congregate housing settings also used
gatekeepers to identify older adults at high-risk of psychiatric
problems.^33,34^ The Psychogeriatric Assessment and Treatment in City
Housing (PATCH) model incorporates components of the Gatekeeper program
and assertive community treatment. The PATCH psychiatric nurse met with
the building administrator, an education program was provided to housing
personnel to enhance recognition of high-risk residents and to clarify
procedures for making referrals of high-risk residents, and weekly nurse
visits included in-home psychiatric evaluation and case management
services for residents ages 60 and older. This study of the PATCH model
found that outreach services were associated with a decrease in overall
psychiatric symptom severity for individuals with a variety of
psychiatric disorders.^35^

#### *Psychotherapeutic Interventions*

Disability associated with chronic medical disorders in late life is
often a precursor to depressive symptoms. As such, interpersonal and
problem-solving therapies hold promise for preventing depression among
individuals with specific late-life medical illnesses^36^ (also see
section on Ongoing Selective Prevention Programs Under Evaluation). In
addition, these psychotherapeutic approaches have promise in preventing
the progression from minor or sub-syndromal depression into major
depression.

#### *Problem-Solving Therapy*

Two studies have evaluated the effectiveness of problem-solving therapy
(PST) for older adults with dysthymia or minor depression.^37,38^ The
PEARLS program, evaluated by Ciechanowski and colleagues,^39^ was found
to be associated with improved depressive symptoms and functional and
emotional well-being. In addition, compared to a control group, those
receiving PST were more likely to achieve remission of depressive
symptoms (36% vs. 12%). In contrast, Williams and colleagues^38^
evaluated PST compared to an antidepressant medication (paroxetine) or a
placebo. They found that neither treatment was associated with a
difference in rates of remission compared to placebo. However, for those
patients with minor depression, both paroxetine and PST improved mental
health functioning in patients with initial low functioning. Only
paroxetine was associated with improvement for persons with dysthymia.

#### *Interpersonal Therapy*

One study found interpersonal therapy (IPT) to be effective at
preventing an increase in depressive symptoms.^39^ Mossey and colleagues
compared IPT to usual care. IPT was associated with improved self-rated
health and after 6 months, three-fifths of the intervention group,
compared to approximately one-third of the control group, had
experienced a reduction in depressive symptoms.

#### *Exercise*

In contrast to the universal prevention study evaluated by Penninx and
colleagues that found that resistance training was no more effective
than placebo in preventing depression,^40^ a study of older persons with
pre-existing depressive symptoms (59% with minor depression or
dysthymia) found that resistance training was more effective than health
education alone in preventing the worsening of depression.^41^ Remission
was achieved by six of seven (86%) participants in the resistance
exercise group, compared to 4 of 10 (40%) participants in the health
education control group.^41^

#### *Interventions for Care Providers*

Two studies evaluate whether modifications to the provision of care can
affect depressive symptoms. Cuijpers and colleagues^42^ evaluated a
multifaceted education and support program administered in a residential
care setting, compared to usual care. The intervention included training
for caregivers and other employees of the residential home,
informational meetings for residents and their relatives, support
groups, and discussion and feedback sessions for care providers. The
target population included older persons who were incapable of living
independently due to physical, psychiatric, or psychosocial constraints;
yet did not require extensive nursing home care. Results indicate that
an intervention providing education, support and feedback to residential
care providers can reduce depressive symptoms and maintain
health-related quality of life for older persons.^42^ Waterreus^43^ and
Blanchard^44^ evaluated the effectiveness of care delivered through a
nurse case management system in which the care plan was developed
through coordination of a multidisciplinary psychogeriatric team.
Compared to a usual care control group, the intervention group exhibited
greater reduction in depression severity, but was not associated with
fewer cases of depression.

#### *Interventions for Family Caregivers*

Family caregivers, such as spouses or children caring for loved ones
with dementia are also at risk for developing depressive disorders. In
the early 1990s, Mittelman and colleagues developed and tested an
intervention consisting of scheduled individual and family counseling
sessions, unlimited consultation on request, and continuous support
group participation for family caregivers of persons with dementia.^45^
This intervention was found to delay nursing home placement by an
average of 329 days, prompting researchers to develop, refine, and test
similar interventions to support the capacity of natural caregivers to
care for their loved one in the home environment. In addition to
improving outcomes for the individual with Alzheimer's disease, this
intervention also has been found to reduce stress and psychological
symptoms for caregivers. The counseling and support provided to families
is associated with greater satisfaction with assistance received from
others, as well as decreased caregiver depression.^46^ In addition, PST
has been successfully used to enhance the ability of caregivers to cope
with stress and to decrease the incidence of depression and other
adverse outcomes. For example, Teri and colleagues studied the
effectiveness of PST as an intervention for reducing depression among
individuals with dementia and their caregivers. Caregivers who
participated in PST decreased their levels of depression and burden over
a 6-month period.^47^ Of note, a recent systematic review evaluated
major outcomes in family caregiving interventions for dementia, as
published in 43 studies since 1996. Findings indicate that the major
impact on caregivers includes decreased incidence and severity of
depression, moderate decreases in reported anger, moderate improvement
in stress management, positive changes in clinical health indicators
such as blood pressure and stress, and small improvements in caregiver
burden.^48^

## Ongoing Selective Prevention Programs Under Evaluation

A search of ongoing research grants identified two projects that are
specifically designed to prevent depression in older adults. These
studies examine approaches to preventing depression in older adults who
have increased risk due to debilitating medical conditions. In the
first, Rovner and colleagues^49^ are conducting a National Institute of
Mental Health (NIMH) supported clinical trial, entitled "Preventing
Depression in Macular Degeneration," to evaluate the efficacy of PST
among non-depressed older adults with bilateral age-related macular
degeneration. Macular degeneration is a progressive eye disease that
results in blindness and is associated with high rates of physical
disability; up to one-third of older adults with bilateral vision loss
develop depression.^50^ In this study, older adults who have developed
macular degeneration are randomly assigned to either PST or a usual care
control condition. The primary outcome measure is a DSM-IV diagnosis of
depression. Patients are evaluated at baseline, month 2 (immediately
post-intervention), month 6 (for the primary efficacy analysis), and
month 12 (to evaluate sustained effects). The study will also assess the
impact of PST on levels of disability and vision-related quality of
life. Approximately 230 participants are expected to enroll in this
trial, which should reach completion in 2005. Preliminary results are
not yet available.^49^ The second ongoing study designed to prevent
depression targets older persons who are at-risk for depression due to a
previous stroke. In this study, Robinson and colleagues^51^ are
evaluating the relative effectiveness of antidepressant medications and
PST in preventing depression among older persons who have suffered a
stroke. This randomized, double-blind, placebo-controlled trial,
entitled "Prevention of Post-Stroke Depression - Treatment Strategy,"
will treat non-depressed stroke patients with antidepressants or PST to
determine the most effective treatments for preventing depression.
Participants in this study will be randomly assigned to receive PST, an
antidepressant medication (escitalopram), or placebo for 12 months.
Participants who display depressive symptoms for 2 weeks or more will be
removed from the study. After 12 months, treatment will be discontinued
and participants will be monitored for an additional 6 months.
Approximately 200 participants are expected to enroll in this study,
which began in 2002.^51^

## Conc**l**usions

This review highlights the scientific evidence for the prevention and
early intervention of depression and anxiety in older adults. As shown,
several programs have identified positive effects in preventing
depression or reducing depression symptoms. The best evidence exists for
the effectiveness of exercise and psychotherapeutic interventions, such
as problem-solving therapy and interpersonal therapy. In addition, there
is evidence to suggest that targeted outreach to older adults is
effective in engaging isolated and vulnerable older persons in treatment
for mental health and substance abuse problems. Other potentially
effective strategies include life review, reminiscence therapy,
educational classes, mind-body wellness, and provider education. Many of
these approaches require further evaluation prior to establishing their
effectiveness among older adults. Our review also revealed that there is
minimal evidence for programs that target the prevention of anxiety
among older adults. As one in five older adults experiences symptoms of
anxiety,^27^ programs are needed in this area.

