Collaborative Care and Geriatric Psychiatry: Meeting Patients Where They Are

Dax Volle, MD; and Brian Rosen, MD

Nuchylee/AdobeStock

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 Adults^1,2,4

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

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

Time to Care About Apathy: A Practical Guide for General Psychiatrists

Mario Fahed, MD

stopabox/AdobeStock

Apathy, defined as a quantitative reduction in goal-directed activity compared with a patient’s previous functioning, is highly prevalent and pervasive in patients with cognitive impairment. It significantly impacts treatment outcomes across psychiatric and neurological conditions.¹ Despite its prevalence and clinical significance, apathy as a syndrome remains underrecognized and undertreated in general psychiatric practice.² Recent advances in assessment tools, treatment approaches, and our understanding of apathy subtypes now provide evidence-based strategies for effective management.

The 2021 consensus criteria define apathy as persistent symptoms (≥ 4 weeks) affecting at least 2 of the following domains: diminished initiative, diminished interest, or diminished emotional expression/responsiveness.³ Unlike depression, apathy involves emotional blunting and indifference rather than persistent negative mood states (Table 1).⁴

TABLE 1. Key Clinical Features Distinguishing Apathy From Depression⁴

Case Vignette 1: Late-Life Depression vs Apathy

“Gemma,” a retired teacher aged 73 years, presents with her daughter’s concerns about “giving up on everything” during the past 3 months. Gemma has stopped gardening, no longer calls her friends, and shows little interest in her grandchildren’s visits. She denies feeling sad, hopeless, or guilty, stating, “I just don’t see the point anymore.” She does not show any somatic preoccupation. Her daughter notes Gemma responds to direct requests but rarely initiates activities independently.

This presentation illustrates the distinction between apathy and depression, which often co-occur with neurocognitive disorders.⁴ Although both conditions involve reduced activity and interest, apathy is characterized by emotional neutrality rather than negative affect.² Gemma’s lack of dysphoria, guilt, or hopelessness, as well as somatic preoccupation combined with her responsiveness to external stimuli, suggests primary apathy rather than depression.

The 3 Subtypes of Apathy

Research has identified 3 neurobiologically distinct apathy subtypes, each requiring different therapeutic approaches⁵:

1. Executive apathy (cognitive).

• Difficulty planning and organizing goals
• Problems with sustained attention and task completion
• Associated with dorsolateral prefrontal cortex dysfunction
• Best assessed with: Trail Making Test, Wisconsin Card Sorting Test

2. Emotional apathy (affective).

• Reduced emotional reactivity and empathy
• Diminished response to positive/negative events
• Linked to orbitofrontal and ventromedial prefrontal circuits
• Key observations: flat affect, reduced facial expression

3. Initiation apathy (auto-activation).

• Lack of self-initiated behavior despite preserved response to prompts
• Difficulty generating thoughts or actions spontaneously
• Associated with anterior cingulate and basal ganglia dysfunction
• Key observations: preserved ability when externally prompted

The Patient and Caregiver Experience

Recent qualitative research by Burgon et al reveals that patients and caregivers did not recognize apathy as a manifestation of neurocognitive decline but rather as an understandable response to everyday struggles with cognitive and physical decline.⁶ Clinicians can reframe apathy for families as a neurobiological symptom rather than a behavioral choice. This reduces caregiver distress and guilt while promoting therapeutic engagement.

Key themes from patient and caregiver interviews include the following⁶:

• Identity preservation. Patients withdraw to protect their remaining sense of self.
• Effort-outcome imbalance. Activities require increased effort for diminished reward.
• Environmental barriers. Lack of support and opportunities exacerbates symptoms.
• Misunderstanding. Families often interpret apathy as a willful lack of cooperation.

Assessment Algorithm

To best assess for apathy, screen all patients 65 years or older with the Brief Dimensional Apathy Scale (b-DAS) as part of routine visits or the comprehensive Apathy Motivation Index (AMI) assessment (Table 2). Clinicians can then identify predominant subtype(s) for targeted intervention and evaluate environmental and social contextual factors.⁶ It is also important to rule out depression, cognitive impairment, and potential medication effects during assessment. Lastly, it is imperative to support any potential caregiver burnout. The following tools can be used during this process.

TABLE 2. Assessment Algorithm

For quick screening (2-3 minutes)…

b-DAS⁷: There are 9 items assessing all 3 subtypes with a clinical cutoff for significant apathy for each.

• Executive (clinical cutoff > 4 points): “When doing a demanding task, does the patient have difficulty working out what they have to do?”
• Emotional (clinical cutoff > 5 points): “Is the patient indifferent to what is going on around them?”
• Initiation (clinical cutoff > 6 points): “Does the patient think of new things to do during the day?”

For comprehensive assessment (10-15 minutes)…

AMI⁸: There are 18 items with excellent psychometric properties.

• Behavioral activation (6 items): “I make decisions firmly and without hesitation.”
• Social motivation (6 items): “I suggest activities for me and my friends to do.”
• Emotional sensitivity (6 items): “I feel awful if I say something insensitive.”
• Cutoff: Above 1.91 for moderate apathy and above 2.38 for severe apathy.

