From the outside, Cerebral appeared to be a Silicon Valley success story.
The San Francisco-based startup launched in 2020 with a bold mission — to democratize access to high-quality mental-health treatment. Patients would pay for access to antidepressants like Prozac the same way they’d pay for an Amazon Prime membership. For a set monthly fee, they could see a nurse practitioner through an app and log off with a prescription on the way to their doorstep.
Kyle Robertson, a business-school graduate with no healthcare background, and Dr. Ho Anh, a former medical director at the telehealth company Hims, started Cerebral just ahead of the coronavirus pandemic, which shuttered doctors’ offices and generated more demand for online mental-health care. Investors clamored to back mental-health startups like Cerebral, and the company brought in a total of $462 million in funding.
But a cache of internal company documents and interviews with more than 30 current and former employees from across Cerebral suggest a startup operating in flagrant disregard of clinical standards.
It took on patients it didn’t have the resources to treat, sometimes putting them in danger, and jeopardized its clinicians’ licenses.
The documents viewed by Insider include Cerebral’s company policies, internal communications, meeting agendas, memos, and about 2,060 incident reports filed by employees from seven months in 2021, many flagging serious concerns with patient care.
They show the company enrolled patients with complex conditions, such as bipolar disorder, and assigned them to clinicians and other staff members who lacked sufficient training, oversight, and support to treat them.
Cerebral put dozens of patients on questionable treatment plans, according to the authors of the incident reports. Some patients were flagged as misdiagnosed. On occasion, company medical providers prescribed potentially lethal combinations of drugs to patients or prescribed addictive drugs to patients with histories of addiction — mistakes that could have been avoided, the documents suggest. Because the reports don’t contain identifying information, Insider was unable to reach out for comment to the patients they describe.
“The incident reports are deeply concerning,” said Dr. Ravi Shah, an assistant professor of psychiatry at Columbia University, who reviewed hundreds of the Cerebral reports related to prescribing practices for Insider.
In a statement to Insider, Dan Childs, a spokesperson for Cerebral, said it’s essential to put the volume of Cerebral’s incident reports in context with the size of the company’s patient population, but declined to say how many patients Cerebral treated in 2021. “Any incident reports you obtained show Cerebral’s dedication to quality,” he said, adding: “You can’t take a relatively small group of incident reports and draw conclusions about our care.”
The reports show Cerebral’s problems were not just clinical in nature. Technology issues and a failure to retain clinicians left many patients without consistent access to care, documents show. Cerebral shuffled patients from one provider to the next and routinely bungled their prescriptions, which in some cases caused patients to experience drug withdrawal or to take the wrong medication, the documents show. In one case, a patient was left waiting for two weeks for a referral to a psychiatric clinician at Cerebral. She later said she spent eight days in a psychiatric ward during that time, according to a September report.
The company also skirted state regulations, putting many clinicians’ licenses in jeopardy, according to former employees and documents seen by Insider.
Healthcare companies collect incident reports like the ones Insider reviewed to identify and fix major problems so they don’t recur. They’re often monitored by quality committees made up of people with clinical backgrounds. At Cerebral, staff could use a Google form to report incidents outside the normal course of business. Childs said the reports are monitored by various teams at Cerebral and used to identify areas of improvement in clinical training and processes, without offering details on how that process works.
Yet two former senior employees told Insider that the incident reports were monitored by just a couple of employees who had other responsibilities at the company, and leadership repeatedly pushed off dealing with the systemic issues that the reports revealed. A former Cerebral psychiatric nurse practitioner who wrote several incident reports said they never heard back about a single one and eventually quit filing them.
“You have startup pains, growth pains,” one of the former senior employees told Insider. “But the issues that we had were detrimentally affecting patients, and we were not creating safeguards in a timely manner.”