It is important to acknowledge that several programs developed to
prevent depression have not demonstrated effectiveness. For instance,
among the brief interventions for older adults with minor depression
reviewed by Cole and Dendukuri,^8^ several trials showed no effect in
the prevention of depression. These studies were primarily focused on
bereavement support groups or life review. The lack of effect on the
prevention of depression was also noted in a social support network
intervention for seniors.^52,53^ Finally, it is likely that many
ineffective programs are never published or disseminated as they have
not demonstrated positive effects on the prevention or reduction of
symptoms of depression or anxiety.

It is also important to note that several of the programs evaluated in
this review have shown positive effects on reducing depressive symptoms,
however these effects have often been small and the design of some of
the studies brings into question the validity of their findings (i.e.,
small sample sizes, inclusion and exclusion criteria, evaluation
instruments). However, despite these limitations, it appears that some
programs have merit in preventing depression at a universal, selective,
and indicated level. As indicated by the studies in progress, there is a
great deal to be learned about effective prevention efforts. Bird and
Parslow^7^ suggest that programs designed to increase understanding of
late-life depression for providers and for older adults may hold
promise. For example, physician education could include information on
the prevalence and costs of depression, warning signs, and available
treatments. Older adults could be educated to improve their ability to
recognize the symptoms of depression, to reduce stigma, and to access
effective mental health treatments.^7^ However, to our knowledge, the
effectiveness of such programs has not been rigorously evaluated among
older adults. Finally, system-wide quality improvement efforts may offer
benefits in preventing late-life mental illness. A treatment guideline
was recently released that discusses appropriate care of older persons
who are moving to a continuing care facility or who are awaiting
hospital discharge. This treatment guideline focuses on promoting nurses
awareness of depression in older people, promoting positive mental
health and well-being, assessment and care-planning, and education and
training. Specific recommendations include: (a) nursing staff attention
to physical and mental health needs, (b) easing the transition to
assisted living and increase independence and control, (c) minimizing
the perceived losses that the person may experience in moving into the
care home, (d) care planning focusing on the individuals strengths,
coping patterns, and daily activities, (e) enabling access to advocacy
services, (f) providing psychosocial support, (g) maintaining community
linkages, and (h) engagement in meaningful activities.^54,55^ Despite
the promise of these approaches, many remain to be tested.

Finally, it is important to remember that late-life depression is often
chronic or characterized by a relapsing course. Although this review
focuses on the universal prevention of late-life depression and
selective and indicated prevention of the exacerbation of minor
depression into major depression, an important area of research
addresses the prevention of further disability among older adults who
have developed depression. Prevention strategies should focus attention
on preventing relapse, recurrence, and residual symptoms among older
adults with current or remitted major depression.^36^

Table 1. Universal prevention of late-life depression or anxiety

+-----+----+------+---+---------+----------+------------+-----------+
| Ref | S  | Mode | A | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | g |         |          | Measures   | mitations |
| nce | dy | ndit | e |         |          | and        | /Comments |
|     | De | ions |   |         |          | Results    |           |
|     | si |      |   |         |          |            |           |
|     | gn |      |   |         |          |            |           |
+=====+====+======+===+=========+==========+============+===========+
| H   | R  | Life | 5 | Ho      | 8-week   | No change  | Small     |
| aig | CT | Re   | 0 | mebound | program. | in         | sample    |
| ht, |    | view | + | elderly | 51 of 60 | d          | size.     |
| et  |    | (    |   | s       | ra       | epression. | Minimal   |
| a   |    | LR); | M | ubjects | ndomized | Life       | d         |
| l., |    | Frie | e | r       | c        | sa         | epressive |
| 19  |    | ndly | a | andomly | ompleted | tisfaction | symptoms  |
| 88^ |    | V    | n | s       | the      | and        | in any    |
| 56^ |    | isit | a | elected | study    | psy        | group at  |
|     |    | (    | g | from    | (85%).   | chological | baseline. |
|     |    | FV); | e | M       |          | well-being |           |
|     |    | No   | r | eals-On |          | were       |           |
|     |    | t    | a | -Wheels |          | improved   |           |
|     |    | reat | n | rec     |          | in the LR  |           |
|     |    | ment | g | ipients |          | group.     |           |
|     |    | con  | e | and     |          |            |           |
|     |    | trol | d | persons |          |            |           |
|     |    | (NT) | f | re      |          |            |           |
|     |    |      | r | ceiving |          |            |           |
|     |    | LR   | o | home    |          |            |           |
|     |    | and  | m | health  |          |            |           |
|     |    | FV   | 7 | se      |          |            |           |
|     |    | met  | 3 | rvices. |          |            |           |
|     |    | for  | t | 78%     |          |            |           |
|     |    | 1    | o | female. |          |            |           |
|     |    | h    | 7 |         |          |            |           |
|     |    | our/ | 9 | LR:     |          |            |           |
|     |    | week | y | n=16    |          |            |           |
|     |    | for  | e |         |          |            |           |
|     |    | 6    | a | FV:     |          |            |           |
|     |    | we   | r | n=16    |          |            |           |
|     |    | eks. | s |         |          |            |           |
|     |    |      | . | NT:     |          |            |           |
|     |    |      |   | n=19    |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| G   | Pr | DE   | R | Male    | 6-week   | Incidence  | S         |
| ild | e- | C+S: | a | at      | program, | of         | elf-rated |
| en, | po | 6-   | n | tendees | 24-month | depression | d         |
| et  | st | week | g | at a    | f        | (based on  | epression |
| a   |    | diab | e | Ve      | ollowup. | Zung       | outcomes. |
| l., |    | etes | : | teran's | 100%     | Depression | Did not   |
| 19  |    | e    | 5 | d       | f        | Scale      | adjust    |
| 92^ |    | duc. | 7 | iabetes | ollowup. | \>50)      | for       |
| 14^ |    | cla  | - | clinic. |          |            | d         |
|     |    | ss + | 8 | Groups  |          | DEC+S: 17% | epression |
|     |    | sup  | 2 | matched |          |            | or        |
|     |    | port |   | for age |          | DEC: 45%   | exclude   |
|     |    | g    | D | and     |          |            | depressed |
|     |    | roup | E | d       |          | Control:   | persons   |
|     |    | foll | P | iabetes |          | 75%        | at        |
|     |    | owed | + | du      |          |            | baseline. |
|     |    | by   | S | ration. |          |            | Baseline  |
|     |    | 18   | : |         |          |            | rates of  |