Assessment should tackle not just symptom severity but also environmental factors and caregiver dynamics that influence the presentation of apathy. Consider and document social support availability, environmental considerations, impediments to engagement, caregiver understanding, and cultural factors (as expression of motivation varies across cultural backgrounds) in your assessment.⁶

Etiology-Specific Interventions

Alzheimer Disease

Initiate donepezil or galantamine if the patient is not already receiving it for Alzheimer dementia.⁹ Add-on methylphenidate. The landmark ADMET 2 trial established methylphenidate 20 mg daily as the first evidence-based treatment for apathy in Alzheimer disease. Over 6 months, 27% of treated participants achieved complete remission vs 14% with placebo.¹⁰

Dosing Strategy:

• Start: 5 mg twice daily with breakfast and lunch.
• Titrate: Increase by 5 mg every 3 to 4 days.
• Target: 10 mg twice daily (most effective dose).
• Monitor: Blood pressure, weight, appetite (especially if combined with acetylcholinesterase inhibitors), and sleep. Mind interactions and contraindications (uncontrolled hypertension, recent myocardial infarction, arrhythmia).
• Maintain for 6 months.

Parkinson Disease

Dopamine agonists are the preferred first-line treatment. Network meta-analysis demonstrates efficacy of dopaminergic agonists but found them to be comparable in efficacy to other medication classes (cholinesterase inhibitors and antidepressants).¹¹ Dopaminergic medications are especially helpful for apathy in early Parkinson disease.¹²

Treatment Hierarchy Based on Quality of Evidence⁹:

1. Rotigotine patch: 2 to 8 mg/d (if not already on a dopamine agonist)
2. Pramipexole: 0.125 mg 3 times a day
3. Piribedil: 50 mg 3 times a day
4. Monitor for impulse control disorders with all dopamine agonists

Late-Life Depression

Address selective serotonin reuptake inhibitor (SSRI)–induced apathy. Ranges of 20% to 92% of patients on SSRIs develop treatment-emergent apathy.¹³ Recent evidence supports switching strategies rather than augmentation.

Management Algorithm:

1. Dose reduction of SSRI and monitor response.
2. Switch to another antidepressant class, such as bupropion XL 300 mg daily (dopaminergic activity) or vortioxetine.
3. Augmentation: Methylphenidate 5 to 10 mg twice a day if switching ineffective

Case Vignette 2: Alzheimer Disease With Apathy

“Robert,” a man aged 78 years, has mild Alzheimer disease, which was diagnosed approximately 18 months ago. His wife now reports that he has stopped his woodworking hobby, rarely speaks during family dinners, and needs prompting for basic hygiene. Donepezil has helped his memory but has not addressed the motivational decline. Mini-Mental State Exam: 24/30; AMI score: 2.1 (predominantly initiation apathy).

After 8 weeks of treatment with methylphenidate 5 mg twice a day, titrated to 10 mg twice daily over 2 weeks, Robert resumed simple woodworking projects and was more conversational at follow-up. His wife noted he now initiates some daily activities independently sometimes.

Pharmacological Interventions

Based on the 3 subtypes of apathy mechanisms^4,9:

Cognitive Processing Deficits (Dorsolateral PFC-Caudate):

• First-line: Cholinesterase inhibitors (donepezil, galantamine)
• Second-line: Methylphenidate

Emotional-Affective Processing Deficits (Orbital-medial PFC):

• Consider: Agomelatine
• Avoid: SSRIs

Auto-Activation Deficits (Basal Ganglia Output):

• Dopamine agonists (piribedil, rotigotine)
• Cholinesterase inhibitors (rivastigmine)

Nonpharmacological Interventions

Executive Apathy

Several behavioral activation interventions can be used to target executive apathy, including structured and predictable activity scheduling with graded task assignment, breaking complex activities into manageable steps, using external prompts and reminders, and focusing on previously enjoyed activities with high potential for reward.

Emotional Apathy

Interventions for emotional apathy can focus on social engagement. This can include group activities that target interpersonal connection. Music therapy has shown evidence in Parkinson disease,14 whereas virtual reality environments have shown promise in socially isolated patients.15

Environmental Modification for Initiation Apathy

Patients with initiation apathy may respond best to environmental modifications. Whenever possible, clinicians should help patients reduce decision-making demands, help provide or plan clear daily structure and routines, use visual cues and prompts, and train caregivers in prompting techniques.

Future Directions

Both repetitive transcranial magnetic stimulation (rTMS) and digital monitoring have shown promise in addressing apathy. High-frequency rTMS protocols targeting dorsolateral prefrontal cortex show efficacy in Alzheimer disease,¹⁶ and wearable devices may present an opportunity to screen for apathy through activity patterns, potentially enabling early detection and treatment response monitoring.

Concluding Thoughts

Apathy is a pervasive and treatment-resistant syndrome requiring systematic assessment and targeted intervention. By using validated screening tools for routine apathy detection, understanding apathy subtypes, and applying condition-specific, evidence-based pharmacological and behavioral treatment algorithms, psychiatrists can improve the quality of life of patients and their families.

Dr Fahed is an associate professor of psychiatry at the University of Connecticut School of Medicine in Farmington and an adjunct faculty member at the Yale School of Medicine in New Haven, Connecticut. He is board certified in geriatric psychiatry and adult psychiatry.

References

1. Robert P, Lanctôt KL, Agüera-Ortiz L, et al. Is it time to revise the diagnostic criteria for apathy in brain disorders? the 2018 international consensus group. Eur Psychiatry. 2018;54:71-76.

2. Steffens DC, Fahed M, Manning KJ, Wang L. The neurobiology of apathy in depression and neurocognitive impairment in older adults: a review of epidemiological, clinical, neuropsychological and biological research. Transl Psychiatry. 2022;12:525.

3. Miller DS, Robert P, Ereshefsky L, et al. Diagnostic criteria for apathy in neurocognitive disorders. Alzheimers Dement. 2021;17(12):1892-1904.

