Psychosocial Interventions for the Prevention of Depression in Older Adults: Systematic Review and...

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published online 8 October 2010J Aging HealthAnna K. Forsman, Isabell Schierenbeck and Kristian Wahlbeck

Adults: Systematic Review and Meta-AnalysisPsychosocial Interventions for the Prevention of Depression in Older

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1Nordic School of Public Health, Gothenburg, Sweden2THL National Institute for Health and Welfare, Mental Health Promotion Unit, Vaasa, Finland3University of Gothenburg, Gothenburg, Sweden4Vaasa Central Hospital, Vaasa, Finland

Corresponding Author:Anna K. Forsman, THL National Institute for Health and Welfare, Mental Health Promotion Unit, Sarjakatu 2 C, 65320 Vaasa, Finland Email: [email protected]

Psychosocial Interventions for the Prevention of Depression in Older Adults: Systematic Review and Meta-Analysis

Anna K. Forsman, MSocSc1,2,Isabell Schierenbeck, PhD3, and Kristian Wahlbeck, MD4

Abstract

Objectives: To assess the effectiveness of psychosocial interventions for the prevention of depression in older people. Method: Systematic review and meta-analysis of prospective controlled trials. Results: Thirty studies were included. Overall, psychosocial interventions had a small but statistically significant effect on depressive symptoms (17 trials, standardized mean differ-ence = -0.17, 95% CI = -0.31 to -0.03). In comparison with no-intervention controls, social activities were effective in reducing depressive symptoms, but results should be interpreted with caution due to the small number of trials. No statistically significant effect on depressive symptoms was found for physical exercise, skill training, reminiscence, or for multicomponent interventions.



2 Journal of Aging and Health XX(X)

Discussion: Psychosocial interventions have a small but statistically significant effect in reducing depressive symptoms among older adults. The current evi-dence base for psychosocial interventions for primary prevention of depression in older people is weak, and further trials warranted especially for the most promising type of interventions evaluated, that is, social activities.

Keywords

systematic review and meta-analysis, prevention of depression among older adults, psychosocial interventions

Introduction

Unipolar depression is expected to become the largest contributor to the world-wide disease burden in 2030 (WHO, 2008). Among the aging population, anxiety and depression are the most prevalent mental health problems (de Beurs et al., 2005; Luijendijk et al., 2008; WHO, 2008), with around 12% of adults aged 65 or older currently affected by depressive syndromes in Europe (Copeland et al., 1999, 2004). Given the growth of the older adult population worldwide (Department of Economic and Social Affairs, 2002), depression in older adults is set to become an increasingly important health issue (Jané-Llopis & Gabilondo, 2008; WHO, 2008). Effective interventions are needed to prevent depression and depressive symptoms.

According to a large body of research, older women are more at risk of depression than older men (Cole & Dendukuri, 2003; Smit, Ederveen, Cui-jpers, Deeg, & Beekman, 2006; Steunenberg, Beekman, Deeg, & Kerkhof, 2006). Various medical conditions and functional limitations are common risk factors for depressive symptoms (Bisschop, Kriegsman, Beekman, & Deeg, 2004) and depressive disorders (Beekman et al., 1995; Smit et al., 2006) among older people. The association between poor socioeconomic status and the onset of late-life depression has also been highlighted (Smit et al., 2006). Older individuals’ social network (Bisschop et al., 2004; Jongenelis et al., 2004; Steunenberg et al., 2006) and social support (Jonge-nelis et al., 2004; Lynch et al., 1999) are negatively associated with depressive symptoms and depression.

Research has demonstrated a significant reduction in depressive symptoms through adequate prevention programs directed to different age groups, but the number of studies targeting the incidence of depressive disorder and its preven-tion among older adults specifically is limited (Jané-Llopis, Hosman, Jenkins,



Forsman et al. 3

& Anderson, 2003). The objective of this review is to assess the effectiveness of psychosocial interventions in the primary prevention of depressive symptoms and unipolar depressive disorders in people aged 65 or above.

MethodSearchesEleven electronic databases were searched (AgeLine, ASSIA, CENTRAL, Cinahl, Embase, Medline, OpenSIGLE, Sociological Abstracts, Social Services Abstracts, PsycINFO, and Web of Science) for eligible studies. With guidance from informatics experts, search strategies were constructed for each of the electronic databases and applied in October 2009. Hand-searching of journals was conducted, covering issues of The Gerontologist and Journal of the American Geriatrics Society published from 2006 to 2009.

SelectionOnly prospective controlled studies with all participants aged 65 years or older, or an average participant age of 70 years or older, were considered for this review. Trial participants must not have met the diagnostic criteria for a depressive disorder at the time of enrolment. Thus we included trials targeting the general older adult population, older adults at risk for depression, or those who already suffer from subclinical symptoms of depression, but who did not at that time fulfill the diagnostic criteria for a depressive disorder (according to the Inter-national Statistical Classification of Diseases and Related Health Problems [ICD] or Diagnostic and Statistical Manual of Mental Disorders (DSM) or according to depression rating scales if ICD or DSM criteria not used). All studies where the participants suffered from a psychiatric disorder (e.g., dementia) were excluded from the review. Trials were included regardless of setting, that is, institution or community.