|     |    | mo   | 6 | DEC+S:  |          |            | d         |
|     |    | nths | 9 | n=13    |          |            | epression |
|     |    | of   | [ |         |          |            | are not   |
|     |    | sup  | + | DEC:    |          |            | noted.    |
|     |    | port | ] | n=11    |          |            |           |
|     |    | gr   | { |         |          |            |           |
|     |    | oup; | . | C       |          |            |           |
|     |    |      | u | ontrol: |          |            |           |
|     |    | DEC: | n | n=8     |          |            |           |
|     |    | 6-   | d |         |          |            |           |
|     |    | week | e |         |          |            |           |
|     |    | diab | r |         |          |            |           |
|     |    | etes | l |         |          |            |           |
|     |    | e    | i |         |          |            |           |
|     |    | duc. | n |         |          |            |           |
|     |    | c    | e |         |          |            |           |
|     |    | lass | } |         |          |            |           |
|     |    | foll | 1 |         |          |            |           |
|     |    | owed |   |         |          |            |           |
|     |    | by   | D |         |          |            |           |
|     |    | 18   | E |         |          |            |           |
|     |    | mo   | P |         |          |            |           |
|     |    | nths | : |         |          |            |           |
|     |    | of   |   |         |          |            |           |
|     |    | sup  | 6 |         |          |            |           |
|     |    | port | 9 |         |          |            |           |
|     |    | gr   | [ |         |          |            |           |
|     |    | oup; | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    | Con  | { |         |          |            |           |
|     |    | trol | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 1 |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | C |         |          |            |           |
|     |    |      | o |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | t |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | o |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | : |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
|     |    |      | [ |         |          |            |           |
|     |    |      | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    |      | { |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 3 |         |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| Eme | R  | E    | 5 | P       | 10-week  | EXESM      | Small     |
| ry, | CT | xerc | 0 | atients | program. | greater    | sample    |
| et  |    | ise, | + | with    | 92%      | reduction  | size. WL  |
| a   |    | ed   |   | stable  | co       | in         | also      |
| l., |    | ucat | E | COPD    | mpletion | depression | showed    |
| 19  |    | ion, | X | for 6+  | rate.    | than ESM.  | improved  |
| 98^ |    | and  | E | months. | (Dr      | S          | de        |
| 57^ |    | st   | S | 53%     | op-outs: | ignificant | pression. |
|     |    | ress | M | female. | 4 in     | time and   | Short     |
|     |    | mgmt | : |         | EXESM    | time by    | duration  |
|     |    | (EXE |   | EXESM:  | due to   | group      | makes it  |
|     |    | SM); | 6 | n=29    | medical  | effect.    | difficult |
|     |    | E    | 5 |         | illness; | EXESM and  | to        |
|     |    | duca | . | ESM:    | 2 in ESM | WL         | determine |
|     |    | tion | 4 | n=25    | due to   | decreased  | the       |
|     |    | and  | [ |         | transp   | d          | duration  |
|     |    | st   | + | WL:     | ortation | epression, | of the    |
|     |    | ress | ] | n=25    | issues.) | but not    | effect.   |
|     |    | mgmt | { |         | Among 25 | ESM.       |           |
|     |    | (E   | . |         | persons  | Greater    |           |
|     |    | SM); | u |         | co       | reduction  |           |
|     |    |      | n |         | mpleting | in anxiety |           |
|     |    | Wait | d |         | EXESM,   | for EXESM  |           |
|     |    | list | e |         | they     | than for   |           |
|     |    | (WL) | r |         | attended | ESM or WL. |           |
|     |    |      | l |         | a mean   |            |           |
|     |    |      | i |         | of 29.7  |            |           |
|     |    |      | n |         | s        |            |           |
|     |    |      | e |         | essions. |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 4 |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | E |         |          |            |           |
|     |    |      | S |         |          |            |           |
|     |    |      | M |         |          |            |           |
|     |    |      | : |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 4 |         |          |            |           |
|     |    |      | [ |         |          |            |           |
|     |    |      | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    |      | { |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 5 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 9 |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | W |         |          |            |           |
|     |    |      | L |         |          |            |           |
|     |    |      | : |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | [ |         |          |            |           |
|     |    |      | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    |      | { |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 5 |         |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| H   | R  | Life | R | Nursing | 6-week   | S          | S         |
| aig | CT | re   | a | home    | program  | ignificant | elf-rated |
| ht, |    | view | n | re      | with     | difference | d         |
| 19  |    | for  | g | sidents | 12-month | between    | epression |
| 98^ |    | 1    | e |         | f        | the        | outcomes. |
| 16^ |    | h    | : | Interv: | ollowup. | in         | No        |
|     |    | our/ | 6 | n=60    | 53%      | tervention | d         |
|     |    | week | 0 |         | co       | and        | ifference |
|     |    |      | - | C       | mpletion | control    | in        |
|     |    |      | 1 | ontrol: | rate.    | group at   | suicide   |
|     |    |      | 0 | n=60    |          | 12 months  | ideation, |
|     |    |      | 4 |         |          | in         | life      |
|     |    |      | M |         |          | d          | sati      |
|     |    |      | e |         |          | epression, | sfaction, |
|     |    |      | a |         |          | hop        | or        |
|     |    |      | n |         |          | elessness, | sel       |
|     |    |      | : |         |          | and        | f-esteem. |
|     |    |      | 7 |         |          | psy        |           |
|     |    |      | 9 |         |          | chological |           |
|     |    |      | . |         |          | w          |           |
|     |    |      | 6 |         |          | ell-being. |           |
|     |    |      |   |         |          | Only       |           |
|     |    |      |   |         |          | depression |           |
|     |    |      |   |         |          | improved   |           |
|     |    |      |   |         |          | at 8-week  |           |
|     |    |      |   |         |          | a          |           |
|     |    |      |   |         |          | ssessment. |           |
+-----+----+------+---+---------+----------+------------+-----------+

