Challenges to Quality Mental Health Care


The founders of Cerebral (an on-line telehealth company) may have started out with idealistic motives, but reporting clearly suggests that if this was the case that the company transformed into a profit driven enterprise with little regard for anything else.  The Journal’s (a Wall Street Journal Podcast) series on Cerebral (1) detailed how once the company began to prescribe stimulant medications, particularly Adderall, that the company’s  focus appeared to become almost exclusively on profits and growth.  As a practitioner who has evaluated and treated ADHD for decades, the ways in which ADHD was assessed and Adderall prescribed by Cerebral staff is mortifying. Per the Journal, nurse practitioners were assessing ADHD based on a brief screening measure and a half an hour appointment. Anyone familiar with the voluminous writings and research on ADHD should find these standards appalling (2). To assess ADHD in adults one needs to establish: the presence of sufficient current symptoms, that symptoms are impeding or impairing functioning, that there is a consistent history of ADHD symptoms back to childhood, and that no other disorders or issues better explain current symptoms. Optimally, an assessor would also obtain input from significant others, review archival records (such as old report cards or evaluations, if available), and administer and score rating scales (not just use a screening scale but a more extensive and validated instrument).   How all this can be accomplished in a 30 minute initial teletherapy appointment is inconceivable. While some of the nurse practitioners interviewed for the series (current and mostly former employees of Cerebral) advocated for longer appointments, e.g, a 45 minute slot), this seems like an incredibly insufficient remedy. 

This is not to suggest that medication based treatment of ADHD is inappropriate. Clearly, there is a substantial body of evidence that medication treatment is likely the most effective treatment for ADHD (though there is research supporting the value of Cognitive Behavioral therapy for adults, (3)). The issue is how Cerebral employees assessed and treated ADHD.  In addition, the series highlighted how Cerebral monitored the nurse practitioners prescribing patterns, encouraged/pushed the prescribing of Adderall, and apparently did not consider concerns employees raised about these practices. 

Fortunately, Cerebral is no longer prescribing controlled substances, including Adderall and other stimulants. Unfortunately, it appears that Cerebral is not the only on-line company that engages in this type of practice. A quick google search identified multiple ads for on-line companies offering to assess ADHD and provide medication treatments quickly and easily for low costs.  An example is a business called Klarity, which is sadly only one of many examples of this type of shoddy and potentially dangerous practice (4). The approach used by Cerebral (and similar approaches used by other on-line providers) for assessing and prescribing are pernicious and dangerous.  As the Klarity ad notes Adderall (and other stimulants) while potentially helpful medications are also easily abused and extremely dangerous if misused.  Moreover, there are medical risks that need to be assessed in adults, e.g., cardiac concerns, and potentially negative side effects that need to be monitored. 

Cerebral and similar companies are not the only examples of the negative effects and costs of telehealth.  Clearly, the ability to provide teletherapy and telehealth services during the pandemic has been an incredibly valuable benefit for many.  However, the proliferation of investor driven firms modeled after tech start-ups (with an emphasis on profits and a “most fast and break things” ethos) poses significant risks for individuals seeking mental health services. When an intense focus on the bottom line and willingness to cut corners is combined with slick and deceptive marketing practices, these companies can present significant risks to consumers.  The goal of providing more accessible and affordable care is laudable, but when these forces lead to a lowering and compromising of standards the costs and risks are substantial. The entry of venture capital into healthcare may result in some efficiencies when it comes to the provision of services but when these so-called efficiencies are nothing more than an effort to maximize profit quality care is undermined.  These companies also prey on consumers’ desire for quick access, easy solutions, and vulnerability to manipulation through unscrupulous advertising, and the use of celebrity spokespeople.  

In addition to the harm caused by inadequate assessments and over-prescribing, mental health professionals and our understanding of mental health care are harmed.  Mental health problems are often portrayed in unrealistic ways. The complexity of many diagnoses, the impact of social and cultural factors, and the hard work often involved in treating, managing and overcoming mental health problems are all minimized or ignored.  While the benefits of an increased acceptance of mental health problems and mental health treatment cannot be exaggerated, the dangers associated with some of the ways in which mental health problems are defined and treatments offered cannot be ignored. 

In closing, we understand that more traditional approaches to diagnosis and treatment can be frustrating, expensive, and time consuming, as well as involving hard work on the part of our clients.  However, the cost of too good to be true sounding services cannot be overstated. Part of our job as professionals is to make these points more clearly and to be sure they are shared more widely. 

Works Cited

  1. The link to the Journal podcast, and its series, “Uncontrolled Substances,”  on Cerebral:  At times the series does take a somewhat sensational approach. However, the gist of the podcast and the underlying reporting are clear: Cerebral appears to have put profit first and quality care was not a real concern.  
    1. The Wall Street Journal article, The Failed Promise of Online Mental health Treatment” provides additional discussion of these issues:
  2. See the work of Russell Barkley and Thomas Brown as examples. Barkley’s book, Taking Charge of Adult ADHD,offers an accessible examination of Adult ADHD, and the appropriate ways this disorder should be assessed and treated in adults. 
    1. Russell A. Barkley (Author), Christine M. Benton (Contributor) Taking Charge of Adult ADHD: Proven Strategies to Succeed at Work, at Home, and in Relationships Second Edition
    2. Thomas Brown, A New Understanding of ADHD in Children and Adults: Executive Function Impairments 1st Edition
  3. See the work of Ramsay and Solanto, for a few examples of this research. 
    1. Ramsay, J. Russell; Rostain, Anthony L., Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach (Practical Clinical Guidebooks)
    2. Solanto, Mary. Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction
  4. The link to the Klarify ad which stresses the low cost and quick access to ADHD assessment and treatment, i.e., an Adderall prescription.