Psychosocial interventions were defined as any intervention that emphasizes psychological or social factors rather than biological factors (Ruddy & House, 2005). This definition allows for the inclusion of psychological therapies and health education as well as interventions with a focus on social aspects, such as social support and networking. Interventions with a physiological component in addition to a psychosocial component (e.g., exercise groups for older people) were also considered. The psychosocial interventions could appear in any format, for example, in groups or individually, as long as they were described in the study and would allow for replication. Interventions with organization of care




as the main focus were not considered for this review. All trials of secondary and tertiary preventive interventions, relapse prevention, and pharmacological interventions were excluded.

The trials considered for this review had depressive symptoms or depression as a measured outcome. Furthermore, to be eligible, trials had to encompass a control condition: either care as usual, waiting list, or no intervention.

Data Abstraction and Assessment of Methodological QualityAll publications retrieved from the databases were screened for inclusion by the primary reviewer and an independent researcher separately. Available data were extracted and coded independently by the primary reviewer and a second data extractor.

The methodological quality of the included intervention studies was assessed and rated according to the Cochrane Collaboration Handbook (Higgins & Green, 2008). The studies were rated by taking six individual domains into consideration (sequence generation; allocation concealment; blinding of participants, personnel, and outcome assessors; incomplete outcome data; selec-tive outcome reporting; and other sources of bias) and giving them a quality rating of “low risk of bias,” “unclear,” or “high risk of bias.”

Outcomes MeasuredThe primary outcome of the review was the occurrence of depression and depressive symptoms, as measured by depression rating scales (such as the Geriatric Depression Scale). Secondary outcomes were functional level and quality of life. The outcome measures were recorded either immediately after the intervention or at end of follow-up.

Calculation of Effect Sizes and Statistical AnalysesData were entered into Review Manager 5.0 software (The Nordic Cochrane Centre, 2008) by the principal reviewer and duplicated by an independent researcher separately. For binary efficacy outcomes (e.g., depression), the Mantel-Haenszel random effects model for calculating odds ratio (OR) was applied. Where intention-to-treat (ITT) data were not available, end-point con-tinuous data for trial completers were used. For continuously distributed out-comes, the weighted mean difference (WMD) or standardized mean difference (SMD) were calculated as appropriate using a random effects model. SMD was calculated when outcomes had been measured using different scoring systems.



Forsman et al. 5

If measures of variance of outcomes could not be found through publications, through calculations, or by contacting the authors, the outcome was excluded from the meta-analysis. Substantially skewed data (where the standard devia-tion was more than twice the mean value) were not entered in the meta-analysis. The impact of statistical heterogeneity on the meta-analysis was assessed by quantifying inconsistency among the studies with the I2 Index test (Higgins & Green, 2008). Sensitivity analyses were conducted looking at randomized trials only and at studies with low risk of bias only (i.e., at least two out of six domains were rated as low risk of bias for the study).

ResultsTrial FlowThe searches yielded 3,972 hits (including duplicates from different databases). By screening the retrieved titles and abstracts according to the inclusion criteria, the number of publications was reduced to 790, and after having checked these in detail, the final number of included studies were narrowed to 30 (Figure 1). The main reasons for exclusion of the retrieved publications were that trial participants already suffered from depression at baseline and that the participants’ age did not meet the inclusion criteria. Eleven of the included trials did not provide data suitable for the meta-analysis. Efficacy estimates are thus based on data from 19 trials.

Study CharacteristicsThe mean age of the pooled trial participants was 77 years. In studies reporting gender proportions, 71% of the participants were women. The participants of eight trials lived in nursing homes or other institutions, while 18 trials considered older adults living independently, receiving health services at home, or living in senior communities. Four of the studies did not clearly state the living situ-ation of the participants.

Out of the 30 included studies, 7 were nonrandomized controlled studies (Andersson, 1982, 1984; Arnetz, Eyre, & Theorell, 1982; Arnetz & Theorell, 1983; Arnetz, Theorell, Levi, Kallner, & Eneroth, 1983; Baker, 2001; Chao et al., 2006; Cohen et al., 2006; Collier, 1997; Wahl, Becker, Burmedi, & Schilling, 2004; Wahl et al., 2006). The other included studies (N = 23) had a randomized controlled design.

Three types of prevention (WHO, 2004) were distinguished from among the trials: universal prevention among older adults (such as general health education),




regardless of whether they were at a higher than average risk average of develop-ing depression (12 trials); selective prevention, targeting older people in high-risk groups not yet suffering from depression (15 trials); and indicated prevention directed to people with subclinical symptoms of depression (3 trials).

All interventions except one were provided by health or social care professionals or other trained personnel. One intervention involved the older participants themselves in a volunteer activity (mentoring English conversational skills to English-as-a-second-language students). Besides this intervention study, none of the interventions were reportedly provided by lay people alone.

Records identified throughdatabase searching

(n = 3,908)

Scr

een

ing

Incl

ud

edE

ligib

ility

Iden

tifi

cati

on

Additional records identifiedthrough other sources

(n = 64)

All records (including duplicates)(n = 3,972)

Records screened(including duplicates)

(n = 3,972)

Records excluded(n = 3,182)

Full-text articlesassessed for eligibility

(n =790)

Full-text articles excludeddue to inadequate trialdesign or participants’

characteristics(e.g. low mean age orsuffering from mental

disorders(n = 760)

Studies included inreview

(n = 30)

Studies included inmeta-analysis

(n = 19)

Figure 1. PRISMA 2009 flow diagramSource: Moher, Liberati, Tetzlaff, Altman, and The PRISMA Group (2009).



