SPECIAL REPORT: GERIATRIC PSYCHIATRY
By 2030, adults 65 years and older will comprise approximately 20% of the US population. Yet fewer than 1400 board-certified geriatric psychiatrists practice nationwide, just 3% of the total psychiatric workforce. This falls far short of the growing demand for specialized mental health care in older adults. If we want every older adult with primary psychiatric illness, dementia-related neuropsychiatric symptoms, complex comorbidities, and polypharmacy to have access to timely expert input, we must move beyond siloed specialty clinics. Instead, geriatric psychiatry must be spread “thinly but broadly” across the health system by integrating it into primary care, geriatrics, and other frontline clinical settings.1
A collaborative care model (CoCM) and its related approaches offer a scalable answer. Initially developed at the University of Washington, the original CoCM blends measurement-based treatment, team-based case review, and steppedcare principles. This approach doubled remission rates for late-life depression while reducing overall costs compared with usual care.2Evidence from the landmark IMPACT trial in older adults highlights the long-term effectiveness of the CoCM, with benefits sustained for up to 5 years.3 Table 1 shows a potential continuum of psychiatric consultation models for older adults.1,2,4
TABLE 1. A Continuum of Psychiatric Consultation Models for Older Adults1,2,4
This article outlines how a continuum of psychiatric consultation models for older adults can address the rapidly growing need for high-quality geriatric mental health care, thereby mitigating the challenges posed by siloing of care, specialist scarcity, and long wait times.
Practical Tips and Clinical Pearls
Also In This Special Report
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Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP
New Hope for Older Adults With Medical and Psychiatric Comorbidities
Brandon C. Yarns, MD, MS; and Aubrey M. Freitas
Time to Care About Apathy: A Practical Guide for General Psychiatrists
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Nina Vadiei, PharmD; Jinjiao Wang, PhD, RN; and Samantha Catanzano, PharmD
1. Start with triage, not diagnosis.
Ask: “Can this question be answered without the patient in the room?” If yes, consider asynchronous options such as e-consult, telephone consult, or enrollment in a formal CoCM program. If no, the situation may warrant considering embedded or longitudinal care.
2. Write recommendations for real-world colleagues.
- Use active verbs (start, stop, monitor, refer).
- Limit to 3 or fewer primary actions.
- Include clear contingencies (“If no response in 4 weeks, increase by 50%.”).
- Reference readily available resources (eg, handouts, local caregiver classes).
- Provide references to reinforce recommendations.
- Demonstrate how these recommendations can be easily incorporated into daily clinical workflows, allowing colleagues to modify and expand their clinical practice.
3. Leverage billing to sustain programs.
Medicare now reimburses CoCM under Current Procedural Terminology (CPT) 99492-99494 (and Healthcare Common Procedure Coding System G2214) when 36 minutes or more per month of care manager time are documented. In addition, billing codes are available for e-consultations (CPT 99451, 99452) and telephone consultations (CPT 9946-99449).5 Table 2 shows specialist codes.
TABLE 2. Specialist Billing Codes to Reimburse CoCM
We recommend billing for embedded consultations using standard evaluation and management codes. We strongly encourage our specialty organizations to advocate for commercial payers’ adoption and coverage of these codes at the state and national levels to ensure equitable access to geriatric psychiatric care across care settings.
4. Mind the medication list.
We propose a quick, practical framework for the medication list in CoCM. First, identify high-risk medications: focus on drugs that contribute to cognitive impairment (eg, benzodiazepines, anticholinergic agents), increase falls (eg, sedative hypnotics, α-blockers), or interact with psychiatric medications (eg, nonsteroidal anti-inflammatory drugs, lithium). The 2023 AGS Beers Criteria update is an excellent and high-yield resource to check for potentially problematic drug-drug or drug-disease interactions.5
Then, consider function, not just diagnosis: Does this medication help to improve function, cognition, or well-being? Be sure to start low, go slow, but aim for therapeutic targets: Titration in older adults should be cautious but purposeful. Subtherapeutic dosing delays improvement and can lead to frequent medication changes. Lastly, look for opportunities to address multiple problems with a single medication. Prioritize agents that can target multiple concerns simultaneously (mirtazapine can help depression, insomnia, and anorexia of aging).
5. Geriatric telepsychiatry eases geographic and access disparities, improving care in rural areas while alleviating wait times in urban and academic centers.
A 2023 US Department of Veterans Affairs (VA) pilot of hub-and-spoke video consults demonstrated high feasibility and satisfaction for veterans, caregivers, and local clinicians.6 Additionally, data from asynchronous electronic and telephone consultations in a large academic health system show that these models are easy to implement, result in high recommendation uptake, and are well received by referring providers, without the need for patients to wait weeks to months for a specialty appointment.
6. Respect age-related nuance.
Effective psychiatric care for older adults demands an appreciation for the distinct clinical, cognitive, psychosocial, and functional complexities of aging. Each case challenges the clinician to navigate the following:
- Diagnostic complexity: Psychiatric symptoms often develop in combination with multimorbidity, polypharmacy, and cognitive decline.
- Altered pharmacokinetics/pharmacodynamics: Age-related changes in metabolism, renal clearance, and absorption occur.
- Functional and cognitive considerations: Function and cognitive decline can heavily impact adherence and engagement with treatment recommendations. The recommendations should be tailored to functional baseline and caregiver support.
- Differing social contexts and goals of care: Bereavement, new caregiving roles, and housing/community transitions all can complicate and alter psychiatric needs.
- Wisdom and the lived experience: Older age can bring new insight, coping strategies, and an appreciation for life’s challenges.