4. Lanctôt KL, Ismail Z, Bawa KK, et al. Distinguishing apathy from depression: a review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders. Int J Geriatr Psychiatry. 2023;38(2):e5882.

5. Levy R, Dubois B. Apathy and the functional anatomy of the prefrontal cortex-basal ganglia circuits. Cereb Cortex. 2006;16(7):916-928.

6. Burgon C, Goldberg S, van der Wardt V, Harwood RH. Experiences and understanding of apathy in people with neurocognitive disorders and their carers: a qualitative interview study. Age Ageing. 2023;52(3):afad031.

7. Radakovic R, McGrory S, Chandran S, et al. The brief Dimensional Apathy Scale: a short clinical assessment of apathy. Clin Neuropsychol. 2020;34(2):423-435.

8. Ang YS, Lockwood P, Apps MAJ, et al. Distinct subtypes of apathy revealed by the apathy Motivation Index. PLoS One. 2017;12(1):e0169938.

9. Theleritis C, Siarkos K, Politis A, et al. A systematic review of pharmacological interventions for apathy in aging neurocognitive disorders. Brain Sci. 2023;13(7):1061.

10. Mintzer J, Lanctôt KL, Scherer RW, et al; ADMET 2 Research Group. Effect of methylphenidate on apathy in patients with Alzheimer disease: the ADMET 2 randomized clinical trial. JAMA Neurol. 2021;78(11):1324-1332.

11. Mai AS, Lee YS, Yong JH, et al. Treatment of apathy in Parkinson’s disease: a bayesian network meta-analysis of randomised controlled trials. Heliyon. 2024;10(4):e26107.

12. Castrioto A, Schmitt E, Anheim M, et al. Improvement of apathy in early Parkinson’s disease. NPJ Parkinsons Dis. 2025;11(1):89.

13. Masdrakis VG, Markianos M, Baldwin DS. Apathy associated with antidepressant drugs: a systematic review. Acta Neuropsychiatr. 2023;35(4):189-204.

14. Shah-Zamora D, Anderson S, Barton B, Fleisher JE. Virtual group music therapy for apathy in Parkinson’s disease: a pilot study. J Geriatr Psychiatry Neurol. 2024;37(1):49-60.

15. Ho KY, Cheung PM, Cheng TW, et al. Virtual reality intervention for managing apathy in people with cognitive impairment: systematic review. JMIR Aging. 2022;5(2):e35224.

16. Jin Y, Li J, Xiao B. Efficacy and safety of neuromodulation for apathy in patients with Alzheimer’s disease: a systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2024;171:17-24.

New Hope for Older Adults With Medical and Psychiatric Comorbidities

Brandon C. Yarns, MD, MS; and Aubrey M. Freitas

Karla/AdobeStock

SPECIAL REPORT: GERIATRIC PSYCHIATRY

An overwhelming accumulation of evidence indicates that older adults have increases in both chronic medical conditions and so-called “medically unexplained” somatic symptoms.¹ One example is the high prevalence of somatic symptom disorder (SSD) in older adults. SSD is a DSM-5 diagnosis characterized by 1 or more distressing somatic symptoms for at least 6 months, accompanied by excessive thoughts, feelings, or behaviors related to the symptoms.² A recent epidemiologic study found that the prevalence of SSD was 1.56 times higher in older adults (age 60 years and older) than in younger adults.¹ Nearly two-thirds (63.2%) of older adults met criteria for SSD vs 45.3% in younger adults. Moreover, 20.4% of cases in older adults were classified as severe vs only 12.0% in younger adults.¹ The extremely high rates of SSD, a psychiatric disorder, in older adults raise questions about the appropriate roles for psychiatrists and other mental health clinicians in treating somatic symptoms.

Historically, psychiatric providers’ main roles in patients’ somatic presentations have been limited to treating psychiatric comorbidities, such as depression and anxiety; providing patient education on stress management, physical activity, and avoiding alcohol and recreational drugs; and occasionally referring for cognitive behavior therapy to help patients manage or cope with symptoms. This strategy is sensible for symptoms from chronic medical illnesses that have a biomedical cause, such as cancer, rheumatologic, or endocrinologic diseases. However, psychiatric providers tend to use the same or a similar approach for SSD, often coupling their interventions with regular visits with primary care for reassurance, even though SSD-related symptoms rarely have a biomedical cause. For SSD, this standard treatment approach produces only modest improvements, with remission quite rare; only 21.4% of SSD patients were shown to enter remission at an average of 4 years of follow-up in a large study.³ Additionally, a 32-week trial of citalopram for 30 older adults with anxiety and SSD produced only small effect size reductions in somatic symptoms.⁴ Very recently, new paradigms and treatment strategies have been developed that provide new hope for older adults with troubling disorders such as SSD.

Neuroplastic Symptoms: A Treatable Set of Conditions

A more recent (and perhaps more useful) construct than medically unexplained symptoms, or SSD, is the concept of neuroplastic symptoms.⁵ Neuroplastic symptoms are real, physical symptoms (ie, not to be confused with malingering or factitious symptoms) caused by neuroplasticity in the brain rather than damage, disease, or dysfunction in the body. Examples of disorders that often end up being neuroplastic are most types of musculoskeletal pain conditions (eg, nonspecific back and neck pain, fibromyalgia), irritable bowel syndrome, some types of chronic fatigue, vertigo or dizziness, long COVID,⁶ and others. Stress is the reason for the neuroplasticity that leads to symptoms.⁵ As such, diagnosing a symptom as neuroplastic is not necessarily just a diagnosis of exclusion (although lack of a known biomedical diagnosis certainly increases the likelihood of a symptom being neuroplastic), but the diagnosis can be ruled in by evaluating the role of stress in the symptom’s onset and course, as well as other symptom characteristics, such as those listed in the Table.