Forsman et al. 7

The prevention interventions included were categorized into one of the following 6 groups: physical exercise, skill training, group support, reminis-cence, social activities, and multicomponent interventions (Table 1). The group of physical exercise trials involved individual or group physical exercise. The skill-training trials group contained interventions with educational components or with the aim of developing cognitive skills or everyday life management strategies. Social support in groups was considered within the group support category, and different types of social activities where the participants have an active role were allocated to the group of social activity trials. Several trials contained various forms of life reviewing and recalling past events in life and this group of interventions were classified as reminiscence trials. Some of the trials contained components from several intervention categories and these were classified as multicomponent interventions.

There was a wide range of different scales used for measuring trial outcomes. In measuring depression, the following scales were used: the Geriatric Depression Scale (GDS); the Center for Epidemiologic Studies Depression Scale (CES-D); the Profile of Mood States (POMS) Depression Scale; the Depression, Anxiety and Stress Scales (DASS); the Hamilton Depression Rating Scale (HDRS); the Brief Symptom Inventory (BSI); and the Zung Self-rating Depression Scale (ZSDS).

For measuring quality of life, the following assessment scales were used: the Health Survey Short Form (SF-36), the WHO Quality of Life-BREF Scale, The Flanagan’s Quality of Life Scale, and the Pearlman’s Quality of Life Scale.

Table 1. Number of Trials and Participants Within Each Type of Intervention

Type of intervention

Number of studies in review

Number of studies in

meta-analysis

Number of participants (of studies included in meta-analysis)

Physical exercise 7 3 277

Skill training 7 5 375

Group support 1 0 No eligible data for meta-analysis

Reminiscence 6 5 179

Social activities 3 2 194

Multicomponential 6 4 672

Total 30 19 1,697




Functional ability was measured with the Older Americans Resources and Services (Instrumental Activities of Daily Living)—known as the OARS (IADL)—the Barthel Index (BI), and various forms of activities-of-daily-living measurements.

In most cases, several domains of the trial’s methodological quality were rated as unclear, due to scarce reporting. Five of the studies were rated as having low risk of bias in relation to the sequence generation domain. Four studies had a low risk of bias in blinding and two of the included trials evidenced clear cases of selective reporting. Twelve studies were rated as having a high risk of bias related to other possible domains.

EfficacyOverall, in the pooled analysis, psychosocial interventions had a weak but statistically significant effect on depressive symptoms (17 trials, SMD = -0.17, 95% CI = -0.31 to -0.03; Table 2). The overall heterogeneity for the depression outcome was 25%.

The pooled results for the dichotomous depression outcome indicated a nonsignificant reduction of new depression cases (3 trials, OR = 0.69, 95% CI = 0.41 to 1.17; Table 3).

Only 4 trials reported eligible data on the secondary outcomes quality of life or functional ability. Overall, no statistically significant effect on quality of life was found (3 trials, SMD = -0.09, 95% CI = -0.37 to 0.19), neither for the overall functional ability outcome (2 trials, SMD = -0.28, 95% CI = -0.70 to 0.13).

When analyzing types of interventions separately, physical exercise had at most a weak nonsignificant effect on depressive symptoms (3 trials, SMD = -0.10, 95% CI = -0.36 to 0.16; Table 4).

Skill training showed a statistically nonsignificant weak effect on depres-sive symptoms (4 trials, SMD = -0.12, 95% CI = -0.56 to 0.32). Two trials within this intervention type reported incidence of depressive disorders (dichot-omous data). No significant effect could be evidenced (OR = 0.84, 95% CI = 0.53 to 1.33).

Reminiscence interventions showed a small, statistically nonsignificant effect (5 trials, SMD = -0.24, 95% CI = -0.62 to 0.13) on depressive symptoms, compared to no-intervention controls.

Compared to no intervention, social activities significantly reduced depres-sive symptoms among the participants (2 trials, SMD = -0.41, 95% CI = -0.72 to -0.10). This result should, however, be interpreted with caution as it is based on two studies only.



9

(con

tinue

d)

Tab

le 2

. Effe

ct o

f Psy

chos

ocia

l Int

erve

ntio

ns V

ersu

s N

o-In

terv

entio

n C

ontr

ols

on D

epre

ssio

n (c

ontin

uous

dat

a)

Inte

rven

tion

Con

trol

Std.

mea

n di

ffere

nce

Std.

mea

n di

ffere

nce

Stud

y or

sub

grou

pM

SDTo

tal

MSD

Tota

lW

eigh

tIV

, ran

dom

, 95%

CI

IV, r

ando

m, 9

5% C

I

1. E

xerc

ise

Col

lier

(199

7)3.

844.

1125

43.

7413

3.8%

−0.

04 [

−0.

71, 0

.63]

Tsa

ng, M

ok, A

u Ye

ung,

and

Cha

n (2

003)

6.13

4.14

245.

164.

1426

5.2%

0.23

[−

0.33

, 0.7

9]

W

illia

ms

and

Lord

(19

97)

3.25

4.47

714.

617.

3178

11.0

%−

0.22

[−

0.54

, 0.1

0]

Su

btot

al (

95%

CI)

120

117

19.9

%−

0.10

[−

0.36

, 0.1

6]

H

eter

ogen

eity

: Tau

2 = 0

.00;

Chi

2 = 1

.93,

df =

2 (

p =

.38)

; I2 =

0%

Test

for

over

all e

ffect

: Z =

0.7

4 (p

= .4

6)

2. S

kill

trai

ning

Brod

y et

al.

(200

2)42

.423

.57

6643

.42

28.7

111

011

.7%

−0.

04 [

−0.