Table 1. Universal prevention of late-life depression or anxiety
(continued)

+-----+----+------+---+---------+----------+------------+-----------+
| Ref | S  | Mode | A | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | g |         |          | Measures   | mitations |
| nce | dy | ndit | e |         |          | and        | /Comments |
|     | De | ions |   |         |          | Results    |           |
|     | si |      |   |         |          |            |           |
|     | gn |      |   |         |          |            |           |
+=====+====+======+===+=========+==========+============+===========+
| Wa  | R  | Di   | 6 | Senior  | 6-month  | Outcome    | Im        |
| lla | CT | sabi | 5 | center  | program. | measures   | provement |
| ce, |    | lity | + | at      | 10%      | (SF-36     | in        |
| et  |    | Pr   |   | tendees | dropout  | subscales  | d         |
| a   |    | even | I |         | rate.    | and CES-D  | epression |
| l., |    | tion | n | Interv: | Data     | scores)    | only      |
| 19  |    | Pro  | t | n=53    | c        | improved   | noted as  |
| 98^ |    | gram | e |         | ollected | in the     | mean      |
| 10^ |    | (i   | r | C       | at       | in         | CES-D     |
|     |    | nclu | v | ontrol: | b        | tervention | scores.   |
|     |    | ding | : | n=47    | aseline, | group and  | Pr        |
|     |    | e    | 7 |         | 2        | declined   | oportions |
|     |    | xerc | 1 |         | months,  | in the     | were not  |
|     |    | ise, | . |         | and 6    | control    | p         |
|     |    | nu   | 1 |         | months.  | group.     | resented. |
|     |    | trit | [ |         |          | Most       | Fe        |
|     |    | ion, | + |         |          | d          | asibility |
|     |    | home | ] |         |          | ifferences | improved  |
|     |    | saf  | { |         |          | were found | by use of |
|     |    | ety) | . |         |          | at 2       | low-cost  |
|     |    |      | u |         |          | months,    | community |
|     |    |      | n |         |          | with       | sites     |
|     |    |      | d |         |          | smaller    | that      |
|     |    |      | e |         |          | i          | offer     |
|     |    |      | r |         |          | ncremental | social    |
|     |    |      | l |         |          | im         | a         |
|     |    |      | i |         |          | provements | ctivation |
|     |    |      | n |         |          | at 6       | and other |
|     |    |      | e |         |          | months.    | r         |
|     |    |      | } |         |          |            | esources. |
|     |    |      | 4 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 3 |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | C |         |          |            |           |
|     |    |      | o |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | t |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | o |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | : |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
|     |    |      | 2 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 9 |         |          |            |           |
|     |    |      | [ |         |          |            |           |
|     |    |      | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    |      | { |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 4 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 8 |         |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| R   | R  | Mu   | 5 | Members | 6-week   | Classroom  | Only 270  |
| yba | CT | ltic | 0 | of an   | program. | and home   | of 527    |
| rcz |    | ompo | + | urban   | Pre- and | course     | patients  |
| yk, |    | nent |   | staff   | post-t   | resulted   | referred  |
| et  |    | m    | R | model   | reatment | in         | to the    |
| a   |    | ind- | a | HMO     | measures | decreased  | study     |
| l., |    | body | n | with 6+ | ad       | pain,      | agreed to |
| 1   |    | well | g | primary | dressed. | sleep      | pa        |
| 999 |    | ness | e | care    | 15% of   | dif        | rticipate |
| ^9^ |    | cou  | : | visits  | part     | ficulties, | and only  |
|     |    | rse. | 5 | in the  | icipants | and        | 210 and   |
|     |    | Cl   | 0 | past    | dropped  | depression | 178       |
|     |    | assr | - | year    | out.     | and        | completed |
|     |    | oom, | 8 | and     |          | anxiety    | pre- and  |
|     |    | Home | 7 | r       |          | symptoms,  | po        |
|     |    | cou  |   | eferred |          | compared   | st-questi |
|     |    | rse, | M | by the  |          | to control | onnaires, |
|     |    | and  | e | primary |          | group.     | resp      |
|     |    | W    | a | phy     |          |            | ectively. |
|     |    | ait- | n | sician. |          |            | Length of |
|     |    | list | A | 82%     |          |            | followup  |
|     |    | Con  | g | female. |          |            | difficult |
|     |    | trol | e |         |          |            | to        |
|     |    | co   |   | Cla     |          |            | i         |
|     |    | ndit | C | ssroom: |          |            | nterpret. |
|     |    | ions | l | n=54    |          |            | No        |
|     |    |      | a |         |          |            | intent    |
|     |    |      | s | Home:   |          |            | -to-treat |
|     |    |      | s | n=61    |          |            | analysis. |
|     |    |      | : |         |          |            | H         |
|     |    |      | 6 | C       |          |            | ome-based |
|     |    |      | 7 | ontrol: |          |            | course    |
|     |    |      | . | n=63    |          |            | has lower |
|     |    |      | 6 |         |          |            | costs,    |
|     |    |      | ; |         |          |            | greater   |
|     |    |      |   |         |          |            | acces     |
|     |    |      | H |         |          |            | sibility, |
|     |    |      | o |         |          |            | and       |
|     |    |      | m |         |          |            | potential |
|     |    |      | e |         |          |            | for       |
|     |    |      | : |         |          |            | greater   |
|     |    |      |   |         |          |            | disse     |
|     |    |      | 6 |         |          |            | mination. |
|     |    |      | 1 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 5 |         |          |            |           |
|     |    |      | ; |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | W |         |          |            |           |
|     |    |      | a |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | t |         |          |            |           |
|     |    |      | - |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | s |         |          |            |           |
|     |    |      | t |         |          |            |           |
|     |    |      | : |         |          |            |           |
|     |    |      | 6 |         |          |            |           |
|     |    |      | 4 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| Bur | R  | G    | A | Me      | 2-year   | Both       | Mostly    |
| ns, | CT | eria | g | dically | ev       | groups had | male      |
| et  |    | tric | e | ill     | aluation | improved   | sample.   |
| a   |    | Ev   | 6 | p       | of GEM   | d          | General   |
| l., |    | alua | 5 | atients | program. | epression, | izability |
| 20  |    | tion | + | a       | 128      | but        | limited   |
| 00^ |    | and  | R | dmitted | people   | sig        | by VA     |
| 58^ |    | Ma   | a | to      | entered  | nificantly | sample.   |
|     |    | nage | n | m       | study.   | greater    | Most      |
|     |    | ment | g | edical, | 30 died  | i          | lived     |
|     |    | (    | e | su      | before   | mprovement | within 60 |
|     |    | GEM) | : | rgical, | 2-year   | in GEM     | miles of  |
|     |    | and  | 6 | and     | f        | group. GEM | a large   |
|     |    | U    | 6 | neuro   | ollowup. | also had   | met       |
|     |    | sual | - | logical | Analyses | more       | ropolitan |
|     |    | Care | 9 | s       | on 98    | i          | center.   |
|     |    | (    | 5 | ervices | r        | mprovement | The level |
|     |    | UC). |   | at a VA | emaining | than UC in | of        |
|     |    | GEM  | G | clinic. | p        | general    | d         |
|     |    | incl | E | Ran     | atients. | w          | epression |
|     |    | uded | M | domized |          | ell-being, | was low   |
|     |    | i    | : | at      |          | life       | at study  |
|     |    | nter |   | dis     |          | sat        | rand      |
|     |    | disc | 7 | charge. |          | isfaction, | omization |
|     |    | ipli | 1 | 3%      |          | global     | (mean     |
|     |    | nary | . | female. |          | social     | CESD of   |
|     |    | pri  | 7 |         |          | activity,  | 11).      |
|     |    | mary | [ | GEM:    |          | and had    |           |
|     |    | care | + | n=49    |          | fewer IADL |           |
|     |    | team | ] |         |          | im         |           |
|     |    | with | { | UC:     |          | pairments. |           |
|     |    | j    | . | n=49    |          | In         |           |
|     |    | oint | u |         |          | addition,  |           |
|     |    | c    | n |         |          | UC used    |           |
|     |    | ompr | d |         |          | 40% more   |           |
|     |    | ehen | e |         |          | clinic     |           |
|     |    | sive | r |         |          | visits     |           |
|     |    | as   | l |         |          | than GEM.  |           |
|     |    | sess | i |         |          |            |           |
|     |    | ment | n |         |          |            |           |
|     |    | and  | e |         |          |            |           |
|     |    | co   | } |         |          |            |           |
|     |    | ntin | 6 |         |          |            |           |
|     |    | uing | . |         |          |            |           |
|     |    | l    | 3 |         |          |            |           |
|     |    | ong- |   |         |          |            |           |
|     |    | term | U |         |          |            |           |
|     |    | c    | C |         |          |            |           |
|     |    | are. | : |         |          |            |           |
|     |    |      |   |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
|     |    |      | 0 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 8 |         |          |            |           |
|     |    |      | [ |         |          |            |           |
|     |    |      | + |         |          |            |           |
|     |    |      | ] |         |          |            |           |
|     |    |      | { |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | u |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | d |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | r |         |          |            |           |
|     |    |      | l |         |          |            |           |
|     |    |      | i |         |          |            |           |
|     |    |      | n |         |          |            |           |
|     |    |      | e |         |          |            |           |
|     |    |      | } |         |          |            |           |
|     |    |      | 3 |         |          |            |           |
|     |    |      | . |         |          |            |           |
|     |    |      | 7 |         |          |            |           |
+-----+----+------+---+---------+----------+------------+-----------+
| Phi | R  | 1.5  | R | Older   | 10-week  | S          | Did not   |
| lli | CT | hr/  | a | African | program  | ignificant | adjust    |
| ps, |    | week | n | Am      | with 12- | difference | for       |
| 20  |    | a    | g | ericans | and      | at 12 and  | d         |
| 00^ |    | rthr | e | with    | 24-month | 24 months  | epression |
| 13^ |    | itis | : | ar      | f        | based on   | or        |
|     |    | e    | 6 | thritis | ollowup. | CESD.      | exclude   |
|     |    | duca | 7 |         | 98%      |            | depressed |
|     |    | tion | - | Interv: | co       |            | persons   |
|     |    | clas | 7 | n=101   | mpletion |            | at        |
|     |    | ses. | 5 |         | rate.    |            | baseline. |
|     |    |      | M | C       |          |            | Multidis  |
|     |    |      | e | ontrol: |          |            | ciplinary |
|     |    |      | a | n=101   |          |            | team with |
|     |    |      | n |         |          |            | each      |
|     |    |      | : |         |          |            | member    |
|     |    |      | 6 |         |          |            | re        |
|     |    |      | 9 |         |          |            | sponsible |
|     |    |      | . |         |          |            | for two   |
|     |    |      | 3 |         |          |            | lectures. |
|     |    |      |   |         |          |            | Done in a |
|     |    |      |   |         |          |            | community |
|     |    |      |   |         |          |            | center.   |
+-----+----+------+---+---------+----------+------------+-----------+

Table 1. Universal prevention of late-life depression or anxiety
(continued)