TABLE. Characteristics of Neuroplastic Symptoms

Using these criteria, a recent study found that over 88% of back pain in an outpatient practice could be considered neuroplastic.⁷ It is important to reiterate that older adults, who do have many chronic medical conditions, often present with both neuroplastic symptoms and symptoms with a biomedical/bodily cause. Each should be diagnosed and treated appropriately by the relevant clinicians. Notably, making a diagnosis of neuroplastic symptoms should not be stigmatizing in the least. In fact, receiving this diagnosis is excellent news, because these symptoms are treatable, even in older adults.

Emotional Awareness and Expression Therapy

Recognizing the important roles that trauma, stress, and relationships have on neuroplastic symptoms (especially chronic pain conditions), psychologist Mark Lumley, PhD, and internist Howard Schubiner, MD, developed emotional awareness and expression therapy (EAET) in the early 2010s to directly target these major symptom drivers.⁸ EAET draws on several sources, including intensive short-term dynamic psychotherapy (ISTDP), written emotional disclosure, and pain reprocessing therapy.⁹ The basic premise of EAET is that trauma, relationship conflicts, and other forms of stress produce a sequence of difficult and often painful emotions, including anger, guilt, and sadness. Avoiding such emotions can lead to neuroplasticity that increases the likelihood of developing symptoms, whereas facing, processing, and releasing these emotions can lead to symptom relief.

For instance, a patient who is preoccupied with guilt and fear about a traumatic violation against them, such as a robbery, may require help accessing a sense of healthy anger that could contribute to greater motivation, a sense of agency, and empowerment. Another patient may hold onto anger and resentment after experiencing a trauma but miss a sense of sadness for oneself that can lead to greater self-compassion.¹⁰ Patients are encouraged to feel each feeling physically during the session (eg, a bodily experience of rising heat or energy for anger, crying for sadness) and to release the feeling using visualization (eg, to imagine lashing out in anger or imagine giving a hug with sadness).¹¹ Visualization is a critically important and powerful technique for releasing feelings, which was discovered by Habib Davanloo, MD, the founder of ISTDP.¹² Visualization is a compromise between suppressing an impulse (which can be hurtful to the patient) and acting on it (which can be hurtful to the patient or others)—but in this case no one gets hurt because the impulse is expressed only in the imagination and in words, rather than outwardly through actions.¹³

A dozen clinical trials have evaluated between 1 and 8 sessions of EAET for adults with various neuroplastic symptom presentations, including fibromyalgia, chronic pelvic pain, irritable bowel syndrome, and musculoskeletal pain.⁸ Two trials in Sweden^14,15 evaluated an online self-help version of EAET based on Schubiner’s book¹⁶ for adults with SSD that showed promising results. In addition, our group has led 3 clinical trials of EAET focused on older veterans with chronic musculoskeletal pain.^17-19 Our most recent randomized clinical trial, published in JAMA Network Open, evaluated EAET delivered as a single 90-minute individual session followed by 8 weekly 90-minute sessions in small groups of 6 veterans vs the same number and type of sessions of cognitive behavior therapy for chronic pain (CBT-CP).¹⁸ At the end of treatment, 63% of veterans randomly assigned to EAET experienced a clinically significant (at least 30%) reduction in the severity of chronic pain compared with only 17% of veterans randomly assigned to CBT-CP.¹⁸ EAET was also more effective at reducing depression, anxiety, and posttraumatic stress disorder symptoms, and higher levels of these symptoms moderated a greater reduction in pain severity after EAET but not CBT-CP. Overall, these results indicate that “addressing the emotional body”²⁰ is a powerful technique for improving chronic pain in older adults—and this likely applies to other neuroplastic symptoms as well.

Concluding Thoughts

Psychiatrists and other mental health clinicians have rarely attempted to directly address older adults’ somatic symptoms, despite their frequent co-occurrence with common psychiatric symptoms we do treat, such as depression and anxiety.¹ Reasons could include assumptions that older adults’ somatic symptoms are necessarily biomedical and a lack of tools to accurately assess what symptoms are caused by the body and what symptoms by the brain. Yet, the recent concept of neuroplastic symptoms includes highly effective and evidence-based diagnostic and treatment approaches—especially EAET—that can be applied by mental health clinicians, bringing new hope for older patients with these troubling symptoms.

Dr Yarns is a board-certified geriatric psychiatrist, assistant professor in the UCLA Department of Psychiatry and Biobehavioral Sciences, and assistant director of the VA Health Systems Research Center for the Study of Healthcare Innovation, Implementation, and Policy at VA Greater Los Angeles Healthcare System. He has practiced, taught, and researched EAET for older veterans over 8 years. Ms Freitas is a research coordinator at VA Greater Los Angeles Healthcare System currently working with Dr Yarns to investigate EAET for older veterans.

Disclosures

Dr Yarns has conducted professional training in EAET, a treatment mentioned in this article, and has received fees for this training. Ms Freitas has nothing to disclose.

References

1. Wu Y, Tao Z, Qiao Y, et al. Prevalence and characteristics of somatic symptom disorder in the elderly in a community-based population: a large-scale cross-sectional study in China. BMC Psychiatry. 2022;22(1):257.

2. DSM-5-TR. American Psychiatric Association; 2022.

3. Behm AC, Hüsing P, Löwe B, Toussaint A. Persistence rate of DSM-5 somatic symptom disorder: 4-year follow-up in patients from a psychosomatic outpatient clinic. Compr Psychiatry. 2021;110:152265.

