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--:-- Sean Ramos: Big tech wants to help with your telephone, with your transportation, with your food delivery, with your entertainment, with your photos, with your news, with your blood. That didn't go very well. Miss Grace Theranos, founder and CEO, found guilty on four of 11 counts in her landmark Silicon Valley fraud case. With your brain? In the case of Cerebral, that's also not going very well.
--:-- Sean Ramos: I'm making this late night video as a general PSA to anyone who is thinking about joining Cerebral. Do not walk, but run. Adderall via Instagram. The rise and sort of stumbly fall of Cerebral. Coming up on Today Explained.
--:-- Sean Ramos: Support for Today Explained comes from Saks Fifth Avenue. Fall is here. Might be time to find some nice new pieces you can wear again and again. With Saks Fifth Avenue, it can be a breeze to shop for your personal style, like maybe a relaxed Prada blazer or Gucci loafers that are great for both work and the weekend.
--:-- Sean Ramos: This is very Sean. This is very Sean-coded. Gucci loafers. Saks says Saks makes shopping feel totally customized to you, whether that's from an in-store stylist or a visit to Saks.com, where they can show you just what you want to see. They say they'll even let you know when arrivals from your favorite designers are in or when something you've been eyeing is back in stock. You can find inspiration for your personal style every day at Saks Fifth Avenue.
--:-- Sean Ramos: Support for this show comes from strawberry.me. Be honest. Are you happy with your job? Or are you stuck in one you've outgrown or never wanted in the first place? Sure, you can probably list the reasons for staying, but are they actually just excuses for not leaving? Let a career coach from strawberry.me help you get unstuck. Discover the benefits of having a dedicated career coach in your corner. Go to strawberry.me slash unstuck to claim a special offer.
--:-- Sean Ramos: My name is Rolf Winkler. I'm a reporter at The Wall Street Journal. And I'm Sean Ramos, for I'm host of Today Explained from Vox. Rolf is here to tell us about Cerebral.
--:-- Rolf Winkler: Cerebral is an online mental health company that, after launching two short years ago, January 2020, has exploded to a $5 billion valuation and is treating tens of thousands of patients for mental health conditions. It's one of the fastest growing mental health companies online today.
--:-- Sean Ramos: But there is a but. A controversy has ensued.
--:-- Rolf Winkler: Correct. The controversy is over their prescriptions of controlled substances, in particular Adderall and stimulants to treat ADHD.
--:-- Sean Ramos: I was able to get in and see a clinician and get on medication within like two weeks. And their advertising. Therefore, it's dangerous to have ads that highlight very general symptoms, being spacey or forgetful or chatty as you potentially having like a mental health condition.
--:-- Rolf Winkler: There was advertising that was criticized as inappropriate. Instagram took it down. The company admitted mistakes in its advertising, said it would form a new review board to look at it. They were doing ads that, you know, connected obesity and ADHD. Are you overeating? Maybe you have ADHD. Come and get treatment, which people thought was over the line.
--:-- Sean Ramos: And on the other side of it, there are concerns, and we reported a lot on this, about nurse practitioners on the platform, the people who prescribed the medication. Ones we spoke to said they had felt pressured by the company to prescribe stimulants for people who came in saying that they had ADHD.
--:-- Rolf Winkler: And, of course, a large number of them do have ADHD and need treatment, and stimulants are the best treatment for that. That's agreed on by psychiatrists. On the other hand, a lot of other people were coming in to seek this medication, the nurses said, and they would have to do battle with them. Basically, you are just sort of seeking this stimulant, and I'm not going to give it to you. And the company would pressure them to provide stimulants, to go ahead and prescribe them because that would keep people paying their subscription fee. That's what the nurses said, that they felt that pressure.
--:-- Sean Ramos: Now, the company, of course, says we don't pressure any nurses, we trust their clinical judgment, and we've never punished anybody for not prescribing medication.
--:-- Rolf Winkler: So let's wind back a little bit and talk about how this company got started. What's its origin story?
--:-- Sean Ramos: It started in January 2020. The original idea for the business was they were going to prescribe medication for mental health concerns. At the time, a lot of the online mental health services would provide therapy.