+-----+----+------+----+--------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |        |          | Measures   | mitations |
| nce | dy | ndit |    |        |          | and        | /Comments |
|     | De | ions |    |        |          | Results    |           |
|     | si |      |    |        |          |            |           |
|     | gn |      |    |        |          |            |           |
+=====+====+======+====+========+==========+============+===========+
| Pe  | RC | Aer  | 6  | Older  | 3, 9,    | Aerobic    | Unknown   |
| nni | T. | obic | 0+ | adults | and 18   | exercise,  | general   |
| nx, | S  | e    | M  | with   | months.  | but not    | izability |
| et  | ub | xerc | ea | knee   | At 18    | resistance | to all    |
| a   | an | ise; | n: | ost    | months,  | exercise,  | older     |
| l., | al |      | 68 | eoarth | 20% of   | sig        | adults.   |
| 20  | ys | Re   | .8 | ritis. | aerobic  | nificantly | Unable to |
| 02^ | is | sist | [+ | 70%    | group    | decreased  | control   |
| 40^ | of | ance | ]{ | f      | and 17%  | depressive | for       |
|     | F  | e    | .u | emale. | of       | symptoms   | social    |
|     | AS | xerc | nd | High   | re       | compared   | support.  |
|     | T: | ise; | er | depr   | sistance | to         | No        |
|     | Fi | E    | li | essive | group    | controls.  | d         |
|     | tn | duca | ne | sy     | dropped  | Better     | iagnostic |
|     | es | tion | }5 | mptoms | out. No  | results    | e         |
|     | s, | con  | .6 | (      | di       | for        | valuation |
|     | Ar | trol |    | n=98); | fference | persons    | of        |
|     | th |      |    | Low    | in       | who are    | de        |
|     | ri |      |    | depr   | co       | most       | pression. |
|     | ti |      |    | essive | mpliance | compliant  |           |
|     | s, |      |    | sy     | or       |            |           |
|     | a  |      |    | mptoms | drop-out |            |           |
|     | nd |      |    | (      | between  |            |           |
|     | S  |      |    | n=340) | high and |            |           |
|     | en |      |    |        | low      |            |           |
|     | io |      |    | AE:    | de       |            |           |
|     | rs |      |    | n=149; | pressive |            |           |
|     | T  |      |    |        | groups.  |            |           |
|     | ri |      |    | RE:    |          |            |           |
|     | al |      |    | n=146  |          |            |           |
|     |    |      |    |        |          |            |           |
|     |    |      |    | Educ:  |          |            |           |
|     |    |      |    | n=144  |          |            |           |
+-----+----+------+----+--------+----------+------------+-----------+
| Zau | Qu | Remi | 6  | 43     | 6-week   | Depressive | Small     |
| sni | as | nisc | 5+ | m      | program; | symptoms   | sample    |
| ews | i- | ence |    | embers | followup | reduced    | size. No  |
| ki, | ex | the  | Ra | of     | 12 weeks | from       | c         |
| et  | pe | rapy | ng | reti   | po       | baseline   | omparison |
| a   | ri | thr  | e: | rement | st-inter | to 6 weeks | c         |
| l., | me | ough | 6  | commun | vention. | post-int   | ondition. |
| 20  | nt | 6    | 7- | ities. | 21%      | ervention, | The ESC   |
| 04^ | al | we   | 98 | 79%    | dropped  | based on   | is not a  |
| 15^ |    | ekly |    | f      | out.     | the        | commonly  |
|     |    | 2-   | M  | emale. |          | Emotional  | used      |
|     |    | hour | ea |        |          | Symptom    | i         |
|     |    | g    | n: |        |          | Checklist  | nstrument |
|     |    | roup | 84 |        |          | (ESC)      | for       |
|     |    | s    |    |        |          |            | measuring |
|     |    | essi |    |        |          |            | de        |
|     |    | ons. |    |        |          |            | pression. |
|     |    | "Ref |    |        |          |            | No change |
|     |    | lect |    |        |          |            | in        |
|     |    | ions |    |        |          |            | anxiety   |
|     |    | for  |    |        |          |            | or        |
|     |    | Seni |    |        |          |            | a         |
|     |    | ors" |    |        |          |            | gitation. |
+-----+----+------+----+--------+----------+------------+-----------+