4. Lenze EJ, Karp JF, Mulsant BH, et al. Somatic symptoms in late-life anxiety: treatment issues. J Geriatr Psychiatry Neurol. 2005;18(2):89-96.

5. Association for the Treatment of Neuroplastic Symptoms. Accessed July 29, 2025. https://www.symptomatic.me/

6. Donnino M, Howard P, Mehta S, et al. Psychophysiologic Symptom Relief Therapy (PSRT) for post-acute sequelae of COVID-19. Mayo Clin Proc Innov Qual Outcomes. 2023;7(4):337-348.

7. Schubiner H, Lowry WJ, Heule M, et al. Application of a clinical approach to diagnosing primary pain: prevalence and correlates of primary back and neck pain in a community physiatry clinic. J Pain. 2024;25(3):672-681.

8. Lumley MA, Schubiner H. Emotional awareness and expression therapy for chronic pain: rationale, principles and techniques, evidence, and critical review. Curr Rheumatol Rep. 2019;21(7):30.

9. Ashar YK, Gordon A, Schubiner H, et al. Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: a randomized clinical trial. JAMA Psychiatry. 2022;79(1):13-23.

10. Yarns BC, Zhu TA, Najafian Jazi A. Chronic pain in older adults: a neuroscience-based psychological assessment and treatment approach. Am J Geriatr Psychiatry. 2022;30(12):1342-1350.

11. Ahlquist LR, Yarns BC. Eliciting emotional expressions in psychodynamic psychotherapies using telehealth: a clinical review and single case study using emotional awareness and expression therapy. Psychoanal Psychother. 2022;36(2):124-140.

12. Davanloo H. Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. Wiley; 2000.

13. Yarns BC, Cassidy JT, Jimenez AM. At the intersection of anger, chronic pain, and the brain: a mini-review. Neurosci Biobehav Rev. 2022;135:104558.

14. Maroti D, Lumley MA, Schubiner H, et al. Internet-based emotional awareness and expression therapy for somatic symptom disorder: a randomized controlled trial. J Psychosom Res. 2022;163:111068.

15. Maroti D, Ek J, Widlund RM, et al. Internet-administered emotional awareness and expression therapy for somatic symptom disorder with centralized symptoms: a preliminary efficacy trial. Front Psychiatry. 2021;12:620359.

16. Schubiner H, Betzold M. Unlearn Your Pain. 3rd ed. Mind Body Publishing; 2016.

17. Yarns BC, Molaie AM, Lumley MA, et al. Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: a pilot study. Clin Gerontol. 2024;47(1):136-148.

18. Yarns BC, Jackson NJ, Alas A, et al. Emotional awareness and expression therapy vs cognitive behavioral therapy for chronic pain in older veterans: a randomized clinical trial. JAMA Netw Open. 2024;7(6):e2415842.

19. Yarns BC, Lumley MA, Cassidy JT, et al. Emotional awareness and expression therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: a preliminary randomized comparison trial. Pain Med. 2020;21(11):2811-2822.

20. Karst M. Addressing the emotional body in patients with chronic pain. JAMA Network Open. 2024;7(6):e2417340.

Improving the Quality of Life of Older Adults With Psychiatric Disorders

Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP

stopabox/AdobeStock

SPECIAL REPORT: GERIATRIC PSYCHIATRY

The population of older adults in the world is growing at a rapid rate.¹ By 2030, 1 in 6 individuals worldwide will be 60 years or older. By 2050, this population is expected to rise to 2.1 billion. Simultaneously, the population of individuals 80 years or older is expected to triple to 426 million by 2050. Approximately 14% of adults 60 years or older have a psychiatric disorder, and these disorders account for 10.6% of the total years lived with disability for this age group.² Common psychiatric disorders among older adults include personality, anxiety, mood, substance use, and neurocognitive disorders, especially due to Alzheimer disease (AD).^3,4

Although psychiatric disorders are common among older adults and cause significant disability, they are often undiagnosed and untreated.⁵ When compared with younger individuals, older adults are less likely to receive a psychiatric diagnosis (P < .001), have fewer visits with a psychiatrist (P < .001), receive less psychotherapy (P < .001), but have greater rates of psychotropic medication visits (121.4 per 100 population vs 56.8 per 100 population).⁶ Additionally, nonpsychiatrists often prescribe most of the psychotropic medications for older individuals, with 1 study identifying that only 4.8%, 3.5%, 17.3%, and 12.9% of the visits for antidepressants, anxiolytics, antipsychotics, and mood stabilizers among the older population were with a psychiatrist.⁷ Furthermore, inadequate assessment and treatment of common psychiatric disorders among older individuals can worsen outcomes including decreasing their quality of life, and increasing morbidity and mortality rates.^5,8

Currently in the United States, there are only 2.6 geriatric psychiatrists per 100,000 older adult population.⁹ Rhode Island (14.1), New York (7.5), and Hawaii (7.0) are the states with the highest concentration of geriatric psychiatrists per 100,000 older adults. Oklahoma (0.2), Mississippi (0.0), and North Dakota (0.0) are the states with the lowest concentration of geriatric psychiatrists per 100,000 older adults. During the 2024-2025 academic year, there were 60 Accreditation Council for Graduate Medical Education–accredited geriatric psychiatry fellowship programs in the US, with only 44 on-duty trainees enrolled in these programs.¹⁰ The corresponding numbers during the 2019-2020 academic year were 62 accredited programs, and 42 on-duty trainees enrolled in these programs.¹¹ Given the overwhelming evidence that the workforce needed to provide appropriate psychiatric care to older adults in the US is falling behind, there is an urgent need to intervene to rectify this situation.^12,13

One way to improve the care of this vulnerable population is to educate professionals about the best practices in caring for older adults with psychiatric disorders. To assist with this important task, Psychiatric Times has compiled a 2-part Special Report focused on psychiatric disorders among older adults. We hope that our readers find these articles interesting and informative. Additionally, we hope that the information in these articles will help clinicians improve the quality of life of the older adults with psychiatric disorders who are under their care.