See Table 3 for recommendations on synthesizing guidelines into your daily workflow.7
TABLE 3. Synthesizing Guidelines Into Daily Workflow and Recommendations
Case Study
“Ellen,” a woman aged 80 years with a history of generalized anxiety disorder, major depressive disorder (MDD), hypertension, fibromyalgia, and stage 3 chronic kidney disease (CKD3), presented to her primary care provider with 1 year of worsening depression in the setting of her husband’s death a year prior. Ellen and her children expressed concerns about her increasing difficulty navigating life independently. She struggled to manage her husband’s estate, organize her medications, and prepare adequate meals. Ellen’s challenges and decline were so abrupt that she expressed concern she was developing dementia.
Ellen reported fatigue, poor appetite, insomnia, low mood, anhedonia, and significant guilt/hopelessness. Given the psychiatric complexity in the context of bereavement and possible dementia, Ellen was referred to the CoCM team for case discussion.
The behavioral health care manager conducted an initial assessment, obtained psychometric screening, and reviewed Ellen’s history with the consulting geriatric psychiatrist. Ellen was found to have persistent depressive symptoms despite 3 prior antidepressant failures. The team identified a benzodiazepine, clonazepam, that was started following her husband’s death for anxiety and insomnia. At the first case review, the CoCM team recommended obtaining a Montreal cognitive assessment (MoCA), tapering and discontinuing the benzodiazepines, and optimizing mirtazapine, which had been started initially for sleep.
The MoCA revealed a score of 19/30, prompting a referral for an in-person evaluation with embedded care geriatric psychiatry. Following the comprehensive assessment, the embedded psychiatrist diagnosed MDD and dementia syndrome of depression. Vilazodone was initiated at 10 mg with cautious titration of an additional 10 mg every 6 weeks to a maximum of 40 mg. Ellen continued regular follow-up with the behavioral health care manager. Over 3 months, her Patient Health Questionnaire-9 (PHQ-9) declined markedly. She reported improvement in mood, energy, and functionality. A repeat MoCA showed marked improvement to 29/30. Ellen no longer required embedded psychiatric care and was successfully transitioned back to her primary care team with the option to re-refer to CoCM in the future.
Future Implications and Directions
Broader implementation will reduce wait times for expert geriatric consultation, improving access for older adults with complex psychiatric and neurocognitive presentations. In terms of future tools, artificial intelligence–augmented registries may soon flag patterns (eg, escalating antipsychotic doses, worsening scores on scales), prompting proactive outreach. Also of note is the potential of expanded provider types; the 2025 Medicare rules now allow licensed professional counselors and marriage and family therapists as CoCM care managers. This widens the workforce but requires psychiatrists to understand these professions’ training and practice scope.4 Additionally, hybrid tele-embedded clinics may merge video psychiatry with onsite nursing and therapist support, shrinking waitlists without brick-and-mortar expansion.6
Lastly, policy levers like value-based contracts could incentivize systems to prioritize depression remission and dementia care coordination metrics, aligning finances with geriatric-friendly outcomes.
Take-Home Lessons
Collaborative care alone will not solve the care gap for geriatric patients, but it levels the playing field—bringing specialty expertise to the examination room, the video screen, and even the inbox. That is “meeting patients where they are” in the broadest, most practical sense. When seeking to utilize a CoCM, be sure to do the following:
- Match the model to the question. Not every issue needs a full consultation.
- Measurement matters. Registries and standardized scales turn hunches into action.
- Write for busy colleagues. Concrete, contingency-based plans outperform exhaustive treatises and endless options.
- Age-specific knowledge and recommendations. The Beers Criteria list is a consultant’s cheat code, and age-friendly recommendations have the potential to truly enhance patient care.
- Sustain with billing. Know and use your CoCM-specific codes; they keep the lights on.
Dr Volle is an assistant professor of psychiatry and medical education at the Geisel School of Medicine at Dartmouth College in Hanover, New Hampshire, and the section chief of geriatric psychiatry at Dartmouth Health. Dr Rosen is an assistant professor of psychiatry and dermatology at the Geisel School of Medicine at Dartmouth College and a geriatric and collaborative care psychiatrist at Dartmouth Health.
References
1. Volle D, Rosen B, Doumlele K, et al. Asynchronous consultations in geriatric psychiatry: experiences in a rural academic health system. Am J Geriatr Psychiatry. 2024;2(4):43-50.
2. About collaborative care. AIMS Center, University of Washington. Accessed July 23, 2025. https://aims.uw.edu/collaborative-care/
3. IMPACT trial results. University of Washington, Division of Integrated Care & Public Health. Updated March 6, 2014. Accessed July 23, 2025. https://aims.uw.edu/wordpress/wp-content/uploads/2023/06/IMPACTTrialResults_0.pdf
4. Greenberg SA. The American Geriatrics Society (AGS) 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Hartford Institute for Geriatric Nursing. Accessed July 23, 2025. https://hign.org/consultgeri/try-this-series/american-geriatrics-society-ags-2023-updated-ags-beers-criteria-r
5. Behavioral health integration services. Centers for Medicare & Medicaid Services. April 2025. Accessed July 23, 2025. https://www.cms.gov/files/document/mln909432-behavioral-health-integration-services.pdf
6. Gould CE, Carlson C, Alfaro AJ, et al. Supporting veterans, caregivers, and providers in rural regions with telegeriatric psychiatry consultation: a mixed methods pilot study. Am J Geriatr Psychiatry. 2023;31(4):279290.
7. Learn about the collaborative care model. American Psychiatric Association. Accessed July 23, 2025. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn
