Shifts in Antipsychotic Prescribing by Clinician Type for Medicare Part D Beneficiaries, 2013-2023

TL;DR

From 2013 to 2023, non-physician clinicians like nurse practitioners and physician assistants became the top prescribers of antipsychotics for Medicare beneficiaries, surpassing psychiatrists and primary care physicians.

Contribution

The study reveals a significant shift in antipsychotic prescribing patterns, showing non-physician clinicians now lead in prescriptions for Medicare beneficiaries.

Findings

Prescriptions by APRNs and PAs increased from 13.8% to 39.6% between 2013 and 2023.

Psychiatrist prescriptions decreased from 48.4% to 32.4% during the same period.

Rural areas saw larger shifts from PCPs to APRNs and PAs compared to urban areas.

Abstract

How have patterns of antipsychotic prescribing by clinician type changed among Medicare Part D beneficiaries from 2013 to 2023?

In this repeated cross-sectional study, the proportion of antipsychotic prescriptions written by advanced practice registered nurses and physician assistants increased from 13.8% to 39.6%, making them the largest group of prescribers. During the same period, the proportion of antipsychotic prescriptions written by psychiatrists decreased from 48.4% to 32.4% and by primary care physicians from 33.0% to 23.8%.

This study suggests that nonphysician clinicians now account for a larger proportion of antipsychotic prescribing among Medicare beneficiaries, indicating shifts in the mental health care workforce and prescribing practices.

Despite safety warnings, antipsychotics remain commonly prescribed to older adults, particularly those with dementia, and for off-label indications. However, little is known about how prescribing patterns vary by clinician type over time.

To examine trends in antipsychotic prescribing by clinician type among Medicare beneficiaries from 2013 to 2023.

This repeated cross-sectional study used the Medicare Part D Prescribers by Provider and Drug dataset from 2013 to 2023. Participants included Medicare beneficiaries enrolled in Medicare Part D. Analyses were performed between November 2024 and June 2025.

Prescribing clinician type, categorized as psychiatrist, primary care physician (PCP), advanced practice registered nurse (APRN) or physician assistant (PA), or other physician.

Annual antipsychotic prescription claims, the proportion of claims by clinician type, the number of prescribing clinicians, and the mean number of claims per clinician.

From 2013 to 2023, annual antipsychotic prescription claims decreased from 10.8 million to 7.8 million for psychiatrists (average annual percentage change [AAPC], −3.2% [95% CI, –3.7% to –2.7%]; P < .001) and from 7.4 million to 5.7 million for PCPs (AAPC, −2.6% [95% CI, –3.2% to –2.3%]; P < .001). In contrast, claims prescribed by APRNs or PAs more than tripled from 2013 to 2023, increasing from 3.1 million to 9.5 million (AAPC, 11.8% [95% CI, 10.9%-12.7%]; P < .001). The proportion of prescriptions decreased for psychiatrists (48.4% to 32.4%) and PCPs (33.0% to 23.8%) but increased for APRNs and PAs (13.8% to 39.6%) from 2013 to 2023. These shifts were associated primarily with the expanding number of prescribing APRNs and PAs rather than an increase in the mean number of claims per clinician. Although trends were observed in both rural and urban areas, rural areas experienced larger shifts from PCPs to APRNs and PAs, whereas urban areas experienced larger shifts from psychiatrists to APRNs and PAs.

In this cross-sectional study of Medicare Part D data from 2013 to 2023, antipsychotic prescribing shifted from psychiatrists and PCPs to APRNs and PAs, reflecting growth in nonphysician prescribers. These findings suggest evolving roles in antipsychotic medication management and highlight the need for appropriate training for the full range of clinician types who prescribe these medications to Medicare enrollees.

This cross-sectional study examines patterns in antipsychotic prescribing by clinician type, as well as variation by rural vs urban clinician status and across states, among Medicare Part D beneficiaries from 2013 to 2023.

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