34, 0

.27]

Ras

mus

son,

Reb

ok, B

ylsm

a, an

d Br

andt

(19

99)

1.43

1.65

353.

53.

511

3.5%

−0.

92 [

−1.

63, −

0.21

]

W

ahl e

t al

. (20

06)

4.14

3.29

382.

92.

716

4.7%

0.39

[−

0.20

, 0.9

8]

W

inoc

ur e

t al

. (20

07)

3.46

3.26

273.

733.

6315

4.2%

−0.

08 [

−0.

71, 0

.55]

Subt

otal

(95

% C

I)16

615

224

.1%

−0.

12 [

−0.

56, 0

.32]

Het

erog

enei

ty: T

au2 =

0.1

2; C

hi2 =

7.9

7, d

f = 3

(p =

.05)

; I2 =

62%

Test

for

over

all e

ffect

: Z =

0.5

4 (p

= .5

9)

3. R

emin

isce

nce

Cha

o et

al.

(200

6)2.

912.

7710

4.63

28

2.0%

−0.

67 [

−1.

63, 0

.30]

Emer

y (2

002)

3.17

2.39

183

1.51

82.

6%0.

08 [

−0.

76, 0

.91]

Hai

ght

(199

2)19

.67

13.4

510

19.7

13.2

253.

3%−

0.00

[−

0.74

, 0.7

3]

K

offm

an (

1998

)4.

213.

123

44.

5212

3.5%

0.06

[−

0.64

, 0.7

5]

M

aste

l-Sm

ith, M

cFar

lane

, Sie

rpin

a, M

alec

ha, a

nd H

aile

(20

07)

42.6

3.07

1547

.81

8.29

163.

2%−

0.80

[−

1.54

, −0.

07]

Subt

otal

(95

% C

I)76

6914

.6%

−0.

24 [

−0.

62, 0

.13]

Het

erog

enei

ty: T

au2 =

0.0

3; C

hi2 =

4.6

3, d

f = 4

(p =

.33)

; I2 =

14%

Test

for

over

all e

ffect

: Z =

1.2

6 (p

= .2

1)



10

Inte

rven

tion

Con

trol

Std.

mea

n di

ffere

nce

Std.

mea

n di

ffere

nce

Stud

y or

sub

grou

pM

SDTo

tal

MSD

Tota

lW

eigh

tIV

, ran

dom

, 95%

CI

IV, r

ando

m, 9

5% C

I

4. S

ocia

l act

iviti

es

C

ohen

et

al. (

2006

)1.

141.

8477

1.84

1.89

6410

.5%

−0.

37 [

−0.

71, −

0.04

]

Yu

en, H

uang

, Bur

ik, a

nd S

mith

(20

08)

4.92

4.25

139

7.79

132.

8%−

0.63

[−

1.42

, 0.1

6]

Su

btot

al (

95%

CI)

9077

13.4

%−

0.41

[−

0.72

, −0.

10]

Het

erog

enei

ty: T

au2 =

0.0

0; C

hi2 =

0.3

4, d

f = 1

(p =

.56)

; I2 =

0%

Test

for

over

all e

ffect

: Z =

2.6

2 (p

= .0

09)

5.

Mul

ticom

pone

nt in

terv

entio

ns

C

lark

, Rub

enac

h, a

nd W

inso

r (2

003)

4.5

2.1

324.

81

306.

1%−

0.18

[−

0.68

, 0.3

2]

R

esni

ck, L

uisi

, and

Vog

el (

2008

)0.

410.

7964

0.79

1.1

398.

3%−

0.41

[−

0.81

, −0.

01]

Salm

inen

, Iso

aho,

Vah

lber

g, O

janl

atva

, and

Kiv

ela

(200

5)40

.11

7.16

116

40.0

68.

4310

613

.5%

0.01

[−

0.26

, 0.2

7]

Su

btot

al (

95%

CI)

212

175

28.0

%−

0.16

[−

0.41

, 0.1

0]

H

eter

ogen

eity

: Tau

2 = 0

.02;

Chi

2 = 2

.93,

df =

2 (

p =

.23)

; I2 =

32%

Test

for

over

all e

ffect

: Z =

1.1

7 (p

= .2

4)

Tota

l (95

% C

I)66

459

010

0.0%

−0.

17 [

−0.

31, −

0.03

]

Het

erog

enei

ty: T

au2 =

0.0

2; C

hi2 =

21.

43, d

f = 1

6 (p

= .1

6); I

2 = 2

5%

Test

for

over

all e

ffect

: Z =

2.3

8 (p

= .0

2)

Not

e: C

I = c

onfid

ence

inte

rval

.

Tabl

e 2.

(co

ntin

ued)

–2

–1

01

2

Fa

vors

tre

atm

ent

Fa

vors

co

ntr

ol



11

Tab

le 3

. Effe

ct o

f Psy

chos

ocia

l Int

erve

ntio

ns V

ersu

s N

o-In

terv

entio

n C

ontr

ols

on D

epre

ssio

n (D

icho

tom

ous

Dat

a)

Inte

rven

tion

Con

trol

OR

OR

Stud

y or

sub

grou

pEv

ents

Tota

lEv

ents

Tota

lW

eigh

tM

-H, r

ando

m,

95%

CI

M-H

, ran

dom

, 95%

CI

1. S

kill

trai

ning

Brod

y et

al.

(200

2)20

8634

144

40.6

%0.