Now, Cerebral is in a free fall. At least two federal agencies — the Drug Enforcement Administration and the Department of Justice — are investigating Cerebral’s prescribing. The Federal Trade Commission is investigating whether Cerebral deceived consumers. Major health insurers and pharmacies have severed relationships with the company.
In May, as pressure mounted, Cerebral pledged to stop prescribing most controlled substances by October — a practice that had been at the heart of its business model. Then Cerebral ousted Robertson and replaced him with Dr. David Mou, the company’s president and chief medical officer, who oversaw clinical care. When reached for comment independently, Robertson deferred to his lawyer, who did not return Insider’s request for comment.
In June, Mou announced layoffs, blaming market conditions. Childs did not make Mou available for an interview.
An aggressive new model
Early in the pandemic, Cerebral saw an opportunity to turbocharge its growth.
The company took advantage of a temporary federal rule change allowing healthcare providers to prescribe controlled substances such as the stimulant Adderall, used to treat ADHD, online without requiring an in-person visit.
Controlled medications are closely watched by regulators because of their addictive potential. Cerebral was one of just a handful of online companies prescribing them, and it set the startup apart.
Plus, aggressive advertising on social media from TikTok to Instagram helped propel the company. In October, Cerebral named the Olympic gymnast Simone Biles its chief impact officer, tasked with promoting its services through ads and media appearances following her spectacular withdrawal from the summer Tokyo Olympics in 2021. Representatives for Biles did not respond to requests for comment.
By December 2021, Cerebral claimed to be the largest, fastest-growing online mental-health company in the world.
The startup had more than 210,000 active patients across 50 states and the UK at the end of March, according to a presentation by Cerebral leadership obtained by Insider. It employed about 4,500 people, the presentation said, just shy of the size of Lyft’s workforce before its initial public offering.
To handle that growth, Cerebral needed to quickly bring on more workers.
Early this year, Robertson said Cerebral planned to hit 10,000 workers by the end of 2022. Leaders, including Robertson, pushed recruiters to hire faster and shorten interviews, two former recruiters told Insider. The quality of the clinical hires suffered as the startup grew, a former Cerebral employee with direct knowledge said.
That employee, like most current and former Cerebral employees Insider interviewed, requested anonymity because they feared retaliation from the company or harm to their future job prospects.
The company encouraged its nurse practitioners, which it calls “prescribers,” to prescribe quickly and widely. Two unnamed sources told Businessweek earlier this year that as chief medical officer, Mou told staff that 95% of Cerebral patients seeing a nurse should get a prescription. One nurse practitioner who spoke with Insider recalled being questioned by a supervisor as to why she wasn’t hitting that metric. (Childs, the Cerebral representative, said the goal was to offer prescriptions to only 95% of qualifying patients.)
Contracted nurse practitioners, who make up the bulk of prescribers at Cerebral, were paid $10 to refill stimulants to treat ADHD in between appointments, according to screenshots of Cerebral’s controlled-substance policies obtained by Insider in early April, but they received no extra money for other refills. Childs said the compensation covered the additional work required for controlled-substance prescriptions.
Early this year, the company was issuing anywhere from roughly 7,800 to more than 13,000 controlled-substance prescriptions in a single week, according to company documents reviewed by Insider showing Cerebral’s weekly prescriptions for such drugs.
Childs said controlled substances are and have always been a limited part of Cerebral’s business and that the numbers likely include new and ongoing treatment.
“Cerebral has never pressured clinicians to prescribe medication,” Childs said.
The prescriber didn’t really ask questions and immediately asked if she wanted Adderall.Cerebral internal incident report
Cerebral was tested as patients with serious mental illnesses turned to the app.
Nurses were allotted 30 minutes for intake visits and 15 minutes for follow-ups. In dozens of internal messages seen by Insider, nurses protested that the appointments were too short to manage serious patients effectively. And most Cerebral patients were seen by family nurse practitioners without specialized training. Some Cerebral clinicians said they were uncomfortable treating the patients assigned to them and felt their licenses were at risk.