--:-- Rolf Winkler: Support for the show today comes from BetterHelp. They wanted to do for mental health, for depression and anxiety, something similar to what Hems and Roman did for erectile dysfunction and hair loss. Roman makes it simple and convenient to take care of ED. So when the moment's right, you're ready. Roman ready. Let's make it easy to prescribe and get people access to the medication that could help them for these issues.
--:-- Sean Ramos: Its co-founder, former co-founder, but he's no longer with the company, had been at HIMSS. So that was January 2020. A key development was two months later, COVID hit, the pandemic.
--:-- Rolf Winkler: If you don't test, you don't have any cases. Then some of the guardrails around telehealth were lifted, including they made an exception to something called the Ryan Hate Act, which is a law that prohibits prescribing schedule two medications without at least one in-person visit.
--:-- Sean Ramos: In other words, if you want a schedule two med like Adderall or another stimulant, other meds in this category include Oxycontin and Vicodin. This is a DEA category you know the schedules Schedule two includes substances that can be prescribed but have a high potential for abuse.
--:-- Rolf Winkler: That they were now allowed to prescribe. So now all of a sudden you could treat ADHD online and prescribe stimulants. So they moved pretty aggressively into that marketplace and it became a key growth area for them.
--:-- Sean Ramos: How did they move aggressively? They spend a lot of money on advertising, for instance.
--:-- Rolf Winkler: Whether you struggle with anxiety, depression, ADHD, or you're just feeling unsure, Cerebral gives you access to a team of licensed therapists, counselors, and prescribers online. And their business model is not unlike my business model. I work at the Wall Street Journal. I'm at a newspaper. We sell subscriptions. Our business is to write stories you want to read so that you keep paying your subscription fee every month, right? Cerebral is in a similar business. They're a subscription business, and a primary thing they sell you is called medication management.
--:-- Sean Ramos: Come to us for the medication that you need to treat whatever conditions you have, whether it's depression, anxiety, insomnia, ADHD, and we'll give you medication. And you pay us every month, and we'll manage that medication, including renewing your prescriptions for you to be renewed.
--:-- Rolf Winkler: What does their advertising look like? A lot of social media ads, a lot of ads on TikTok, a lot of ads on Instagram. You might know this company also because they signed up Simone Biles to be their chief impact officer last fall after her very public battles with mental health during the Olympics.
--:-- Sean Ramos: For me, it's cerebral. It eases my anxiety. I choose to do weekly therapy. But if a licensed prescriber decides you need prescription medication, Cerebral can have it delivered to your door. Having the support and tools...
--:-- Rolf Winkler: So how does Cerebral's business do in the pandemic? Exploded. Remember, this is a company that launched January of 2020. So start from zero. And by last year, when they're raising money, they're treating over 100,000 patients already. That's fast growth. That's fast growth.
--:-- Sean Ramos: How does the service work? The way the business works is you're paying your subscription fee, which is roughly $80 a month for medication management. And the nurse practitioner is paid on the order of $40 to $50 for that initial assessment. And then, say, $20, $25 per month thereafter for follow-up visits when they see you in person, when they do a follow-up visit.
--:-- Rolf Winkler: How does Cerebral's process at this point compare to, say, a regular, traditional, in-office diagnosis of ADHD and, say, prescription for Adderall?
--:-- Sean Ramos: Sean, that is the key question because it's short. It's a much shorter appointment. They did half-hour appointments to diagnose ADHD. And that is a lot shorter than your standard appointment.
--:-- Rolf Winkler: When we talk to experts, they say, look, the shortest ADHD appointments, they should run at least 90 minutes and many of them can run, they can run three, four hours and have you fill out lots of information and then the psychiatrist may, or the person evaluating you may interview your family and so the cerebral appointments, much shorter at 30 minutes.
--:-- Sean Ramos: And as you mentioned earlier, Cerebral's allowed to do this thanks to the reversal of something called the Ryan Hate Act.