98 [

0.52

, 1.8

4]

R

o vne

r, C

aste

n, H

egel

, Lei

by, a

nd T

asm

an

(200

7)20

9526

9537

.9%

0.71

[0.

36, 1

.38]

Su

btot

al (

95%

CI)

181

239

78.5

%0.

84 [

0.53

, 1.3

3]

To

tal e

vent

s40

60

H

eter

ogen

eity

: Tau

2 = 0

.00;

Chi

2 = 0

.48,

df =

1 (

p =

.49)

; I2 =

0%

Test

for

over

all e

ffect

: Z =

0.7

4 (p

= .4

6)

2. M

ultic

ompo

nent

inte

rven

tions

van’

t Vee

r-Ta

zela

ar e

t al

. (20

09)

686

1584

21.5

%0.

34 [

0.13

, 0.9

4]

Su

btot

al (

95%

CI)

8684

21.5

%0.

34 [

0.13

, 0.9

4]

To

tal e

vent

s6

15

H

eter

ogen

eity

: Not

app

licab

le

Te

st fo

r ov

eral

l effe

ct: Z

= 2

.09

(p =

.04)

To

tal (

95%

CI)

267

323

100.

0%0.

69 [

0.41

, 1.1

7]

Tota

l eve

nts

4675

H

eter

ogen

eity

: Tau

2 = 0

.07;

Chi

2 = 3

.00,

df =

2 (

p =

0.22

); I2 =

33%

Te

st fo

r ov

eral

l effe

ct: Z

= 1

.38

(p =

.17)

Not

e: O

R =

odd

s ra

tio; C

I = c

onfid

ence

inte

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Multicomponent interventions showed a nonsignificant weak effect on depressive symptoms (3 trials, SMD = -0.16, 95% CI = -0.41 to 0.10). One trial within this intervention category reported only incidence of depressive disorders (dichotomous data) and showed a small but significant effect (OR = 0.34, 95% CI = 0.13 to 0.94).

The effect on quality of life and functional ability was nonsignificant: SMD = -0.03 (2 trials, 95% CI = -0.34 to 0.29) and -0.42 (1 trial, 95% CI = -0.92 to 0.09), respectively. We were unable to retrieve any eligible data for group support trials.

To investigate the robustness of our findings, we performed sensitivity analy-ses looking at only randomized controlled trials and only trials with a low risk of bias rating on at least two out of six domains. We found our results to be robust: considering the randomized controlled trials only, the overall effect of psychosocial interventions on depressive symptoms remained virtually unchanged (13 trials, SMD = -0.17, 95% CI = -0.32 to -0.02).

Table 4. Effect Size (95% CI) for Psychosocial Interventions Compared to No Intervention

Type of intervention

Number of participants (depression/quality of life/

functional level measured) Depression

Quality of life

Functional level

Physical exercise 237/0/0 −0.10 (−0.36, 0.16)

Not estimable

Not estimable

Skill training 318/42/0 −0.12 (−0.56, 0.32)

−0.38 (−1.01, 0.26)

Not estimable

Reminiscence 145/0/35 −0.24 (−0.62, 0.13)

Not estimable

0.00 (−0.73, 0.74)

Social activities 167/0/0 −0.41 (−0.72, −0.10)a

Not estimable

Not estimable

Multicomponent 387/165/62 −0.16 (−0.41, 0.10)

−0.03 (−0.34, 0.29)

−0.42 (−0.92, 0.09)

Any type of psychosocial intervention

1,254/207/97 −0.17 (−0.31, −0.03)a

−0.09 (−0.37, 0.19)

−0.28 (−0.70, 0.13)

Note: CI = confidence interval.a. Statistically significant effect sizes.



Forsman et al. 13

Discussion

Our findings show that psychosocial interventions with a focus on the primary prevention of depressive symptoms among older adults in general are charac-terized by a small or no effect. The results of two trials indicate that social activities significantly reduce depressive symptoms when compared to no-intervention controls. The effect of physical exercise, skill training, reminis-cence, and multicomponent interventions in reducing depressive symptoms was small and not statistically significant. The lack of statistical significance is probably due to the combination of a small effect size and lack of statistical power due to small and few studies.

Only three trials reported data on number of people with depression, and thus our results are mostly based on depression rating scale scores. Primary prevention trials are characterized by none or fairly low levels of depressive symptoms at baseline, which means limited possibilities for detecting a decrease in symptoms in the current review. Taking into account the estimated incidence of major depression in older adults, depression prevention trials will need to include substantially higher number of participants than any of the trials included in this review to show a decrease in incidence of major depression. It is however promising that pooled results of the three trials indicate a reduction of new depression cases, albeit statistically nonsignificant. Determining and measuring different risk factors for depressive disorders, rather than assessing depressive symptoms among nondepressive older popu-lations, might be a more appropriate approach within the primary prevention research. Hence, we included measures of quality of life and functional ability as secondary outcomes.