Table 2. Early intervention of late-life depression or anxiety

+-----+----+------+----+---------+----------+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          | Measures   | mitations |
| nce | dy | ndit |    |         |          | and        | /Comments |
|     | De | ions |    |         |          | Results    |           |
|     | si |      |    |         |          |            |           |
|     | gn |      |    |         |          |            |           |
+=====+====+======+====+=========+==========+============+===========+
| W   | R  | N    | M  | Older   | 3, 6,    | In         | Small     |
| ate | CT | urse | ea | adults  | and 14.5 | tervention | sample,   |
| rre |    | case | n: | living  | months.  | group had  | low       |
| us, |    | ma   | 76 | at      | After 3  | greater    | power,    |
| 19  |    | nage | [+ | home.   | months,  | reduction  | variable  |
| 94^ |    | ment | ]{ | 85%     | 8.5% of  | on         | followup  |
| 43^ |    | im   | .u | female. | inte     | sho        | length,   |
|     |    | plem | nd | Di      | rvention | rt-CARE^6^ | low       |
| B   |    | enta | er | agnoses | group    | depression | imple     |
| lan |    | tion | li | i       | had      | scores,    | mentation |
| cha |    | of a | ne | ncluded | dropped  | but no     | of social |
| rd, |    | care | }6 | 58%     | out and  | difference | and       |
| 19  |    | plan | .8 | with    | 20.4% of | in case    | antid     |
| 95^ |    | cre  |    | minor   | the      | vs.        | epressant |
| 44^ |    | ated |    | depr    | control  | non-case.  | t         |
|     |    | by a |    | ession; | group    | With       | reatment, |
|     |    | ho   |    | 23%     | had      | followup   | most      |
|     |    | spit |    | with    | dropped  | of both    | analyses  |
|     |    | al-b |    | major   | out. At  | groups     | showed no |
|     |    | ased |    | depr    | 14.5     | receiving  | di        |
|     |    | psy  |    | ession, | months,  | care mgmt  | fference. |
|     |    | chog |    | and 6%  | 25.5% of | protocol   |           |
|     |    | eria |    | with    | inte     | by general |           |
|     |    | tric |    | de      | rvention | physician, |           |
|     |    | team |    | mentia. | and      | depression |           |
|     |    |      |    |         | 40.8% of | d          |           |
|     |    |      |    | Interv: | control  | ifferences |           |
|     |    |      |    | n=47    | group    | only       |           |
|     |    |      |    |         | had      | remained   |           |
|     |    |      |    | C       | dropped  | in the     |           |
|     |    |      |    | ontrol: | out.     | subgroup   |           |
|     |    |      |    | n=49    |          | with       |           |
|     |    |      |    |         |          | long-term  |           |
|     |    |      |    |         |          | depression |           |
+-----+----+------+----+---------+----------+------------+-----------+
| M   | R  | I    | 6  | P       | 6-month  | 61% of the | UC        |
| oss | CT | nter | 0+ | atients | f        | IPT group  | included  |
| ey, |    | pers |    | a       | ollowup. | and 35% of | variable  |
| et  |    | onal | Ra | dmitted | 20% of   | the UC     | contact   |
| a   |    | co   | ng | to      | the IPT  | group had  | with a    |
| l., |    | unse | e: | m       | group    | a GDS \<   | primary   |
| 19  |    | ling |    | edicine | and 9%   | 11 at      | care      |
| 96^ |    | (    | 6  | or      | of the   | 6-month    | physician |
| 37^ |    | IPT) | 0- | surgery | UC group | followup.  | and low   |
|     |    | vs.  | 91 | at      | did not  | IPT group  | use of or |
|     |    | u    |    | three   | have 3-  | also had   | adherence |
|     |    | sual | M  | a       | or       | improved   | to        |
|     |    | care | ea | cademic | 6-month  | self-rated | antid     |
|     |    | (UC) | n: | hos     | followup | health,    | epressant |
|     |    |      | 71 | pitals. | data.    | but not    | me        |
|     |    |      | [+ | 78%     |          | physical   | dication. |
|     |    |      | ]{ | female. |          | or social  |           |
|     |    |      | .u | P       |          | fu         |           |
|     |    |      | nd | atients |          | nctioning. |           |
|     |    |      | er | had a   |          |            |           |
|     |    |      | li | GDS     |          |            |           |
|     |    |      | ne | greater |          |            |           |
|     |    |      | }7 | than 10 |          |            |           |
|     |    |      | .7 | but     |          |            |           |
|     |    |      |    | didn't  |          |            |           |
|     |    |      |    | meet    |          |            |           |
|     |    |      |    | c       |          |            |           |
|     |    |      |    | riteria |          |            |           |
|     |    |      |    | for     |          |            |           |
|     |    |      |    | major   |          |            |           |
|     |    |      |    | depress |          |            |           |
|     |    |      |    | ion/dys |          |            |           |
|     |    |      |    | thymia. |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      |    | IPT:    |          |            |           |
|     |    |      |    | n=35    |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      |    | UC:     |          |            |           |
|     |    |      |    | n=41    |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Sin | R  | Pro  | 6  | Co      | 10-week  | Remission  | Small     |
| gh, | CT | gres | 0+ | mmunity | f        | achieved   | sample    |
| et  |    | sive |    | vol     | ollowup. | by 86% of  | size.     |
| a   |    | re   | I  | unteers | No       | in         | Hete      |
| l., |    | sist | nt | with    | part     | tervention | rogeneous |
| 19  |    | ance | er | major   | icipants | group and  | group of  |
| 97^ |    | trai | v: | (n=13)  | dropped  | 40% of     | d         |
| 41^ |    | ning |    | or      | out.     | control    | iagnoses. |
|     |    | of   | 70 | minor   | Median   | group with | Likely    |
|     |    | l    | [+ | dep     | co       | minor      | subject   |
|     |    | arge | ]{ | ression | mpliance | d          | to        |
|     |    | mus  | .u | (n=17)  | with     | epression. | selection |
|     |    | cles | nd | or      | sessions | Remission  | bias as   |
|     |    | 3    | er | dy      | was 93%  | achieved   | only 1%   |
|     |    | d    | li | sthymia | in the   | by 59% and | of        |
|     |    | ays/ | ne | (n=2).  | inte     | 26% in the | persons   |
|     |    | week | }1 | 63%     | rvention | full       | contacted |
|     |    | ve   | .5 | female. | group    | sample.    | by a      |
|     |    | rsus |    |         | and 95%  | Strength   | re        |
|     |    | "ed  | Co | Resi    | in the   | and SF-36  | cruitment |
|     |    | ucat | nt | stance: | control  | scales of  | letter    |
|     |    | ion" | ro | n=17    | group.   | bodily     | were      |
|     |    | con  | l: |         |          | pain,      | eligible  |
|     |    | trol |    | C       |          | vitality,  | and       |
|     |    |      | 72 | ontrol: |          | social     | joined    |
|     |    |      | [+ | n=15    |          | fu         | the       |
|     |    |      | ]{ |         |          | nctioning, | study.    |
|     |    |      | .u |         |          | and role   |           |
|     |    |      | nd |         |          | emotional  |           |
|     |    |      | er |         |          | were all   |           |
|     |    |      | li |         |          | sig        |           |
|     |    |      | ne |         |          | nificantly |           |
|     |    |      | }2 |         |          | improved   |           |
|     |    |      | .0 |         |          | by         |           |
|     |    |      |    |         |          | exercise.  |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Flo | Co | Ga   | 6  | 777     | No       | GK made    | No        |
| rio | mp | teke | 0+ | older   | followup | 40.5% of   | symptom   |
| &   | ar | eper |    | adults  | period   | referrals  | outcomes  |
| Ra  | is | (GK) | G  | with    | employed | to elder   | reported. |
| sch | on | vs.  | K: | em      | in the   | services.  | P         |
| ko, | G  | med  | 7  | otional | study.   | GK         | revention |
| 1   | ro | ical | 4. | distu   |          | referrals  | of poor   |
| 998 | up | refe | 0[ | rbances |          | had        | health    |
|     |    | rral | +] | (63%)   |          | greater    | outcomes  |
| Ra  |    | (MD) | {. | or      |          | economic   | not       |
| sch |    | vs.  | un | co      |          | and social | reported. |
| ko, |    | refe | de | gnitive |          | isolation, |           |
| 1   |    | rral | rl | imp     |          | less       |           |
| 997 |    | by   | in | airment |          | physical   |           |
|     |    | ot   | e} | (60%)   |          | and ADL    |           |
| F   |    | hers | 10 | living  |          | i          |           |
| lor |    |      | .4 | in home |          | mpairment, |           |
| io, |    |      |    | or      |          | and fewer  |           |
| et  |    |      | M  | co      |          | had a      |           |
| a   |    |      | D: | mmunity |          | family     |           |
| l., |    |      |    | se      |          | physician  |           |
| 19  |    |      | 7  | ttings. |          | or social  |           |
| 96^ |    |      | 6. | 68%     |          | support.   |           |
| 29, |    |      | 8[ | female  |          | GK         |           |
| 31, |    |      | +] |         |          | referrals  |           |
| 32^ |    |      | {. | GK:     |          | were       |           |
|     |    |      | un | n=315   |          | younger,   |           |
|     |    |      | de |         |          | female,    |           |
|     |    |      | rl | MD:     |          | more       |           |
|     |    |      | in | n=217   |          | likely to  |           |
|     |    |      | e} |         |          | live       |           |
|     |    |      | 12 | Other:  |          | alone, and |           |
|     |    |      | .5 | n=245   |          | fewer were |           |
|     |    |      |    |         |          | married.   |           |
|     |    |      | Ot |         |          | GK         |           |
|     |    |      | he |         |          | referrals  |           |
|     |    |      | r: |         |          | had        |           |
|     |    |      |    |         |          | greater    |           |
|     |    |      | 7  |         |          | unmet need |           |
|     |    |      | 6. |         |          | for        |           |
|     |    |      | 6[ |         |          | services.  |           |
|     |    |      | +] |         |          |            |           |
|     |    |      | {. |         |          |            |           |
|     |    |      | un |         |          |            |           |
|     |    |      | de |         |          |            |           |
|     |    |      | rl |         |          |            |           |
|     |    |      | in |         |          |            |           |
|     |    |      | e} |         |          |            |           |
|     |    |      | 12 |         |          |            |           |
|     |    |      | .5 |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+

Table 2. Early intervention of late-life depression or anxiety
(continued)