The stakes were high, as the company was treating many patients who were dealing with crises. Some had never received mental-health treatment before, the documents suggest. In the second quarter of 2021, staff members dealt with an average of 349 health crises a week, including patients on the verge of suicide, according to the internal company presentation. By the first quarter of 2022, Cerebral was handling 1,049 weekly crises.
Addictive drugs were carelessly prescribed, reports say
In August 2021, a man in his thirties had to leave his shift at a new retail job because he was hearing things that weren’t there.
He was in recovery from a heroin addiction, having overdosed on fentanyl four months earlier. His clinician at Cerebral wrote that he was feeling depressed and anxious and appeared to have schizophrenia, bipolar disorder, and social anxiety, according to an incident report.
When the man came to Cerebral, he was already taking alprazolam, the generic form of the antianxiety medication Xanax; Invega, a drug used to treat schizophrenia; and Lamictal, a drug used to treat bipolar disorder and seizures. His clinician decided to continue each medication and told the patient to take more of his Invega.
Dr. Laurel Blackman, a Cerebral psychiatrist who filed the incident report on the case, was alarmed. Cerebral nurse practitioners weren’t supposed to treat schizophrenia, she noted, and there was no way to tell whether the patient’s hallucinations were “substance-induced.” The American Psychiatric Association strongly recommends that schizophrenia be treated with a psychiatrist at least weighing in.
Moreover, prescribing Xanax, a controlled substance, to someone with a history of substance abuse risked sparking another addiction, she said.
“This was not a patient to take into Cerebral medication management in my opinion — would not have touched this,” Blackman said in the report.
Blackman, who still works at Cerebral, said her incident reports are all reviewed and addressed by clinical leadership.
Of the more than 2,000 incident reports reviewed by Insider, about 230 involved controlled substances prescribed by Cerebral. More than a third of those involved stimulants to treat ADHD. Others involved benzodiazepines, which are depressants.
These drugs can work well for some. Cerebral has said that controlled substances considered first-line treatments “should be encouraged first and foremost and should be the basis of the treatment plan,” according to the screenshots of the company’s controlled-substance policies.
But because anyone can get addicted to them, Dr. Anna Lembke, a professor of psychiatry and addiction medicine at Stanford University’s school of medicine, said they require more checks and balances than typical drugs, especially when prescribed through telehealth.
Lembke’s addiction-medicine clinic near Palo Alto, California, has used telehealth to see patients who live far away, but providers there still seek to identify drug misuse through online-prescription databases, supplemented by conversations with patients and their family members, she said.
“That’s the central tension,” Lembke said. “We can’t sacrifice access for quality or vice versa. What telehealth allows is increased access. But it also allows for increased exploitation.”
At Cerebral, the reports repeatedly document violations of the company’s own written policies on controlled substances. Nearly 30 reports recount patients who obtained more than one controlled substance at a time, a violation of Cerebral policy, and more than 20 reports describe patients receiving multiple refills of controlled substances, another policy violation.
It appears that you prescribed controlled substances to the client who was 18 months sober.
— Cerebral internal incident report
The documents hint at the risks inherent in prescribing these medications. In August 2021, a patient messaged Cerebral that they wanted to cancel their account because they were becoming addicted to Adderall, one report said. A month earlier, the mother of another patient emailed Cerebral that her son had been sober for 18 months before taking 30 tablets of a Cerebral-prescribed controlled substance in four days, according to another report.
Most states have laws that require healthcare providers to check prescription-drug monitoring programs before prescribing controlled substances. These electronic databases tell providers whether, and when, patients were previously prescribed other controlled drugs, which can help them avoid redundant or dangerous prescriptions. Cerebral policy also requires that clinicians perform these checks.
But the authors of 26 incident reports explicitly state that Cerebral clinicians failed to check the databases or document that they did. Of those, about a dozen cases resulted in clinicians prescribing drugs that could put patients at risk when combined with their other prescriptions.