Dr Tampi is a professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services, both in Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine and a member of the Psychiatric Times editorial board.

References

1. Aging and health. World Health Organization. October 1, 2024. Accessed August 20, 2025. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

2. Mental health of older adults. World Health Organization. October 20, 2023. Accessed August 20, 2025. https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults

3. Reynolds K, Pietrzak RH, El-Gabalawy R, et al. Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey. World Psychiatry. 2015;14(1):74-81.

4. 2024 Alzheimer’s disease facts and figures. Alzheimer’s Association. 2023. Accessed August 20, 2025. https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf

5. de Mendonça Lima CA, Ivbijaro G. Mental health and wellbeing of older people: opportunities and challenges. Ment Health Fam Med. 2013;10(3):125-127.

6. Maust DT, Kales HC, Blow FC. Mental health care delivered to younger and older adults by office-based physicians nationally. J Am Geriatr Soc. 2015;63(7):1364-1372.

7. Maust DT, Oslin DW, Marcus SC. Effect of age on the profile of psychotropic users: results from the 2010 National Ambulatory Medical Care Survey. J Am Geriatr Soc. 2014;62(2):358-364.

8. Lehmann SW, Ellison JM, Sakauye K, et al. Raising the bar on geriatric mental health competency training. Psychiatric Times. December 3, 2020. https://www.psychiatrictimes.com/view/raising-bar-geriatric-mental-health-competency-training

9. Beck AJ, Page C, Buche J, et al. Estimating the Distribution of the U.S. Psychiatric Subspecialist Workforce. University of Michigan School of Public Health Behavioral Health Workforce Research Center. December 2018. Accessed August 20, 2025. https://www.healthworkforceta.org/wp-content/uploads/2023/07/BHWRC_Estimating-Distribution-of-US-Psychiatrist.pdf

10. Number of Accredited Programs and On-Duty Residents/Fellows for the Academic Year by Specialty, 2024-2025. Accreditation Council for Graduate Medical Education. Accessed August 20, 2025. https://apps.acgme-i.org/ads/Public/Reports/ReportRun

11. Number of accredited programs and on-duty residents/fellows for the academic year by specialty, 2019-2020. Accreditation Council for Graduate Medical Education. Accessed August 20, 2025. https://apps.acgme-i.org/ads/Public/Reports/ReportRun

12. Lyness JM. Geriatric workforce crisis in the United States. International Psychogeriatric Association. Accessed August 20, 2025. https://www.ipa-online.org/resources/workforce-issues/geriatric-workforce-crisis-in-the-united-states

13. Rowe JW. The US eldercare workforce is falling further behind. Nat Aging. 2021;1(4):327-329. 

Deprescribing in Older Adults With Serious Mental Illness

Nina Vadiei, PharmD; Jinjiao Wang, PhD, RN; and Samantha Catanzano, PharmD

stopabox/AdobeStock

SPECIAL REPORT: GERIATRIC PSYCHIATRY

Polypharmacy and potentially inappropriate medication (PIM) use is associated with adverse drug events, increased health care use, and greater health care costs.^1-3 These risks are increased for adults 65 years and older, as nearly half of older adults are exposed to polypharmacy. While there is moderately certain evidence that deprescribing (defined as a systematic process of identifying and discontinuing drugs where existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals) is associated with reduced polypharmacy and PIM,⁴ there is less evidence on how to implement deprescribing processes effectively.⁵ The following case is meant to highlight barriers to deprescribing that are less commonly discussed, specifically focusing on common challenges in inpatient psychiatric settings where polypharmacy is more likely to occur.⁶ This is important because, to date, deprescribing research has focused mainly on long-term care (LTC) instead of other care settings such as acute and postacute care.⁷

Case Study 

The medical director of an inpatient psychiatric hospital has scheduled an interdisciplinary case review meeting, including psychiatrists, nursing, pharmacy, social work, occupational therapy, and dietitians. They meet to discuss the case of “Harold,” a 60-year-old man with schizoaffective disorder, polysubstance use disorder, anemia, gastroesophageal reflux disease (GERD), and recurrent aspiration pneumonia who becomes frustrated easily and exhibits poor impulse control. He has had more than 60 hospitalizations as an adult spanning over 40 years. More recently, he has had several medical hospitalizations for shortness of breath secondary to severe chronic obstructive pulmonary disease (COPD) and recurrent aspiration pneumonia/chemical pneumonitis. At the time of the review, he was prescribed haloperidol 10 mg twice daily, quetiapine 900 mg daily, lorazepam 2 mg 3 times daily, valproic acid syrup 1000 mg twice daily, ferrous sulfate 325 mg every other day, omeprazole 40 mg twice daily, and glycopyrrolate/formoterol fumarate 2 puffs twice daily. Each member of the interdisciplinary team was asked to weigh in on the patient’s treatment plan.