--:-- Rolf Winkler: The Ryan Hate Act is still a law that's on the books. The young man from California was only 18 when he overdosed on painkillers that were illegally prescribed over the Internet. But the public health emergency for COVID, which is continuing, has basically created an exception to that rule so that it's temporarily relaxed.
--:-- Sean Ramos: COVID-19 might be getting all the headlines, but patients are still getting sick from other diseases and injuries. And that's left doctors looking for other ways to treat them while minimizing contact. Enter telemedicine.
--:-- Rolf Winkler: When the public health emergency ends, it's my understanding that the Ryan Haidt Act snaps back. And so you won't be able to do some of these controlled substances online anymore without an in-person appointment.
--:-- Sean Ramos: How does Cerebral's sort of newfound ability to expedite this process of diagnosing mental illness and prescribing medication for it start to land them in hot water?
--:-- Rolf Winkler: I think the questions that people started asking were around the quality of the diagnoses that the company's nurse practitioners were providing. Like how much can they actually know in 30 minutes? And were there cases where patients maybe don't have ADHD but are getting the meds anyway?
--:-- Sean Ramos: And the nurses said they felt pressure to prescribe these meds including you know something that happened late last year that the nurses described and we saw documents that showed this process was uh something called auditing where cerebrals clinical quality team would pull charts say a nurse practitioner has a few hundred patients maybe and they'll pull a few charts at random to see are they prescribing the appropriate medication.
--:-- Rolf Winkler: And maybe they pull some ADHD patients and they discover, okay, you diagnosed ADHD, but you didn't prescribe a stimulant, and that's the preferred medication for ADHD. Why haven't you done that? You should either change your diagnosis or switch the medication.
--:-- Sean Ramos: And some nurses looked at that and they said, hold on a minute. It's not the company's job to tell me what to prescribe. I prescribe the medication I feel that is appropriate. It's my prescribing license. That's my job.
--:-- Rolf Winkler: Now, the company says they don't pressure anyone to prescribe medication, and they encourage nurses to follow their best clinical judgment and support them when they do.
--:-- Sean Ramos: A lot has been happening. After people wrote about the company's practices, in particular around its ADHD prescribing, One, we reported that some pharmacies had had issues with controlled substance prescriptions coming from Cerebral and similar companies that do this online.
--:-- Rolf Winkler: Sources telling the Wall Street Journal Walmart CVS and Walgreens have all blocked or delayed prescriptions from certain telehealth providers
--:-- Sean Ramos: Then it came out that there was a DOJ investigation, that they were being investigated for possible violations of the Controlled Substances Act, which the company says, we haven't been accused of violating any laws, and they were going to cooperate fully.
--:-- Rolf Winkler: And last, most recently, the CEO basically got fired by the board.
--:-- Sean Ramos: More with Rolf in a minute on Today Explained.
--:-- Sean Ramos: Support for Today Explained comes from Chime. Nobody likes fees and complicated banking, says Chime. And Chime gets that, says Chime. Chime is a financial technology company that says they understand that every dollar counts. So when you set up direct deposit through Chime, they say you get access to fee-free features, such as free overdraft coverage, getting paid up to two days early with direct deposit, so much more.
--:-- Rolf Winkler: Chime says with qualifying direct deposits, you can be eligible for free overdraft up to $200 on debit card purchases and cash withdrawals. Plus, they say you don't need to worry about monthly fees or maintenance fees.
--:-- Sean Ramos: You can work on your financial goals through Chime today. You can open an account in two minutes at Chime.com slash explained.
--:-- Rolf Winkler: That's Chime.com slash explained. Chime feels like progress. Chime is a financial technology company, not a bank. Banking services and debit card provided by the Bancor Bank N.A. or Stride Bank N.A. Members FDIC.
--:-- Sean Ramos: Spot me eligibility requirements and overdraft limits apply. Timing depends on submission of payment file. These apply at out-of-network ATMs. Bank ranking and number of ATMs according to U.S. News and World Report 2023. Chime checking account required.
--:-- Rolf Winkler: Support for the show comes from Charles Schwab. At Schwab, how you invest is your choice, not theirs. That's why when it comes to managing your wealth, Schwab gives you more choices. You can invest and trade on your own. Plus, get advice and more comprehensive wealth solutions to help meet your unique needs.