“That’s genuinely not OK in this day and age,” Lembke said. “In the context of the opioid epidemic, when these phenomena are now well-described and well-recognized, it really is necessary to check the PDMP, especially when initiating a new prescription.”
In one report, a patient received a Xanax prescription from a Cerebral provider on top of an outside prescription for Ativan, another benzodiazepine. Cerebral’s Blackman only discovered it after a subsequent PDMP search.
Besides that drug, the patient was prescribed five additional psychotropic medications, “many of which interact with each other,” Blackman wrote in the October report. The driver’s license on file was expired and didn’t look like the patient, she added.
About 60 of the reports describe patients who had addictions or showed signs of drug misuse. More than a quarter of them said Cerebral providers prescribed those patients potentially addictive medications anyway.
One Cerebral patient got three separate prescriptions for Adderall in May 2021 alone, one from Cerebral and two from an outside provider, according to a PDMP check conducted later, a psychiatric nurse practitioner wrote in a September report. There was no supporting documentation for the ADHD diagnosis, she said.
The patient saw his second and third Cerebral nurses in August. Both continued the Adderall prescriptions. In September, a fourth Cerebral prescriber consulted with a company doctor who determined the patient shouldn’t have gotten Adderall at all, because he had a history of substance abuse and his father had a heart condition, the report said.
Cerebral policy says patients who have certain heart conditions or family members with certain heart conditions shouldn’t get Adderall unless Cerebral gets clearance from their primary-care providers. The patient’s third provider was the first to arrange for cardiac testing.
Eventually, he was cut off from stimulants. But when the patient demanded a new provider, Cerebral planned to assign him one, according to the report.
Potentially lethal combinations
In May, after Insider broke news that the company was under investigation by the DEA, Cerebral said it would stop prescribing controlled substances. The exception: using controlled drugs like buprenorphine and Suboxone to treat patients addicted to opioids.
Yet some of the most troubling incident reports reviewed by Insider describe Cerebral nurses issuing addictive medication to patients already on buprenorphine and Suboxone, resulting in potentially lethal drug combinations. At times, these mistakes stemmed from failures to check state prescription databases, according to reports.
In September 2021, a Cerebral patient was prescribed 120 1-milligram tabs of Xanax before reporting a week later that they lost the medication, according to an incident report. The maximum recommended dose by the US Food and Drug Administration is 4 milligrams a day. The patient’s nurse turned to a Cerebral doctor over Slack for advice on how to handle the situation.
The doctor approved a refill. According to the physician assistant who filed the report, the physician appeared to have only read the Slack post and likely didn’t see the patient’s chart, the quantity of Xanax he was approving, or that the patient was already on buprenorphine, an opioid. As a result, the patient received 240 tabs of Xanax in one week — well over Cerebral’s 60-pill-a-month limit on controlled substances. The patient also had received previous stimulant prescriptions, the report said.
It’s not unheard of for patients to be on Xanax and buprenorphine or Suboxone, but the combination can result in accidental overdoses. When Lembke’s clinic encounters patients on a benzodiazepine like Xanax, providers will slowly taper them off while starting the addiction medicine, she said.
“The synergistic effects between these drugs slows respiration and heart rate, puts them to sleep, and they don’t wake up again,” Lembke said, describing the worst outcome.
The nurse in the September case was fired, according to the incident report. But the reports document other Cerebral clinicians prescribing benzodiazepines to patients on buprenorphine or Suboxone three previous times.
A few reports also describe patients on medications to treat their addictions who were prescribed Adderall. Cerebral policy states that patients on Suboxone shouldn’t be prescribed any controlled substances because of the risk of respiratory depression.
According to Childs, Cerebral now requires patients to stop taking benzodiazepines before starting Suboxone, and conducts weekly drug screenings to monitor this.
Practicing beyond their expertise
Cerebral has relied heavily on family nurse practitioners, medical professionals trained to provide a wide range of primary-care services, to prescribe medication to patients, according to the incident reports and four current and former employees.