Across all ages, not many systematic reviews and meta-analyses on primary prevention of depression programs are to be found. Until now, no meta-analyses have studied the effect of psychosocial interventions for primary prevention of depressive symptoms and depression among older adults only. Existing systematic reviews and meta-analyses covering all ages have found that primary prevention interventions are effective in preventing the onset of depressive disorders and depressive symptoms (Cuijpers, van Straten, Smit, Mihalopoulos, & Beekman, 2008; Jané-Llopis et al., 2003). One of the reviews highlighted social support as the most effective intervention type, while interventions with behavioral components seemed to be harmful for older adults (Jané-Llopis et al., 2003). Due to more strict inclusion criteria used for this current review, there are some differences in the sets of included studies on older people of the reviews. Studies focusing on the organization of care or targeting older intervention participants with low cognitive abilities were, for instance,




excluded from the current review while considered in one previous review (Jané-Llopis et al., 2003). Previous research has also highlighted the effect of psychosocial interventions on depression and depressive symptoms among older adults younger than the participants in the trials of this review. For example, time-limited, small group-based psychoeducational and skill-training interventions, theoretically based on cognitive behavioral principles, had an impact on depressive symptoms and positive mental health in a randomized controlled trial with participants being 50 years of age or older (mean age 64 years; Coon, Thompson, Steffen, Sorocco, & Gallagher-Thompson, 2003). In this review, no significant effects on the depressive symptoms were found when comparing skill training to no intervention control conditions. This may be due to the fact that the effects of skill training may be age-dependent, that is, older people do not acquire new skills as easily as younger persons.

Group support, such as discussions and exchanges of experiences in groups, has been frequently applied in psychosocial intervention programs (Birk et al., 2004). In the current review, only one trial (Andersson, 1982, 1984) with group support as the main content was included but did not contribute to the meta-analysis due to lack of data. The results of the study indicated that discussion groups designed to strengthen the social networks and support may decrease loneliness among older adults and also helps to increase the social contacts and the social activities of older people. Psychosocial inter-ventions that aim to increase the social contacts of older participants have indicated an improvement in mental well-being as well as a reduction in feelings of loneliness (Onrust, 2008; Stevens, Martina, & Westerhof, 2006; Stevens & Tilburg, 2000). In this review, two social activity trials evidenced effect in reducing depressive symptoms. In addition to the trials in this cat-egory, several of the interventions within the multicomponent group contained different forms of social contact and support that could have contributed to the results. Except for the single trial reporting dichotomous data on depres-sion, the multicomponent interventions showed neither significant reduction in depressive symptoms nor any significant improvements in quality of life or functional level in this review. These results may indicate that a focus on participation in social activities is needed to achieve a preventive effect on depressive symptoms.

One important factor that could explain the relative lack of effect is the duration of the interventions and the frequency of the intervention sessions. Many of the trials had a short intervention program with only a few sessions, while one of the social activity interventions that gave significant results in the meta-analysis lasted for 30 weeks and contained a high frequency of



Forsman et al. 15

sessions (Cohen et al., 2006). Another important ingredient in this particular intervention was visibility; the participants got to display the creative product of the intervention via public performances. The other social activity interven-tion (Yuen, 2002; Yuen, Huang, Burik, & Smith, 2008) considered in the meta-analysis gave the older intervention receivers a social role and an impor-tant task that reportedly made them feel useful and needed. These social ele-ments might have an important impact on the outcomes of the intervention.

A major limitation of the review is the lack of reported data on the outcomes considered. The reporting was not comprehensive, often lacking information essential for the meta-analysis (e.g., trial adherence, means and standard devia-tion values from each of the trial arms and measurement points). There were also difficulties in assessing methodological quality and risk of bias due to poor reporting. Another limitation is the heterogeneity of trials. The trials are, besides various study designs, very different from each other in regard to intervention content, leading to difficulties in categorizing the interventions based on their content. Because of the wide range of outcome measurement scales in the trials included in the review, it was only possible to calculate the standardized mean difference. This makes interpreting the results difficult.

Implications for Research and PracticeFew prospective controlled trials have yet been conducted that study group and individual support and their effect on depressive symptoms or depression, functional ability, and quality of life among older adults. Overall, more large-scale, high-quality controlled trials on psychosocial interventions are needed to detect important effects of primary prevention of depression in older people. In addition, further research on cost effectiveness of psychosocial interventions is called for. A cost-effective approach can be achieved by identifying the risk factors (Heikkinen & Kauppinen, 2004), screening the elderly population for risk factors (Cole & Dendukuri, 2003), and by targeting effective preventive interventions toward the indicated high-risk groups (Smit et al., 2006).

This review points out social activities for proven efficacy among the psy-chosocial interventions to prevent depression. The review suggests that attention should be paid not only to the duration of the interventions but also to the frequency of sessions so as to obtain the best effects. Based on our results, meaningful social activities, tailored to the older individual’s abilities, prefer-ences, and needs, should be considered in the care of older people aiming to prevent the incidence for depression.




Appendix

Search Strategies

AgeLine Search Strategy(kw=controlled clinical trial* or kw=controlled trial* or kw=controlled

stud* or kw=clinical controlled or kw=CCT or kw=prospective or kw=random* assign* or kw=randomized controlled trials or ti=randomi*)

and((de=old old or de=older adults or de=65+ or de=70+) or (kw=geriatr* or

kw=elder* or kw=senile* or kw=late life or kw=old age or kw=Aged, 80-And-Over))

and(ab=depressi* or ab=mood or ab=mental status or ab=psychological well*

or de=psychological well being or ti=psychosocial interventi*)not(kw=antidepress* or kw=drug therapy or de=depression or de=anxiety

disorders or de=anxiety)

Applied Social Sciences Index and Abstracts (ASSIA) Search Strategy

((kw=controlled clinical trial* or kw=controlled trial* or kw=controlled stud* or kw=clinical controlled or kw=CCT or kw=prospective or kw=random* within 1 assign* or kw=random* within 1 stud* or kw=random* within 1 trial* or kw=randomized controlled trial* or ti=random*)

and((de=elderly women or de=elderly men or de=elderly people or de=very

old) or (kw=elderly or kw=geriatr* or kw=senile* or kw=old age or kw=late life or kw=aged, 80-and-over))

and((de=quality of life) or (de=life satisfaction or ab=depressi* or ab=mental

health index or ab=satisfaction or ab=psychological function* or ab=social participation or de=wellbeing or ab=well-being or ab=wellbeing or ab=mood or ab=self-esteem))

not((de=antidepressant drugs or de=medical treatment or kw=drugs or

kw=serotonin reuptake inhibitors) or kw=antidepres*))

Cinahl Search Strategyexp Clinical Trials/clinical trial.pt.