--:-- Sean Ramos: With award-winning service, low costs, and transparent advice, you can manage your wealth your way at Schwab. Visit schwab.com to learn more.
--:-- Rolf Winkler: Whether you struggle with anxiety, depression, ADHD, or you're just feeling unsure, Cerebral gives you access to a team of licensed therapists, counselors, and prescribers online. Prescription medication delivered to your world.
--:-- Sean Ramos: Today Explained, Sean Ramos for him. Back with Rolf Winkler from The Wall Street Journal, who just told us about Cerebral's fast rise during the pandemic, which was followed by lots of questions about its practices and ethics, prescribing things like ADHD, medication, very quickly.
--:-- Rolf Winkler: Rolf, how does the federal government take an interest in Cerebral?
--:-- Sean Ramos: We don't have full answers to that. We know that what they're doing is investigating potential violations of the Controlled Substances Act. And, you know, that's after the DEA has interviewed some nurse practitioners at Cerebral.
--:-- Rolf Winkler: So we're waiting to see. Cerebral hasn't been accused of violating any laws. And they say they're fully cooperating.
--:-- Sean Ramos: Hmm. But this isn't the only problem Cerebral's having right now. Well, you know, they had to shut down that ADHD business. They decided that was the best course of action.
--:-- Rolf Winkler: And the board voted out the CEO and replaced him with the company's existing CMO.
--:-- Sean Ramos: And by the way, that has been quite a mess. The CEO said in a memo to the board that he feels like he's a scapegoat, and the people you're replacing me with have been there the whole time.
--:-- Rolf Winkler: And, you know, the board knew everything. Investors knew everything. You're just blaming me to try to effectively make a clean break.
--:-- Sean Ramos: But is this really a clean break? That's a question for people to ask. Executives now in charge who have been there for, you know, all of the relevant period.
--:-- Rolf Winkler: The CMO joined in February 2021. So that's a question is, you know, how much of a break is it with the past?
--:-- Sean Ramos: We wrote our story about people feeling pressured to prescribe back in late March. So a lot of this has happened pretty quickly.
--:-- Rolf Winkler: How is Cerebral responding to all of this?
--:-- Sean Ramos: Cerebral has had a bunch of different responses. They say that they follow evidence-based best practices for all of their prescribing, that they never pressure nurse practitioners to prescribe.
--:-- Rolf Winkler: They say they provide high quality care and they say you know above all our mission is to expand access for mental health right it is a fact that there's more demand for mental health resources in this country than there are than there is supply you want to go see a psychiatrist one can you afford it a lot of people can't afford that and two a lot of people may not have a psychiatrist near them who can see them you know anytime before three months from now so Cerebral says look we are helping to expand access to behavioral health medication that people in this country need.
--:-- Sean Ramos: I asked you how Cerebral sort of responded to all the controversy Wall Street Journal has done a lot of the reporting here. How have they responded specifically to the reporting you all have done?
--:-- Rolf Winkler: They said it was a broad problem in the telehealth industry at the time we were reporting this. But the thing when we followed up was the telehealth industry doesn't broadly prescribe controlled substances.
--:-- Sean Ramos: They said it was an industry-wide problem. And we had asked, well, who else in the industry is doing controlled substances? Because the top general telehealth players, Teladoc, MD Live, Doctor on Demand, these kinds of services and also the other mental health companies Lyra Health Modern Health Ginger they don't do controlled substances.
--:-- Rolf Winkler: So Cerebral defending their practices but at the same time, they just got rid of their CEO. And ended a lot of their practices around ADHD and controlled substances. They just stopped it all.
--:-- Sean Ramos: So yes, on the one hand, they're saying everything we're doing is great, we follow best practices, and our mission is a good one. And that's for everybody out there to decide right which is it seems like is a way of admitting that things weren't up to snuff they've certainly owned up to mistakes they've certainly said admitted that they made mistakes in various areas and they're going to try to do better.
--:-- Rolf Winkler: So if they're not prescribing these controlled substances, how much of their business remains intact?