The phenomenon extends beyond Cerebral: Nurse practitioners in the US are increasingly filling gaps created by a shortage of physicians in primary care, where many people obtain mental-health treatment.
But a number of incident reports flag concerns that Cerebral’s family nurses had practiced beyond the limits of their expertise when treating the startup’s high-risk patients.
More than 400 of the reports describe patients with complex diagnoses such as schizophrenia and bipolar disorder; patients with substance-use disorders or misuse; patients with histories of suicidal ideation, suicide attempts, or self-harm; patients with serious symptoms such as psychosis or homicidal ideation; patients with histories of abuse or homelessness; and patients who clinicians said were too serious for Cerebral to treat.
“The level of complexity expected to occur in 30 min or 15 min visits is certainly not high-quality mental health care,” one psychiatric mental health nurse practitioner, or PMHNP, wrote in August 2021 in a company Slack message reviewed by Insider. “I am an experienced PMHNP and cannot imagine doing this work when I was an FNP,” or family nurse practitioner.
Childs said patients with complex conditions are required to be seen by nurse practitioners with psychiatric expertise — while treating anxiety, depression, and insomnia falls within the scope of care for family nurse practitioners. He later added that family nurse practitioners can also treat conditions such as ADHD and bipolar II, for which he said Cerebral provides trainings.
Seeing clients with serious mental illness in 30 minutes is unsafe.
— Cerebral internal incident report
In many of the 90 incident reports involving Cerebral patients given a diagnosis of or showing symptoms of serious mental illness, the writers expressed alarm that the patients were mishandled. About a dozen of these reports document that patients with severe mental illness were prescribed controlled substances.
More than a dozen reports complain of patients with bipolar disorder being prescribed too many drugs, or the wrong drugs, or drugs at the wrong dosage, in a few cases without proper laboratory testing being ordered.
Cerebral started roughly 20 patients on medication only to later realize they shouldn’t be treated over telehealth and refer them to therapy or drop them, according to the reports.
According to a July 2021 incident report, a patient told Cerebral she heard voices telling her violent things. The patient said she was previously diagnosed with schizoaffective disorder because of extreme paranoia and hallucinations. “I don’t feel connected to reality at all,” she said, according to the report.
The patient was placed on the schedule of a clinician who refused to see her, saying that her treatment plan — “baby doses” of an antidepressant and an antipsychotic — was inappropriate and that she should have been referred to Cerebral’s therapy-only plan.
“Please stop letting FNPs do these kinds of consults,” the clinician wrote. “It is dangerous and they are practicing out of scope.”
One family nurse practitioner told Insider he knew within two weeks of joining Cerebral that he’d quit, because he thought his license was at risk. He felt comfortable treating anxiety and depression but got a patient with far more complicated conditions on his schedule. He felt unable to treat her, yet couldn’t quickly find her an appropriately trained clinician.
He said referring complex patients up to a psychiatric nurse practitioner or getting a physician consult over Slack wasn’t always easy. It could take a few hours for a doctor to respond, he said. Cerebral staff use the workplace messaging app Slack to handle everything from clinician consults to medication refills to patient crises.
Another family nurse said there was only one psychiatric nurse available in her state, so referrals to that clinician weren’t possible, yet roughly a third of her patients needed a higher level of care. She told Insider she put in her notice during her second week with Cerebral because she also felt her license was on the line.
One provider wrote prescriptions for three controlled substances for a patient before finally referring him up to a psychiatric nurse practitioner. “If the prescriber was not comfortable treating this client he should never have prescribed any of these CS medications,” the psychiatric nurse practitioner wrote in a July report, referring to controlled substances.
Childs said Cerebral has revamped its refer-up process to address any delays in responses from clinicians. He said physicians routinely audit prescribing behaviors of the nurse practitioners under their supervision and flag concerns that can lead to discipline or education.