The clinical pharmacist voiced the following concerns during the meeting: (1) Harold is prescribed scheduled lorazepam despite a comorbid diagnosis of severe COPD, with chronically low oxygen saturation and recurrent pneumonia/pneumonitis; (2) Harold’s documented recurring episodes of agitation are behavioral in nature and not secondary to psychosis; (3) Harold’s quetiapine is above the recommended maximum dose, with notes indicating chronic constipation and severe GERD likely contributing to aspiration episodes. It is also noted that the risks of ongoing scheduled benzodiazepines and high-dose quetiapine likely outweigh potential benefits as the patient’s behaviors remain unchanged, indicating a deprescribing plan for these 2 medications. The rationale provided by the attending psychiatrist for continuing the medication regimen as is, instead of implementing the deprescribing recommendations, is that Harold is currently too agitated/aggressive to be tapered off the scheduled benzodiazepine, and that Harold’s multiple monotherapy antipsychotic regimens have failed, necessitating dual antipsychotic therapy.

Resistance to Deprescribe

Harold’s case is not a unique exception to how discussions regarding deprescribing often go for patients with serious mental illness (SMI). This is particularly true in cases where the patient has limited capacity to participate in shared decision-making, a recommended practice of deprescribing. When deprescribing is indicated, prescribers and staff may voice concerns regarding decompensation and safety that are difficult to challenge, as keeping patients and staff safe is of the highest priority.

In addition, it is not uncommon for prescribing clinicians to show a similar level of resistance to discontinuing medications in patients who are psychiatrically stable. They often convey the, “if it ain’t broke, don’t fix it” mentality, which is also known as prescribing inertia. Unfortunately, this occurs with even the most vulnerable patients, such as older adults who have a greater risk of mortality associated with PIM use.⁸ The reluctance to deprescribe psychotropics is exacerbated even more in settings with high provider turnover.⁹ No matter how egregious a polypharmacy regimen may seem to a new provider, the potential risk of causing a patient to destabilize may seem greater than the risk of continuing the regimen as is.

Addressing Agitation

Patients with SMI have a higher likelihood of developing neurocognitive disorder(s) compared with individuals without SMI.¹⁰ Agitation is one of the most common behavioral and psychological symptoms of dementia (BPSD), and one of the most challenging to manage, leading to caregiver burden and stress that often result in LTC placement.¹¹ To manage agitation secondary to BPSD, guidelines recommend nonpharmacologic treatment, which is highly resource intensive and may not be covered by the patient’s insurance.

Because most institutions lack the resources to manage agitation without pharmacologic treatments in older adults with SMI and/or neurocognitive disorders, psychotropic medications are often used as a last resort—even though pharmacologic interventions tend to be less effective and carry a higher risk of adverse effects (eg, increased risk of death associated with antipsychotic use in older adults with dementia).^12-14 However, the use of these PIMs is generally not because psychiatric clinicians are unaware of the risks of using psychotropic medications in patients with BPSD. Rather, it is because the patient’s agitation poses a more immediate risk of danger to the patient/staff in absence of other solutions, such as behavioral interventions.

With increased scrutiny on LTC facilities to minimize psychotropic use in patients with dementia or otherwise face repercussions related to facility reimbursement, LTC teams are often quick to send patients to the hospital for “medication adjustment” in the event of acute agitation, even when medication adjustments likely will not make a substantial difference in the frequency of future behaviors. More interdisciplinary education is likely needed on realistic treatment expectations when it comes to the effectiveness of pharmacologic interventions for various neuropsychiatric disorders in older adults. Additionally, more consideration may need to be given when a patient has reached the point of futility when deciding whether to continue/discontinue PIMs.¹⁵

Inpatient Complications

Patients hospitalized due to agitation and a request for medication adjustment are also at risk for quicker fixes and problematic prescribing. Research shows antipsychotics are often initiated and titrated to high doses quickly in acute psychiatric hospitals due to the need to discharge patients as soon as possible, despite knowing that the medications often take weeks to months to take effect.¹⁶ Titrating psychotropic doses too quickly before giving the medication time to reach steady state at lower doses (to prevent polypharmacy from developing in the first place) is a real concern.¹⁶ The need for higher doses or more medications is often justified by the patient’s high severity of illness, despite no evidence to support this practice.¹⁷

This practice of rapidly titrating antipsychotic doses is of even greater concern in older adults with SMI, as pharmacodynamic and pharmacokinetic changes in older adults necessitate slower dose titrations to optimize patient safety.

Other Challenges

This is not meant to suggest that prescribers are not receptive to deprescribing interventions; research indicates clinical pharmacist treatment recommendations are often accepted and implemented.^5,18,19 Existing research has limitations that may not tell the full story. For example, some clinical pharmacists are just required to document accepted treatment recommendations to demonstrate indirect cost-savings to leadership (because pharmacists are often unable to bill for clinical services). As such, there is likely insufficient research that reliably captures how frequently deprescribing treatment recommendations are not accepted in routine practice.

Timely communication regarding deprescribing recommendations is also a commonly cited barrier,⁵ suggesting a need for improved lines of communication between those providing deprescribing recommendations and the patient’s prescriber.

Implementing processes for continually reassessing the appropriateness of existing medications, as recommended by Goldberg’s recent review,²⁰ may not be enough to significantly increase the practice of deprescribing. Prescribers are often aware of polypharmacy but believe there is sufficient rationale to continue the medications as prescribed (known as rational polypharmacy).²¹ As such, the recommendation to continue educating psychiatric providers on the importance of deprescribing may be less impactful to those who believe they are already doing this to the best of their abilities.

Studies are needed to determine how often clinicians agree/disagree with the need to continue or discontinue a medication and the rationale for doing so. Additionally, more randomized controlled trials are needed to determine how to safely and effectively deprescribe different types of medications.²² Clinicians may be quicker to adopt deprescribing practices if guidelines are able to recommend this process strongly.