(continued)



Forsman et al. 17

(clinic$ adj trial$1).tw.((singl$ or doubl$ or trebl$ or tripl$) adj (blind$3 or mask$3)).tw.allocat$ random$.tw.random$ alloc$.tw.random$ control$ trial$.mp.randomi?ed trial$.mp.randomi?ed stud$.mp.control$ clinical trial$.mp.clinical$ control$ trial$.mp.control$ stud$.ti,ab.control$ clinical stud$.mp.prospective stud$.mp.CCT.ti,ab.“AGED, 80 AND OVER”/ or AGED/(elderly or geriatric or older adult$ or old age or late life or senil$).tw.Support, Psychosocial/psychosocial support.tw.(psychosocial$ adj2 intervent$).mp.(psychosocial$ adj2 support$).mp.(psychosocial$ adj2 treatment$).mp.(psychosocial$ adj2 training$).mp.psychosocial$.mp.depres$.mp. [mp=title, subject heading word, abstract, instrumentation]or/1-15or/16-17or/18-24and/25-28

The Cochrane Central Register of Controlled Trials (CENTRAL) Search Strategy

random$ control$ trial$.mp.randomi?ed trial$.mp.randomi?ed stud$.mp.control$ clinical$ trial$.mp.randomized controlled trials/randomized controlled trial.pt.(random$ adj alloc$).ti,ab.(random$ adj assign$).ti,ab.clinical$ control$ trial$.mp.

(continued)

Appendix (continued)




CCT.ti,ab.control$ stud$.ti,ab.prospective stud$.mp.“AGED, 80 AND OVER”/ or AGED/(((((((((((((elderly or geriat$ or old$) adj1 adult$) or old$) adj1 people) or

old$) adj1 population$) or old$) adj1 person$) or old) adj1 age) or late) adj1 life) or senil$).mp.

psychosocial.ti.(psychosocial$ adj intervent$).mp.(psychosocial$ adj program$).mp.(psychosocial$ adj support$).mp.(psychosocial$ adj treatment$).mp.(psychosocial$ adj educati$).mp.(psychosocial$ adj training).mp.social support.mp.depres$.mp. [mp=title, original title, abstract, mesh headings, heading words,

keyword]or/1-12or/13-14or/15-22and/23-26

EMBASE Search Strategycontrolled-study.de.clinical -trial#.de.major-clinical-study.de.randomized-controlled-trial.de.double-blind-procedure.de.clinical-article.de.random$9compar$6control$6follow adj up(singl$2 or doubl$2 or tripl$2 or trebl$2) adj (blind$5 or mask$5 or dummy)placebo$2clinic$5 adj (trial$4 or stud$4)1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13


(continued)



Forsman et al. 19

aged.w..de. or very-elderly.de.(elder$5 or geriatr$6 or senil$4 or old$3 adj adult$2 or old$3 adj age$2 or

old$3 adj people or old$3 adj person$2 or aged adj person$2 or late adj life or senior adj citizen$2).ti,ab.

15 or 16depressi$7psychosocial$9.ti.psychosocial$9 adj intervent$8psychosocial$9 adj (support$8 or educati$8 or training$2)19 or 20 or 2114 and 17 and 18 and 22

Medline Search Strategyexp Clinical Trial/randomized controlled trial/clinical trial.pt.random$ control$ trial$.mp,pt.(clinic$ adj trial$1).mp.(random$ adj trial$).mp.(random$ adj allocat$).mp.randomi?ed stud$.mp.controlled clinical trial.pt.prospective stud$.mp.CCT. ti,ab.clinical$ control$ trial$.ti,ab.control$ clinical trial$.ti,ab.control$ stud$.ti,ab.((singl$ or doubl$ or trebl$ or tripl$) adj (blind$3 or mask$3)).tw.double blind method/Single-Blind Method/“AGED, 80 AND OVER”/ or AGED/(elderly or geriatr$ or senil$ or older adult or old age or late life).ti,ab.(psychosocial$ adj intervent$).mp.psychosocial.ti.social support.mp.(psychosocial$ adj support$).mp.(psychosocial$ adj treatment$).mp.


