Study: PAL Program Drastically Reduced State’s Antipsychotic Prescriptions for Children

The Partnership Access Line (PAL) has helped reduce antipsychotic prescriptions for Washington children enrolled in Medicaid by 49% since 2006.

Antipsychotic prescriptions for children enrolled in Washington state’s Medicaid program decreased by nearly half following the implementation of an innovative psychiatric consultation program affiliated with Seattle Children’s, according to a study published in the March 2017 issue of Health Services Research.

The 49% reduction in prescriptions from July 2006 to 2013 is a reversal from the steady statewide growth in the use of antipsychotics to treat children prior to the introduction of the Partnership Access Line (PAL). The number of children on Medicaid treated with antipsychotics in Washington decreased by 940 despite an increase of 186,855 enrollees in the joint Federal/state program during the study. According to the study, this counters a national trend of increased antipsychotic use with children from 2002 to 2015.

Other key findings in the study include:

  • High-dose antipsychotic use fell by 57.8% in children 6 to 12 years old; and by 52.1% in teens
  • 1,458 providers received a direct patient consult through PAL
  • 759 providers attended at least one of PAL’s 31 general psychopharmacology education conferences

PAL, the first program of its kind in the state and only the second in the country, is a telephone-based child mental health consultation system that allows primary care providers (PCPs) to consult directly with child psychiatrists affiliated with Seattle Children’s and the University of Washington School of Medicine. PAL also consults with community psychiatric specialists through the delivery of Medicaid second opinion services.

“Given the limited access to mental and behavioral healthcare across the state, the PAL program arms community providers with the support they need to deliver the best care, and one aspect of that is partnering with them in clinical decisions, such as when to use medications like antipsychotics,” said Dr. Rebecca Barclay, a Seattle Children’s psychiatrist and lead author of the study. “This study shows that the reduction in antipsychotic use has come as a result of PAL interventions.”

Significant decreases in antipsychotic use followed the implementation of each stage of PAL’s three sub-programs: elective consults available to PCPs in 2008; mandatory medication reviews based on young age or high dosage in 2009; and mandatory medication reviews for those treated with an antipsychotic combined with other psychotropics in July 2012.

“We have known for quite some time that PAL is making a difference in promoting best practice evidence based care, helping both providers and patients overcome obstacles like access to care, cost and limited insurance coverage,” said Dr. Robert Hilt, who led the design of the program and is the director of PAL and Community Leadership at Seattle Children’s. “The hope is that studies like this facilitate growth and continued support of programs like PAL, which ultimately help children to receive the appropriate level of care.”

A systematic response to a widespread problem

Concern about the overuse of antipsychotic medications in children is a national issue, especially in some situations when safer and more appropriate treatments are available. Side effects of antipsychotics can include high cholesterol and weight gain, which can contribute to future health complications.

Deciding when antipsychotics are appropriate can be a challenging clinical decision. Antipsychotics provide important relief to children suffering from psychiatric difficulties like bipolar disorder, schizophrenia, and autism that can impact children’s ability to learn and develop.

“Antipsychotics are helpful and necessary in many situations, but we want to make sure that we’re reserving their use to when absolutely appropriate,” Barclay said.

The over-prescription of antipsychotics in Washington may have been a byproduct of the high demand for mental and behavioral healthcare combined with a shortage of specialists. There are only about 100 child psychiatrists in the state, according to the study. Coupled with the fact that many families want their PCP or pediatrician to be the person they go to first with questions, it’s easy to see why PCPs were seeing and continue to see more and more mental and behavioral health cases.

“PCPs are commonly in the situation of knowing there is a problem, but they may not have the specialized training to adequately treat it,” Hilt said. “PAL serves as a vital resource in these situations and we have received thousands of calls from providers since PAL was implemented.”

Increasing impact

The success of PAL, which is supported by the Washington Healthcare Authority, has spurred growth both within Washington and beyond.

In 2011, PAL was implemented in Wyoming. During the first 27 months of the program, the state saw a reduction in pediatric psychotropic prescriptions for preschool-age and for all youth prescribed high doses of medications, as well as a net savings of $1.6 million in the predicted cost of care, according to a study published in Telemedicine and e-Health.

In January, Seattle Children’s announced the launch of PAL Plus, a pilot program that expands the services provided by PAL by offering in-person counseling sessions with local behavioral health providers for children from economically-challenged families in Washington’s Benton and Franklin Counties.

“PAL Plus provides PCPs with that first step in helping families with an evidence-supported approach that addresses issues in accessing next levels of care, reducing length of time to be seen and making sure there is an open line of communication regarding patient care,” Hilt said.

PAL Plus accepts patients ages 5 to 18 years old from Benton and Franklin Counties who have Washington state insurance coverage, including Medicaid; have a diagnosis of mild-to-moderate depression or disruptive behavior; and who are not already enrolled in services at a mental health agency.

For more information, please visit the PAL website  or call 1-866-599-7257 in Washington or 1-877-501-7257 in Wyoming. For more information on PAL Plus, visit the PAL Plus website.