Psychiatric advanced practice practitioners (APPs) provided similar or even better guideline-concordant care to patients with schizophrenia than psychiatrists, while some services from primary care physicians (PCPs) were lacking, new research suggested. 

In a large cross-sectional study, patients with schizophrenia who went to mental health clinics or individual APPs, such as physicians' assistants and nurse practitioners (NPs), were significantly more likely to receive psychosocial services and routine psychotherapy than those who went to individual psychiatrists. Patients who went to PCPs were less likely to receive these services. 

Rates of antipsychotic adherence were similar among patients treated by APPs, mental health clinics, and psychiatrists. Interestingly, patients of PCPs were more likely to receive screening for antipsychotic-related diabetes.

The results showed that patients with schizophrenia who receive treatment from PCPs “may require additional attention to ensure appropriate care receipt,” lead author Annie Yu-An Chen, PhD, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, and colleagues wrote.

On the other hand, the comparable rates of overall care between APPs and psychiatrists “are encouraging and suggest potential to expand access without compromising care quality,” they added.

The findings were published online on December 26 in JAMA Network Open.

Limited Research

Current practice guidelines from the American Psychiatric Association recommend the use of pharmacotherapy, psychosocial interventions, and preventive care used together when treating schizophrenia. Previous studies have shown that receipt of the first two practices, as well as adhering to medication, is linked to a reduction in psychotic relapses. 

“Despite this evidence, rates of guideline-concordant care…remain low among people with schizophrenia,” the investigators wrote.

To help shore up the continuing shortage of mental health specialty-care providers, psychiatric-trained APPs have stepped up.

The researchers noted that the number of residency matches for psychiatric mental health NPs increased more than sevenfold in just one decade — from less than 1000 in 2013 to 7000 in 2023.

However, there were little data to compare the quality of treatment provided by PCPs or APPs with that provided by psychiatrists. 

The investigators conducted a cross-sectional study of adults with schizophrenia using 2014-2021 data from the Massachusetts All-Payer Claims Database. They included 29,713 person-year observations (63% men).

Among all visits, 41% were attributed to psychiatrists, 26% to PCPs, 22% to mental health clinics, and 10.6% to psychiatric APPs.

Better Strategies Needed

Results showed that 72% of all participants received any psychosocial services, but only 23% received routine psychotherapy — defined as at least once every quarter — and just 62% had high adherence to antipsychotics.

Adjusted analyses showed that compared to psychiatrists, mental health clinics and APPs were more likely to provide psychosocial services (72% vs 87% and 80%, respectively) and routine psychotherapy (24% vs 35% and 30%, respectively; P < .001 for all). 

PCPs were less likely than psychiatrists to provide both services (-15.9 and -16.4 percentage points [pp], respectively).

Antipsychotic adherence rates were similar across provider types, although patients who visited mental health clinics had a higher adjusted probability for adherence than those who visited psychiatrists (4.1 pp). PCPs were more likely to screen for antipsychotic-related diabetes (5.7 pp).

There were minimal differences between psychiatrists and APPs in guideline-recommended care rates by schizophrenia caseload intensity.

“Given the expanding role of APPs and PCPs, particularly in rural settings, and consistently low rates of guideline-concordant care across specialties, further research should examine strategies to improve care for people with schizophrenia,” the investigators wrote.

Reaching More Patients

In an accompanying editorial, Evan J. Myers, PhD, Department of Psychiatry, Boston Medical Center, Boston, and colleagues noted that expanding the psychiatrist-only care delivery model to include practitioners from other specialties and training backgrounds could reach more patients. 

“Analysis of claims data by Chen and colleagues provides a much-needed update in examining whether clinician specialty or type and caseload intensity are associated with receipt of guideline-concordant care,” they wrote.

The editorialists added that they were concerned with the low rate (23%) of routine psychotherapy provided for all participants. 

This limited engagement “may reflect established systemic barriers to psychotherapy,” such as low rates of clinician training in schizophrenia-based psychotherapies or the persistent stigma around mental health in general, they noted. 

Still, the study suggests that appropriate schizophrenia care can be delivered by a range of clinicians, they added.

“Further interventions should target increased cardiometabolic screening by psychiatric clinicians and integrating psychotherapy services into care,” they concluded.

The study was funded by the National Institute of Mental Health. The investigators and two of the three editorialists reported no relevant financial relationships. The other editorialist reported having received personal fees from Bristol Myers Squibb and ReachMD outside the submitted work.