(continued)




(psychosocial$ adj educati$).mp.(psychosocial$ adj training).mp.depres$.mp. [mp=title, original title, abstract, name of substance word,

subject heading word]or/1-17or/18-19or/20-26and/27-30

System for Information on Grey Literature in Europe (OpenSIGLE) Search Strategy

(prevent*)and(depress*)and(elder* or older adults or geriatr* or aged)and(psychosocial intervention or psychosocial* or intervention)or(prevent*)and(depress*)and(elder* or older adults or geriatr* or aged)or(elder* or older adults or geriatr* or aged)and(psychosocial intervention or psychosocial* or intervention)and(depression)or(random* or RCT)and(elder* or older adults or geriatr* or aged)and(psychosocial intervention or psychosocial* or intervention)


(continued)



Forsman et al. 21

PsycINFO Search StrategyS1 AB random* stud* or AB RCT or AB random* controlled trial* or AB

random* trial* or AB random* control* stud* or AB random* control* trial* or AB random* assign* or AB random* allocat* or TI random* or TI RCT

S2 TX controlled clinical trial* or TX clinical controlled trial* or TX pro-spective* or KW clinical trial* or MR treatment outcome/clinical trial or TI CCT or AB CCT

S3 SU elderly or SU aging or SU elder care or SU geriatrics or SU geriatric patient* or AB older people or AB old people or AB older persons or AB elderly persons or AB old age or AB aged people or AB geriatr* OR AB late life or AB senil* or AB elderly population or AB older adult* or AB aging or AB aged, 80-and-over or TI aging or TI elderly OR TI geriatr*

S4 AB quality of life or AB life quality or AB depress* or AB mood or AB satisfaction or AB emotional well* or AB mental well*

S5 SU drug therapy or SU pharmacology or SU serotonin reuptake inhibi-tors or SU electroconvulsive or TX antidepressive* or TX antidepressant* or SU drug* or KW medication* or KW medical patient* or KW medical therapy or KW medical treatment*

S6 S1 or S2S7 S3 and S4S8 S6 and S7S9 S8 not S5

Sociological Abstracts Search Strategy((ab=controlled clinical trial* or ab=controlled stud* or ab=controlled trial*

or ab=prospective stud* or ab=prospective trial* or de=intervention* or ti=intervention* or ab=control group* or ab=comparison group* or ab=experimental group or ti=random* or ab=randomized or kw=random* within 1 assign* or kw=random* within 2 stud* or kw=random* within 2 trial* or kw=random* control* trial* or kw= random* assign* or kw=random* allocat*)

and(de=elderly or de=aging or de=older people or de=elder care or ab=elderly

or ab=older adults or ab=old old or ab=old age or ab=late life or ab=senil* or ab=geriatr* or ab=aged, 80-and-over or ab=late adulthood)

and

(continued)





(de=social support or ab=quality of life or ab=mental health index or ab=geriatric depression scale or ab=social behavio* or ab=mental well* or ab=satisfaction or ab=psychological function* or ab=social participation or ab=social activity or ab=social relation* or ab=well-being or ab=wellbeing or ab=mood or ab=self-esteem))

not(de= medications or de=medical model or de=antidepress* or de=medical

treatment)

Social Services Abstracts Search Strategy((ab=controlled clinical trial* or ab=controlled stud* or ab=controlled trial*

or ab=prospective stud* or ab=prospective trial* or de=intervention* or ti=intervention* or ab=control group* or ab=comparison group* or ab=experimental group or ti=random* or ab=randomized or kw=random* within 1 assign* or kw=random* within 2 stud* or kw=random* within 2 trial* or kw=random* control* trial* or kw= random* assign* or kw=random* allocat*)

and(de=elderly or de=aging or de=older people or de=elder care or ab=elderly

or ab=older adults or ab=old old or ab=old age or ab=late life or ab=senil* or ab=geriatr* or ab=aged, 80-and-over or ab=late adulthood)

and(de=social support or ab=quality of life or ab=mental health index or

ab=geriatric depression scale or ab=social behavio* or ab=mental well* or ab=satisfaction or ab=psychological function* or ab=social participation or ab=social activity or ab=social relation* or ab=well-being or ab=wellbeing or ab=mood or ab=self-esteem))

not(de= medications or de=medical model or de=antidepress* or de=medical

treatment)

Web of Science (ISI) Search Strategy TS=(random* OR trial* OR control* OR (singl* OR doubl* OR trebl*

OR tripl*) AND (blind* OR mask*))TS=(randomized controlled trial* OR controlled clinical trial* OR clinical

trial* OR (clinical AND trial) OR random* allocat* OR comparative stud* OR comparative trial*)


(continued)



Forsman et al. 23

TS=(aged OR elder* OR geriatric OR older adult* OR senil* OR older OR old age OR late life)

TS=((psychosocial* AND intervent*) OR psychosocial* OR social support OR (psychosocial* AND support) OR (psychosocial*

AND treatment*) OR (psychosocial* AND educati*) OR (psychosocial* AND training))

TS=(depress*)#1 OR #2#1 AND #2#6 AND #7#8 AND #3 AND #4 AND #5

Acknowledgment

The authors thank Pia Pörtfors and Eeva-Liisa Aatola for guidance and support in designing and conducting the electronic searches. They also thank Anette Engsbo and Johanna Nordmyr for help with study selection and data extraction.

Authors’ Note

The search strategies were designed by A. K. Forsman and K. Wahlbeck with guidance from Pia Pörtfors and Eeva-Liisa Aatola. A. K. Forsman screened the literature, selected the studies, and extracted and coded the data with assistance from K. Wahlbeck, I. Schierenbeck, Anette Engsbo, and Johanna Nordmyr. A. K. Forsman analyzed and interpreted the findings and drafted the manuscript with guidance from K. Wahlbeck and I. Schierenbeck. All three authors contributed to the revision of the manuscript and approved the final version. A. K. Forsman is guarantor.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

Funding

The authors disclosed that they received the following support for their research and/or authorship of this article: This work was supported by the Sixth Research Framework of the European Commission, Grant No. FP6-2005-SSP-5A-041445 and by EVO Research Funding from Vaasa Hospital District, Finland.





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Forsman et al. 25

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