+-----+----+------+----+---------+----------+---+------------+-----------+
| Ref | S  | Mode | A  | Sample  | Followup |   | Outcome    | Li        |
| ere | tu | l/Co | ge |         |          |   | Measures   | mitations |
| nce | dy | ndit |    |         |          |   | and        | /Comments |
|     | De | ions |    |         |          |   | Results    |           |
|     | si |      |    |         |          |   |            |           |
|     | gn |      |    |         |          |   |            |           |
+=====+====+======+====+=========+==========+===+============+===========+
| F   | C  | Ga   | 6  | 88      | 1 year   |   | Older      | Clinician |
| lor | on | teke | 0+ | older   | followup |   | adults     | ass       |
| io, | tr | eper |    | adults  | on 100%  |   | referred   | essments. |
| et  | ol | (GK) | G  | with    | of       |   | by GK, MD, | No        |
| a   | pr | vs.  | K: | d       | parti    |   | and Other  | a         |
| l., | e- | refe | 7  | ementia | cipants. |   | sources    | djustment |
| 19  | po | rral | 8. | (53%),  |          |   | had        | for       |
| 98^ | st | by   | 2[ | dep     |          |   | similar    | severity, |
| 29^ |    | med  | +] | ression |          |   | service    | or        |
|     |    | ical | {. | (16%),  |          |   | u          | baseline  |
|     |    | or   | un | or      |          |   | tilization | dif       |
|     |    | o    | de | bipolar |          |   | and        | ferences. |
|     |    | ther | rl | d       |          |   | o          | Model had |
|     |    | sou  | in | isorder |          |   | ut-of-home | been in   |
|     |    | rces | e} | (5%)    |          |   | p          | place for |
|     |    | (M   | 11 | living  |          |   | lacements. | many      |
|     |    | D/Ot | .2 | in home |          |   | Sig        | years.    |
|     |    | her) |    | or      |          |   | nificantly | P         |
|     |    |      | M  | co      |          |   | more GK    | revention |
|     |    |      | D/ | mmunity |          |   | referrals  | of poor   |
|     |    |      | Ot | se      |          |   | lived      | health    |
|     |    |      | he | ttings. |          |   | alone (70% | outcomes  |
|     |    |      | r: | 68%     |          |   | vs. 35%)   | not       |
|     |    |      |    | female. |          |   | and fewer  | reported. |
|     |    |      | 7  |         |          |   | were       |           |
|     |    |      | 9. | GK:     |          |   | married    |           |
|     |    |      | 5[ | n=40    |          |   | (20% vs.   |           |
|     |    |      | +] |         |          |   | 49%).      |           |
|     |    |      | {. | MD      |          |   |            |           |
|     |    |      | un | /Other: |          |   |            |           |
|     |    |      | de | n=48    |          |   |            |           |
|     |    |      | rl |         |          |   |            |           |
|     |    |      | in |         |          |   |            |           |
|     |    |      | e} |         |          |   |            |           |
|     |    |      | 10 |         |          |   |            |           |
|     |    |      | .0 |         |          |   |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+
| R   | R  | Mu   | 6  | 298     | 26-month |   | In         | No single |
| abi | CT | ltid | 0+ | older   | study.   |   | tervention | sta       |
| ns, |    | is-c |    | adults  | Followup |   | group had  | ndardized |
| 20  |    | ipli | PA | in      | data was |   | more       | t         |
| 00^ |    | nary | TC | senior  | a        |   | i          | reatment. |
| 33^ |    | dev  | H: | low     | vailable |   | mprovement | Rand      |
|     |    | elop | 75 | -income | on 50%   |   | in         | omization |
|     |    | ment | .0 | public  | of the   |   | p          | after     |
|     |    | of   | [+ | h       | PATCH    |   | sychiatric | ident     |
|     |    | care | ]{ | ousing. | group    |   | (BPRS) and | ification |
|     |    | p    | .u | 85%     | and on   |   | depressive | of mental |
|     |    | roto | nd | female  | 58% of   |   | symptoms   | illness,  |
|     |    | col. | er | in the  | the      |   | (MADRS).   | thus      |
|     |    | Nur  | li | PATCH   | control  |   | No         | weighting |
|     |    | se-b | ne | group,  | group.   |   | difference | to        |
|     |    | ased | }8 | c       |          |   | in         | original  |
|     |    | outr | .4 | ompared |          |   | u          | sample    |
|     |    | each |    | to 70%  |          |   | ndesirable | size.     |
|     |    | --   | Co | female  |          |   | moves.     | Dropout:  |
|     |    | (PAT | nt | in the  |          |   |            | 33% death |
|     |    | CH). | ro | Control |          |   |            | or moved; |
|     |    | Comp | l: | group.  |          |   |            | 13%       |
|     |    | ared | 75 |         |          |   |            | refusal.  |
|     |    | to   | .8 | PATCH:  |          |   |            | P         |
|     |    | u    | [+ | n=131   |          |   |            | revention |
|     |    | sual | ]{ |         |          |   |            | of mental |
|     |    | care | .u | C       |          |   |            | health    |
|     |    | con  | nd | ontrol: |          |   |            | outcomes  |
|     |    | trol | er | n=167   |          |   |            | not       |
|     |    | gr   | li |         |          |   |            | reported. |
|     |    | oup. | ne |         |          |   |            |           |
|     |    |      | }8 |         |          |   |            |           |
|     |    |      | .5 |         |          |   |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+
| Wil | R  | Pa   | Pa | Primary | 11-week  | P |            | Response  |
| lia | CT | roxe | ro | care    | tr       | r |            | to PST    |
| ms, |    | tine | x: | p       | eatment. | o |            | was       |
| et  |    | vs   | 71 | atients | 25%      | p |            | highly    |
| a   |    | pro  | [+ | with    | dropped  | o |            | variable  |
| l., |    | blem | ]{ | minor   | out.     | r |            | across    |
| 20  |    | sol  | .u | dep     |          | t |            | study     |
| 00^ |    | ving | nd | ression |          | i |            | sites.    |
| 38^ |    | t    | er | or      |          | o |            |           |
|     |    | reat | li | dys     |          | n |            |           |
|     |    | ment | ne | thymia. |          | o |            |           |
|     |    | (    | }6 | 41%     |          | f |            |           |
|     |    | PST) | .8 | female. |          | p |            |           |
|     |    | vs   |    |         |          | a |            |           |
|     |    | pla  | PS | Paro    |          | t |            |           |
|     |    | cebo | T: | xetine: |          | i |            |           |
|     |    | (    |    | n=137   |          | e |            |           |
|     |    | PBO) | 71 |         |          | n |            |           |
|     |    |      | [+ | PST:    |          | t |            |           |
|     |    |      | ]{ | n=138   |          | s |            |           |
|     |    |      | .u |         |          | i |            |           |
|     |    |      | nd | PBO:    |          | n |            |           |
|     |    |      | er | n=140   |          | r |            |           |
|     |    |      | li |         |          | e |            |           |
|     |    |      | ne |         |          | m |            |           |
|     |    |      | }7 |         |          | i |            |           |
|     |    |      | .0 |         |          | s |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      | PB |         |          | i |            |           |
|     |    |      | O: |         |          | o |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      | 71 |         |          | w |            |           |
|     |    |      | [+ |         |          | i |            |           |
|     |    |      | ]{ |         |          | t |            |           |
|     |    |      | .u |         |          | h |            |           |
|     |    |      | nd |         |          | e |            |           |
|     |    |      | er |         |          | i |            |           |
|     |    |      | li |         |          | t |            |           |
|     |    |      | ne |         |          | h |            |           |
|     |    |      | }7 |         |          | e |            |           |
|     |    |      | .2 |         |          | r |            |           |
|     |    |      |    |         |          | p |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      |    |         |          | r |            |           |
|     |    |      |    |         |          | o |            |           |
|     |    |      |    |         |          | x |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
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|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | g |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | p |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      |    |         |          | w |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | h |            |           |
|     |    |      |    |         |          | l |            |           |
|     |    |      |    |         |          | o |            |           |
|     |    |      |    |         |          | w |            |           |
|     |    |      |    |         |          | b |            |           |
|     |    |      |    |         |          | a |            |           |
|     |    |      |    |         |          | s |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | l |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | e |            |           |
|     |    |      |    |         |          | f |            |           |
|     |    |      |    |         |          | u |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | c |            |           |
|     |    |      |    |         |          | t |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | o |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | i |            |           |
|     |    |      |    |         |          | n |            |           |
|     |    |      |    |         |          | g |            |           |
|     |    |      |    |         |          | . |            |           |
+-----+----+------+----+---------+----------+---+------------+-----------+

Table 2. Early intervention of late-life depression or anxiety
(continued)