This patient had her meds abruptly discontinued here since she was referred out for bipolar I diagnosis.
— Cerebral internal incident report
About half of US states give nurse practitioners authority to practice independently; the others require supervision by doctors. At Cerebral, while doctors are required to supervise nurses in those states, their relationships can be distant, according to internal company documents.
One former Cerebral employee with direct knowledge told Insider that full-time physicians were expected to oversee 75 to 100 nurse practitioners across multiple states. Each nurse could be seeing hundreds of patients. Some states, such as Tennessee, don’t cap how many nurses doctors can oversee. But that’s far more than other states allow: In California, doctors can oversee a maximum of four nurse practitioners, while doctors can oversee only five in Ohio.
Earlier in June, Mou, the new CEO, said Cerebral would focus more on treating serious mental illness. Asked whether Cerebral was implementing changes to handle high-risk patients, Childs pointed to several goals, such as hiring more psychiatric nurse practitioners. He did not disclose the current ratio of family nurses to psychiatric nurses at the company.
A bewildering cocktail of drugs
Last summer, Cerebral’s Blackman filed a report complaining that the company’s prescribers too often started patients on multiple medications at once for competing diagnoses. “I continue to see this over and over again,” she wrote. “It is a pervasive problem.”
Take the case of a young woman who joined Cerebral in January 2021. Her prescriber used a prior Xanax prescription from an urgent-care clinic as a justification to continue the prescription at Cerebral, according to a May report. By April, the patient was on Xanax; two antidepressants; and an antihistamine used to treat anxiety — “at least three symptom-chasing medications without maximizing,” the clinician who authored the report wrote, meaning the patient wasn’t on the highest dose of any individual drug.
“What is the long term plan in prescriber’s thinking and management?” the clinician wrote, adding that the longer the patient took Xanax, the more dependent she may become.
In some cases, Cerebral clinicians prescribed as many as five or six medications at the same time. Those regimens often contained controlled substances.
Starting that many medications at once poses risks, such as side effects, and makes it difficult for clinicians to know which drug is working and which may be causing problems, said Dr. Jessica Gold, an assistant professor of psychiatry at Washington University School of Medicine in St. Louis.
“Every medicine you take has side effects and that can be problematic for people,” Gold said.
My patient had hives after taking Lamictal. No one in the care team has followed up or even checked on the patient.
— Cerebral internal incident report
A psychiatric nurse practitioner who formerly worked for Cerebral said they commonly saw Cerebral clinicians undertreating and overtreating conditions. People with mood swings were likely to get bipolar diagnoses, they said. At the same time, family nurses commonly prescribed antipsychotics to patients with depression before trying to properly calibrate their existing regimen of antidepressants.
“FNPs will just throw antipsychotics around like it’s fucking candy — and it’s not,” the nurse said. “These are very serious medications with very serious side effects.”
Childs said this comment is baseless and unsupported by any evidence.
In July, a psychiatric nurse practitioner determined her patient had anxiety, depression, bipolar disorder, insomnia, night terrors, and post-traumatic stress disorder, according to a report. She started the patient on five medications at the same time, and the patient soon reported side effects including dilated pupils, difficulty eating, shaking, and anxiety.
Over Slack, Cerebral doctors later stepped in to discontinue three of the medications and cut a 75 milligram dose of Effexor, an antidepressant, in half.
“My meds made me extremely sick. Vomiting and dizziness. I’m eating apple sauce and drinking water to try to calm my stomach down,” the patient wrote to their Cerebral care team. “75mg is a bit too much for me, unfortunately.”
That same month, a psychiatric nurse practitioner filed a report, alarmed that a family nurse had given a patient a diagnosis of bipolar disorder without documenting the reason. The family nurse, who did not note which type of bipolar disorder the patient had, prescribed the antipsychotic risperidone, after which the patient gained 30 pounds in just a few months.
