Depression is frequent and chronic in older adults. According to research on community-dwelling older adults, the proportion of individuals reporting depressive symptoms is 2.8% to 35% . The natural course of later-life depressive disorders is poor: a 6-year follow-up study showed that 76% of patients followed an unfavorable but fluctuating course or a severe chronic course of depression, and only 23% of patients experienced full remission .
Depression in older adults deteriorates the sufferers’ quality of life (QOL) more than many other chronic diseases . It gives a negative impact on patients’ QOL in various ways, including wellbeing, perceived physical functioning, bodily pain, and general health perceptions . The mortality rate of people with depression was found to be 1.8 times larger than that of non-depressed subjects due to suicide, unhealthy habits, and medical illnesses .
Depression is also costly. Depressed older adults use more outpatient resources than those without depression, including frequent appointments and increased laboratory and radiographic tests. They also have more non-specific medical complaints, and this is associated with increased total ambulatory care costs . A study in the United States found that the additional medical cost per one depressed older adult was USD 686 for 1 year and USD 5,271 for 4 years .
As the world population continues to age, there is an urgent need therefore for medicine and social policy to find ways to reduce and prevent depression in older adults in the community.
However, to the best of the authors’ knowledge, no simple, effective interventions currently exist for the prevention of depression in the elderly population . The existing prevention studies have limitations in study design or rely on time-consuming psychotherapy, which is unrealistic for a community prevention program. They need weekly sessions with a duration of 45 to 120 minutes for 6 to 10 weeks [9–12], and trained workers or specialists [9, 11–14]. The subjects of most of the studies were not general people in community but those with specific disease or physical symptoms such as diabetes , macular degeneration , hip fracture , chronic pain , and most of the studies recruited subjects in clinical settings [10, 11, 13, 15]. Some studies lacks sample size calculation [9, 10, 12] and were quasi-randomized controlled trials [10, 14].
A postcard intervention was first carried out in the United States in 1976 for suicide prevention among discharged major depression patients. Researchers sent 24 letters over 5 years and reported that this significantly decreased suicide rates for the first 2 years and tended to lower suicide rates up to 13 years in total [16, 17]. Three more postcard intervention trials were conducted in Israel and Australia in 2005, 2010, and 2011, that focused on the prevention of drug overdose or self-harm. The results showed significant decrease in the number of drug overdose episodes, and the rates of suicide ideation and suicide attempts [18–21]. The prevention of depression in patients with a recent stroke by postcard is also planned .
The advantage of the postcard intervention is its low personal and financial cost: it only requires paper, pencil, and postage. Therapists are not required to visit the participants and vice versa. If the postcards do not contain medical and related information, a wide range of people such as elementary school students can take part in the intervention program.
This paper describes the study protocol for a pragmatic, randomized controlled trial designed to examine the effectiveness of the postcard intervention for improvement of depression in community-dwelling individuals aged 65 years or older. This study will focus in particular on those who have increased depressive symptoms and insufficient social support at baseline, because it is expected that the intervention is more effective among such individuals.
For community-dwelling older adults (aged 65+ years) reporting symptoms of depression and limited social support, this study aims to: (1) examine the effectiveness of a postcard intervention for the improvement of depressive symptoms; (2) evaluate the effectiveness of a postcard intervention in global geriatric health indicators such as quality of life (QOL) and the activities of daily living (ADL); and (3) assess the acceptability of the postcard intervention.