+-----+----+------+----+---------+----------+------------+-----------+
| Cui | Qu | Trai | I  | Resi    | 12       | In         | Not       |
| jpe | as | ning | nt | dential | months.  | tervention | ra        |
| rs, | i- | for  | er | care    | 40.6% of | group had  | ndomized, |
| 20  | ex | ca   | v: | fa      | part     | greater    | high      |
| 01^ | pe | regi |    | cility. | icipants | i          | dropout,  |
| 42^ | ri | vers | A  |         | dropped  | mprovement | unknown   |
|     | me | and  | ge | 78.5%   | out      | in         | which     |
|     | nt | o    | 71 | female. | within 1 | depression | par       |
|     | al | ther | -8 | All     | year of  | (GDS^1^)   | ticipants |
|     |    | e    | 0: | re      | the      | and        | received  |
|     |    | mplo |    | sidents | program. | Heal       | group     |
|     |    | yees | 2  | in      |          | th-Related | therapy   |
|     |    | of   | 0. | cluded, |          | Quality of | c         |
|     |    | res  | 2% | but     |          | Life       | omponent. |
|     |    | iden |    | t       |          | (          | Change in |
|     |    | tial | A  | argeted |          | SF-20^2^). | GDS is    |
|     |    | h    | ge | on      |          |            | not       |
|     |    | ome, | 81 | dep     |          |            | c         |
|     |    | i    | -9 | ressive |          |            | linically |
|     |    | nfo. | 0: | sy      |          |            | sig       |
|     |    | mee  |    | mptoms. |          |            | nificant. |
|     |    | ting | 6  |         |          |            |           |
|     |    | for  | 2. | Interv: |          |            |           |
|     |    | r    | 9% | n=213   |          |            |           |
|     |    | esid |    |         |          |            |           |
|     |    | ents | A  | C       |          |            |           |
|     |    | and  | ge | ontrol: |          |            |           |
|     |    | re   | 90 | n=211   |          |            |           |
|     |    | lati | +: |         |          |            |           |
|     |    | ves, |    |         |          |            |           |
|     |    | g    | 1  |         |          |            |           |
|     |    | roup | 3. |         |          |            |           |
|     |    | i    | 6% |         |          |            |           |
|     |    | nter |    |         |          |            |           |
|     |    | vent | Co |         |          |            |           |
|     |    | ions | nt |         |          |            |           |
|     |    | off  | ro |         |          |            |           |
|     |    | ered | l: |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | A  |         |          |            |           |
|     |    |      | ge |         |          |            |           |
|     |    |      | 71 |         |          |            |           |
|     |    |      | -8 |         |          |            |           |
|     |    |      | 0: |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | 2  |         |          |            |           |
|     |    |      | 4. |         |          |            |           |
|     |    |      | 2% |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | A  |         |          |            |           |
|     |    |      | ge |         |          |            |           |
|     |    |      | 81 |         |          |            |           |
|     |    |      | -9 |         |          |            |           |
|     |    |      | 0: |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | 5  |         |          |            |           |
|     |    |      | 2. |         |          |            |           |
|     |    |      | 1% |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | A  |         |          |            |           |
|     |    |      | ge |         |          |            |           |
|     |    |      | 90 |         |          |            |           |
|     |    |      | +: |         |          |            |           |
|     |    |      |    |         |          |            |           |
|     |    |      | 1  |         |          |            |           |
|     |    |      | 9. |         |          |            |           |
|     |    |      | 9% |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+
| Ci  | RC | PST  | 6  | Older   | 12       | In         | Int       |
| ech | T. | d    | 0+ | adults  | months.  | tervention | ervention |
| an- |    | eliv |    | in      | 7% of    | group had  | group had |
| ows | PE | ered | I  | senior  | the      | more       | a greater |
| ki, | AR | by   | nt | public  | inte     | i          | p         |
| 20  | LS | so   | er | h       | rvention | mprovement | roportion |
| 04^ | M  | cial | v: | ousing. | group    | in         | of        |
| 39^ | od | wor  |    | 79%     | and 9%   | depressive | dysthymia |
|     | el | kers | 72 | female. | of the   | symptoms   | than      |
|     |    | with | .6 | Di      | control  | and        | control   |
|     |    | psyc | [+ | agnoses | group    | functional | group.    |
|     |    | hiat | ]{ | i       | dropped  | &          | The       |
|     |    | rist | .u | ncluded | out.     | emotional  | authors   |
|     |    | sup  | nd | dy      |          | w          | believe   |
|     |    | ervi | er | sthymia |          | ell-being. | it to be  |
|     |    | sion | li | (49%)   |          | No         | feasible  |
|     |    | &    | ne | and     |          | difference | to add a  |
|     |    | coor | }8 | minor   |          | in service | d         |
|     |    | dina | .4 | dep     |          | use or     | epression |
|     |    | tion |    | ression |          | social and | m         |
|     |    | with | Co | (51%).  |          | physical   | anagement |
|     |    | PCP  | nt |         |          | w          | service   |
|     |    |      | ro | Interv: |          | ell-being. | to usual  |
|     |    |      | l: | n=72    |          | Remission  | case      |
|     |    |      | 73 |         |          | was        | m         |
|     |    |      | .5 | C       |          | achieved   | anagement |
|     |    |      | [+ | ontrol: |          | by 36% of  | p         |
|     |    |      | ]{ | n=66    |          | the        | ractices. |
|     |    |      | .u |         |          | in         |           |
|     |    |      | nd |         |          | tervention |           |
|     |    |      | er |         |          | group and  |           |
|     |    |      | li |         |          | 12% of the |           |
|     |    |      | ne |         |          | control    |           |
|     |    |      | }8 |         |          | group.     |           |
|     |    |      | .5 |         |          |            |           |
+-----+----+------+----+---------+----------+------------+-----------+

Research Needs and Future Directions

Attention to the prevention and appropriate treatment of substance abuse
and mental health problems was identified as a major priority for older
adults by the President's New Freedom Commission on Mental Health.^59^
As identified in this review, there is a need for organizing,
disseminating, and understanding evidence-based prevention and early
intervention programs for late-life substance abuse and mental illness.
While progress has been made in understanding the effectiveness of these
programs and practices for older adults, there are challenges to
matching these models to different service settings and different
subgroups of older adults.

The growth in the aging population will have a significant impact on the
substance abuse and mental health service delivery systems. ^1,60,61^ In
anticipation of this growing problem, it is essential that substance
abuse and mental health services meet the specific needs of older
adults. For instance, cohorts of the young-old (e.g., baby boomers) and
the old-old have different patterns of service utilization and different
perceptions of stigma associated with receiving care for substance use
or mental health disorders. Moreover, the prevalence of substance abuse,
mental health disorders, and suicidal ideation vary across ethnic
groups.^62-68^ Mental health services are infrequently utilized by older
minority populations^69^ and lower utilization rates may be associated
with limited access, stigma, distrust of mental health providers, and
limited availability of culturally-competent services.^70-71^ The lack
of information on specific ethnic differences and culturally-appropriate
service provision represents a limitation of the current evidence base.
A greater understanding of cultural and ethnic differences is needed to
enhance the ability to provide appropriate prevention and early
intervention to older minorities with substance use and mental health
disorders. For instance, social marketing associated with universal
prevention interventions should be specifically tailored to cultural and
language differences of ethnic groups. In addition, cultural competence
should be enhanced across the full spectrum of prevention interventions.

This report provides a comprehensive review of the evidence for
prevention and early intervention of alcohol abuse, medication misuse,
depression and anxiety, suicide, and co-occurring disorders in older
adults. As indicated by our findings, the development of preventive
interventions associated with substance abuse surpasses that associated
with mental health problems. However, the development and rigorous
evaluation of programs that target both of these areas are sorely
needed. In addition, there is a need to identify methods to
appropriately translate information from clinical trials and research
settings into the health care arenas where older adults most frequently
receive care, and into social services settings where they receive other
needed services. Likewise, population-based programs that target broad
audiences of older adults may also offer hope for the universal
prevention of substance use and mental health problems. In summary,
substance use and mental health problems pose significant risks for the
functioning and well-being of older adults. Although several prevention
and early intervention programs have been developed, there is a
considerable need for dissemination and implementation of effective
programs, as well as for further research aimed at the development and
testing of novel programs.

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