--:-- Sean Ramos: A significant part of it, because a lot of what the company does is also prescribe SSRIs for depression, for instance. They'll prescribe non-controlled substances for depression, anxiety, insomnia. These are all large components of their business, and the majority, really.
--:-- Rolf Winkler: So they still have a fairly sizable business there, for sure.
--:-- Sean Ramos: I'm sure a lot of people listening to this can't help but think of a recent health startup controversy in this country that was recently turned into a TV show. The world works in certain ways until a new great idea comes along and changes everything.
--:-- Rolf Winkler: I think there's a movie coming too. Grace Theranos, founder and CEO, found guilty on four of 11 counts in her landmark Silicon Valley fraud case.
--:-- Sean Ramos: Yeah. Do you draw any lines between the two? Their technology was, it was diagnostic. It was different. It was blood tests. It wasn't medication that you were putting in your body.
--:-- Rolf Winkler: In this case, with Cerebral, hasn't been around nearly as long, only two years. So not as many people have heard of it. The CEO isn't a household name. On the other hand, it prescribes medication, right? So its impact on the daily lives of, again, tens of thousands of people is just very different.
--:-- Sean Ramos: And to be clear, none of our reporting would suggest that most people going to cerebral aren't getting great care.
--:-- Rolf Winkler: Do you think there's some larger problem here that maybe we move too fast, especially with something as serious as prescription medicine or mental health diagnoses?
--:-- Sean Ramos: Should telehealth startups have sort of a different bar than, say, tech startups that help you, who knows, get some food delivered or, you know, book a car?
--:-- Rolf Winkler: So I think it's important to separate out the prescribing of, you know, online mental health, it should be said, is filling a need that is there in this country. A lot of people need help for mental health issues, especially during the pandemic.
--:-- Sean Ramos: And it's hard that those resources just aren't widely available. So there are a lot of companies that are trying to make those resources available.
--:-- Rolf Winkler: And I think everybody would agree that's something that's badly needed, right?
--:-- Sean Ramos: And the question that knowledgeable people in this area have raised for me and the thing they've said to focus on is really the controlled substances aspect of this.
--:-- Rolf Winkler: So to your question about you know silicon valley getting into this right the question is okay if we're looking at controlled substances as the thing where you have to be really careful. I mean we put guardrails around controlled substances for a reason because they're prone to abuse.
--:-- Sean Ramos: And so you ask yourself okay well does the silicon valley direct to consumer playbook where we spend tons somebody to advertise, you bring people in, you make something easier for the client to get. That's the general idea, right? Is that appropriate for controlled substances?
--:-- Rolf Winkler: The sources I spoke to, the answer to that question, and really the challenge, is around the approach to the business and treating the people who come in like clients who are customers who want to buy a product, right?
--:-- Sean Ramos: The nurse practitioners we spoke to said, look, we're being evaluated like Uber drivers. We're getting rated on a scale of one to five. Who do you think are some of the people that give me a one? It's the people I don't give the medication to who want it. But I'm not an Uber driver. I'm supposed to be able to say no to you.
--:-- Rolf Winkler: Our show today was made by Victoria Dominguez. It's her first. She was edited by Matthew Collette, fact-checked by Laura Bullard, and mixed and mastered by Paul Mounsey.
--:-- Sean Ramos: The rest of the day's Explained team includes Halima Shah, Miles Bryan, Victoria Chamberlain, Hadi Mawagdi, and Avishai Artsy.
--:-- Rolf Winkler: Our supervising producer is Amna Al-Sadi. Our director of sound is Afim Shapiro.
--:-- Sean Ramos: My co-host is Noelle King, Our VP of audio at Vox is Liz Kelly Nelson.
--:-- Rolf Winkler: We use music by Breakmaster Cylinder and sometimes Noam Hassenfeld, too. He hosts a show called Unexplainable, and they're launching a series this week on Lost Worlds.
--:-- Sean Ramos: I'm Sean Ramos from Today Explained is part of the Vox Media Podcast Network. We're on the radio across these United States in partnership with WNYC. Check out the context.
