Who treats best? Study reveals APPs' surprising strength in schizophrenia care

A recent analysis of schizophrenia treatment in Massachusetts reveals that psychiatric advanced practice providers (APP), such as nurse practitioners and physician assistants, often deliver guideline-concordant care that's comparable to or even better than what psychiatrists provide. The findings, published Dec. 26 in JAMA Network Open, could offer payers and health systems new strategies to expand access amid ongoing shortages of mental health specialists.

Researchers examined claims data from nearly 30,000 person-years involving adults aged 18 to 64 with schizophrenia between 2014 and 2021. They focused on key measures of quality care, including adherence to antipsychotic medications, use of psychosocial services, routine psychotherapy, diabetes screening for those on antipsychotics and high inpatient utilization as a marker of poorer outcomes.

Annie Yu-An Chen, Ph.D., D.D.S., a researcher at the University of Massachusetts Chan Medical School and lead author, noted in the study that despite strong evidence for treatments like combined pharmacotherapy and psychosocial interventions, adherence to guidelines remains stubbornly low overall. Only about 62% of patients in the sample showed high adherence to antipsychotics, defined as covering at least 80% of their days with medication. Psychosocial services reached 72%, but routine psychotherapy, meaning at least quarterly sessions, hit just under 25%.

Patients were assigned to providers according to outpatient visits: 41% to psychiatrists, 11% to psychiatric APPs, 22% to mental health clinics, and 26% to PCPs. Adjusting for key factors such as age, sex and insurance type revealed significant differences.

Patients seen by psychiatric APPs had an 80% likelihood of receiving psychosocial services, compared with 72% for those under psychiatrists' care. Routine psychotherapy rates were 30% for APP patients versus 24% for psychiatrist patients. Mental health clinics performed even stronger, with 87% for psychosocial services and 35% for routine psychotherapy. Antipsychotic adherence was similar or slightly higher in these groups compared with psychiatrists.

PCP-attributed patients had lower rates of psychosocial services by 15 points and routine psychotherapy by 16 points compared to psychiatrist patients but outperformed them in preventive care with a 6-point advantage in diabetes screening, likely reflecting PCPs' emphasis on physical health.

The study also looked at whether providers who treated more schizophrenia patients, those in the top 25% for their specialty, offered higher-quality care. The findings were varied. In mental health clinics, having more schizophrenia cases was linked to better medication adherence but less frequent routine psychotherapy. For primary care physicians, a higher number of these patients meant greater access to psychosocial services and psychotherapy, though there was a slight drop in medication adherence and screening rates. Psychiatrists with many schizophrenia patients saw more frequent high inpatient use, which may indicate they treated individuals with more severe illness.

These patterns held up even after excluding data from the COVID-19 years of 2020 and 2021, suggesting they're not pandemic artifacts.

Expanding the role of APPs and mental health clinics could help bridge gaps in specialty care, especially as psychiatrist shortages persist. Medicaid, which covers most schizophrenia patients in the study, often struggles with low provider participation. "Fewer than half of psychiatrists accept Medicaid," the authors pointed out, echoing broader access issues.

Incentives to integrate APPs into behavioral health networks or support training programs may be one path. The number of psychiatric nurse practitioner residencies has surged from under 1,000 in 2013 to 7,000 in 2023, according to the study, signaling a growing workforce.

Yet challenges remain. Overall low rates underscore the need for systemic fixes, like better reimbursement for psychosocial services or collaborative care models that blend PCP strengths in physical health with psychiatric expertise. High inpatient use affected about 5% of the sample, highlighting opportunities for population health interventions to prevent costly hospitalizations.

Chen and her colleagues concluded that while APPs and clinics hold promise, strategies to lift care quality across all provider types are essential.