Guideline-Concordant Care and Clinician and Clinic Characteristics for Patients With Schizophrenia

Guideline-concordant care of schizophrenia remains low despite available evidence-based treatments. Primary care providers (PCPs; primary care clinicians) and psychiatric advanced practice practitioners (APPs) increasingly deliver specialty mental health care, but whether care quality differs by clinician or clinic type or patient mix is unclear.

To assess whether clinician or clinic specialty and higher schizophrenia caseload intensity are associated with receipt of guideline-concordant schizophrenia care.

This cross-sectional study (January 1, 2014, to December 31, 2021) used multivariable logistic regression to assess associations between clinician or clinic specialty and guideline-concordant care, adjusting for patient and zip code characteristics. Some models included interactions between specialty and a high schizophrenia caseload intensity indicator to examine associations within specialties. Insured individuals aged 18 to 64 years with schizophrenia from the Massachusetts All Payer Claims Database were studied. Analysis was completed between August 1, 2024, and September 25, 2025.

Clinician or clinic specialty and schizophrenia caseload intensity.

Binary indicators of high medication adherence, any receipt of psychosocial services, routine receipt of psychotherapy, high inpatient use, and receipt of antipsychotic-related diabetes screening.

The final analytic sample included 29 713 person-year observations (18 772 [63.2%] male; 5569 [63.2%] aged 35-64 years). Among these, 12 104 (40.7%) were attributed to psychiatrists, 3144 (10.6%) to psychiatric APPs, 6626 (22.3%) to mental health clinics, and 7839 (26.4%) to PCPs. In adjusted regressions, patients of psychiatric APPs or mental health clinics had higher probabilities of receiving psychosocial services (APP vs psychiatrist: 80.1% vs 72.1%, P < .001; mental health clinic vs psychiatrist: 87.1% vs 72.1%, P < .001) and routine psychotherapy (APP vs psychiatrist: 30.4% vs 24.0%, P < .001; mental health clinic vs psychiatrist: 35.2% vs 24.0%, P < .001) than patients of psychiatrists; antipsychotic adherence was similar or higher. In contrast, those with PCPs were less likely to receive psychosocial services (-15.85 percentage points [pp]; 95% CI, -18.40 to -13.30 pp) or routine psychotherapy (-16.42 pp; 95% CI, -17.80 to -15.05 pp) but more likely to receive antipsychotic-related diabetes screening (5.66 pp; 95% CI, 4.02-7.30 pp). High inpatient use did not significantly differ. Attribution to PCPs with higher schizophrenia caseload intensity was not consistently associated with improved outcomes across specialties.

In this cross-sectional study, guideline-concordant care was similar for patients of psychiatric APPs, mental health clinics, and psychiatrists, but patients of PCPs were less likely to receive psychosocial or psychotherapy services, although higher schizophrenia caseload intensity may mitigate this gap. Strategies to improve care across specialties are needed because overall rates remain low.