Shared Decision-Making

Lastly, when patients/caregivers have decision- making capacity, they should be involved in the deprescribing process. Patients often believe they take a large number of medications, spend too much money on them, and would like their prescribers to reduce the dose of their medicines; a few (13.8%) report bad experiences when stopping their medicines.²³ While some patients may be hesitant to deprescribe their medications, others may be open to it, especially when their providers agree with the plan. Creating a culture where deprescribing is considered at every visit may help to minimize reluctance and fear surrounding medication cessation.

FIGURE. Deprescribing Algorithm to Apply in Practice²⁴

The Figure illustrates steps that can be taken to successfully apply deprescribing in practice.²⁴ To make deprescribing practices more feasible, polypharmacy should be better defined and charted as a billable problem/condition. This way, clinicians can bill for the time spent addressing this issue,⁵ whether it is continuing medications, discontinuing them, or lowering the dosages.

Concluding Thoughts

Deprescribing requires a shared mental model among interprofessional teams and shared decision-making with patients and their caregivers. Systematically identifying priority medications to deprescribe and developing evidence-based approaches for deprescribing is necessary to support prescribers and other clinicians in ensuring safe and effective medication use for patients.

Dr Vadiei is a clinical associate professor of pharmacotherapy and translational sciences at the University of Texas at Austin and a psychiatric pharmacist at San Antonio State Hospital. Dr Wang is a professor at UT Health San Antonio School of Nursing. Dr Catanzano is a clinical associate professor of pharmacy practice at the University of Texas at Austin and a psychiatric pharmacist at UT Health Austin.

References

1. Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383-389.

2. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564.

3. Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician’s guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140(10):795-801.

4. Linsky AM, Motala A, Booth M, et al. Deprescribing in community-dwelling older adults: a systematic review and meta-analysis. JAMA Netw Open. 2025;8(5):e259375.

5. Wang Q, Zhang J, Li K, et al. Effectiveness of different medication management measures in older patients with chronic diseases and polypharmacy: a systematic review and network meta-analysis. Res Social Adm Pharm. 2025;21(10):753-764.

6. Delara M, Murray L, Jafari B, et al. Prevalence and factors associated with polypharmacy: a systematic review and meta-analysis. BMC Geriatr. 2022;22(1):601.

7. Heinrich CH, Hurley E, McCarthy S, et al. Barriers and enablers to deprescribing in long-term care facilities: a ‘best-fit’ framework synthesis of the qualitative evidence. Age Ageing. 2022;51(1):afab250.

8. Zhou Y, Pan Y, Xiao Y, et al. Association between potentially inappropriate medication and mortality risk in older adults: a systematic review and meta-analysis. J Am Med Dir Assoc. 2025;26(2):105394.

9. Nguyen ML, Sunderland B, Lim S, et al. A qualitative exploration of factors contributing to non-guideline adherent antipsychotic polypharmacy. Res Social Adm Pharm. 2022;18(3):2457-2467.

10. Ribe AR, Laursen TM, Charles M, et al. Long-term risk of dementia in persons with schizophrenia: a Danish population-based cohort study. JAMA Psychiatry. 2015;72(11):1095-1101.

11. Carrarini C, Russo M, Dono F, et al. Agitation and dementia: prevention and treatment strategies in acute and chronic conditions. Front Neurol. 2021;12:644317.

12. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14(3):191-210.

13. Yury CA, Fisher JE. Meta-analysis of the effectiveness of atypical antipsychotics for the treatment of behavioural problems in persons with dementia. Psychother Psychosom. 2007;76(4):213-218.

14. Cho E, Shin J, Seok JW, et al. The effectiveness of non-pharmacological interventions using information and communication technologies for behavioral and psychological symptoms of dementia: a systematic review and meta-analysis. Int J Nurs Stud. 2023;138:104392.

15. Coulter A, Schuermeyer I, Sola C. Evaluating ineffective treatments: a proposed model for discussing futility in psychiatric illness. Harv Rev Psychiatry. 2021;29(3):240-245.

16. Vadiei N, Chien J, Enwereji J, et al. Start low, go fast? antipsychotic titration patterns at an inpatient psychiatric hospital. Ment Health Clin. 2020;10(5):275-281.

17. Chakos MH, Glick ID, Miller AL, et al. Baseline use of concomitant psychotropic medications to treat schizophrenia in the CATIE trial. Psychiatr Serv. 2006;57(8):1094-1101.

18. Stuhec M, Tement V. Positive evidence for clinical pharmacist interventions during interdisciplinary rounding at a psychiatric hospital. Sci Rep. 2021;11(1):13641.

19. Adams D, Hastings RP, Maidment I, et al. Pharmacists’ perspectives on deprescribing psychotropic medicines in people with intellectual disabilities. J Ment Health Res Intellect Disabil. 2025:1-20.

20. Goldberg JF. Deprescribing: does the term belong in the psychiatric lexicon? Psychiatric Times. May 5, 2025. 2025;42(5).

21. Harding SL, Ellis KA, Boisseau J, Petreca V. Psychiatric deprescribing: a narrative review. J Am Psychiatr Nurses Assoc. 2024;30(4):810-818.

22. Wang J, Shen JY, Conwell Y, et al. Implementation considerations of deprescribing interventions: a scoping review. J Intern Med. 2024;295(4):436-507.

23. Alemu MA, Yazie TS, Zewdu WS, et al. General polypharmacy, psychotropic polypharmacy, attitudes of patients on psychotropic deprescribing, and associated factors in adult psychiatric outpatients: a survey study in a comprehensive specialized hospital, northwest Ethiopia. BMC Psychiatry. 2025;25(1):347.

24. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.