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Background Depression is common among older women and is shaped by various social, economic, and health-related factors. In Kerala, the rapidly aging population and distinct socio-cultural context may influence the prevalence and risk patterns of depression among elderly women. Literature on depression among older women in Kerala is limited. This study assessed the prevalence and determinants of depression among older women in Thiruvananthapuram District, Kerala, India. Methods A community-based cross-sectional study was conducted among 480 women aged ≥60 years, selected through multistage cluster sampling. Depression was assessed using the Patient Health Questionnaire (PHQ)-9, and severity was dichotomized as moderately severe or severe (PHQ-9 score ≥15) versus mild or moderate (PHQ-9 score <15). Log-binomial models were used to estimate unadjusted prevalence ratios (UPR), and multivariable Poisson regression was applied to obtain adjusted prevalence ratios (APR) with 95% confidence intervals (CI). Results The prevalence of moderately severe or severe depression was 35.8% (n=172, 95% CI: 31.3-40.1). In the multivariable analysis, urban residence (APR=2.83; 95% CI: 2.08-3.86, p<0.001), unmarried status (APR=1.44; 95% CI: 1.15-1.79, p=0.001), presence of chronic morbidity (APR=1.46; 95% CI: 1.10-1.94, p=0.010), and sleep disturbance (APR=1.39; 95% CI: 1.10-1.96, p=0.009) were significantly associated with a higher likelihood of experiencing moderately severe or severe forms of depression. Conclusion Over one-third of older women reported moderately severe or severe depression. These findings highlight the need for community-based screening and targeted mental health interventions focusing on urban residents, unmarried individuals, patients with other chronic conditions, and those with sleep disturbances.