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Objectives: To determine the association between cumulative burden of depressive symptoms and risk of nursing home (NH) placement over 2 decades. Design: Prospective cohort study with data linked to Medicare claims files. Setting: Clinic sites in Baltimore, Maryland; Minneapolis, Minnesota; and the Monongahela Valley near Pittsburgh, Pennsylvania. Participants: Initially community‐dwelling women aged 65 and older (N=3,646). Measurements: Depressive symptom burden was determined using the Geriatric Depression Scale measured over 18 years to calculate accumulation of burden. NH placement was determined using Medicare claims data. Results: In Fine‐Gray proportional hazards analyses including demographic characteristics, medical comorbidities, functional impairment, and recent depression exposure and accounting for competing risk of death, women with low depressive symptom burden were twice as likely to experience NH placement as those with minimal burden (hazard ratio (HR) = 1.92, 95% confidence interval (CI) = 1.16–3.20), women with moderate burden were more than twice as likely (HR = 2.62, 95% CI = 1.59–4.31), and women with high burden (HR = 3.08, 95% CI = 1.87–5.08) were three times as likely. The addition of antidepressant use to this model attenuated the risk only slightly. Conclusion: In older women, cumulative burden of depressive symptoms over nearly 2 decades is associated with greater risk of transitioning from community‐living to a NH irrespective of recent depression exposure, medical comorbidities, functional impairment, and the competing risk of death. This work supports the need for improving recognition, monitoring, and treatment of depressive symptoms early, which may reduce or delay NH placement. See related editorial by Vincent Mor et al [ABSTRACT FROM AUTHOR]