Given its widespread occurrence and consequences, old-age depression has to be regarded as a major public health problem. Drug treatment has been proven effective in the majority of elderly individuals suffering from depression. This study presents pharmacoepidemiological data regarding the use of prescribed antidepressants and those purchased over the counter in the elderly. Furthermore, it links the data to simultaneously assessed depressive symptomatology. A representative survey on the utilization of prescription and over-the-counter antidepressant drugs and depressive symptomatology in community-dwelling (n = 1193) and institutionalized elderly individuals (n = 470) aged 75 and over was conducted in an urban region of Germany. Antidepressant use was found to be remarkably low (synthetic antidepressants: 2.2% of community dwelling individuals, 3.6% of institutionalized individuals; phytopharmaca containing hypericum perforatum: 4.2% of community dwelling individuals, 2.8% of institutionalized individuals). Two-thirds of the individuals treated with synthetic antidepressants received tri- and tetracyclic drugs, which were given at lower dosages than recommended for depression treatment. Selective serotonin reuptake inhibitors (SSRIs) were introduced in community-dwelling individuals only; none of the individuals cared for in residential and nursing homes received SSRIs. Only a minority of individuals with depressive symptoms were treated with antidepressants. The data suggests underutilization of antidepressants in the elderly, in which institutionalized elderly seem especially disadvantaged. The results call for increased efforts to discuss mental health issues in the public and to share scientific knowledge about symptoms, course and treatment options for depression. Furthermore, geronto-psychiatric competence of medical professionals, especially GPs, has to be systematically developed.