The family nurse failed to see the weight gain as a side effect of the drug, continued it, and added the sedative Ambien for sleep and another antipsychotic “without clear reasons why,” the report noted.
“With this amount of weight gain, I am very concerned about the lack of discussion with the patient,” the psychiatric nurse wrote. “I am concerned about documentation across the board not being up to clinical standards.”
Dozens of reports record Cerebral prescribers making other mistakes, such as missing underlying conditions, patient histories, or outside medications that made their Cerebral prescriptions risky. A few reports describe patients with bipolar disorder being prescribed Adderall, which can induce mania, according to Cerebral’s internal controlled-substance policies.
One Cerebral provider prescribed a patient Cymbalta, an antidepressant that can increase blood pressure, after the patient had tried a variety of other drugs to no avail. But the patient had known hypertension, and the Cymbalta caused his blood pressure to rise to an abnormal level, a nurse practitioner wrote in an October report.
“Seems like a miss here,” she said. “Of course, we can never know how each pt will respond to certain meds, but having an underlying condition increasing risk of adverse rxn seems like something that was avoidable.”
Rapid hiring and rushed visits
The quality of care varied dramatically across Cerebral’s clinical staff and seemed to worsen as the company grew, a former Cerebral employee with direct knowledge said.
“The quality is very, very, very variable,” the former employee said. “It’s highly dependent on who you are randomly assigned to.”
Under Robertson’s direction, Cerebral quickly pushed into treating more conditions like weight loss. The company struck a partnership to refer patients for ketamine treatment and plans to add online mental-health treatment for kids, according to its website.
To meet the surging demand for services and plug gaps in the workforce produced by Cerebral’s high turnover, Cerebral tasked recruiters with hiring nurse practitioners and other staff members as fast as possible. Lacking much direction, recruiters weren’t picky about whom they hired, one former recruiter told Insider. A “license and heartbeat” were all it took to get a job, the recruiter said.
That former recruiter and another, Stephanie Leonard, both independently said leadership, including Robertson, directed them to cut interviews with candidates to 20 minutes each from 30 minutes so they could squeeze in more each day. Cerebral managers said “rock star” recruiters should be interviewing 85 nurse practitioners a week, Leonard said.
“It was always more: You need to hire more, you need to do more interviews,” said Leonard, who worked at Cerebral until June 2021.
Childs said Cerebral evaluates clinicians’ experience, education, and licensure. Applicants also take a clinical assessment, he said.
Leonard said nurse practitioners had to say they were willing to prescribe controlled substances or recruiters didn’t hire them. Many nurses who signed on to work at Cerebral quit within a few days, or after they learned about the system of compensation, such as the low pay for no-show visits and the lack of pay for administrative work, she said. Nine current and former employees, including Leonard, confirmed the high turnover among clinical staff.
Some patients wrote to Cerebral that their appointments felt rushed, incident reports show.
In the fall of 2021, a patient who had attempted suicide two weeks before joining Cerebral said he was disappointed by his first appointment. The nurse practitioner said he “had people waiting” and tried to end the visit after 20 minutes, according to an October report. The nurse found the patient to have bipolar disorder and prescribed three medications, but the patient said he wasn’t confident in the diagnosis because of the rushed visit.
While Cerebral physicians are required to review a portion of each nurse practitioner’s charts, there is little additional clinical oversight. One of the company’s main safeguards is a team of clinical administrators who refill medications and check that prescriptions match clinicians’ appointment notes.
Administrators don’t need to have medical licenses. A former clinical administrator said she didn’t feel qualified to tell prescribers about problems with their prescriptions and called the role an “amateur version of auditing.”
Asked whether there are quality assurance measures outside of the medication checkers and physician audits, Cerebral’s Childs pointed to its incident reporting system and quality team. The quality team, headed by a psychiatrist, leads the strategy to improve care at Cerebral, he said.
Other forms of oversight were lacking, too.
At any hospital, incident reports like the ones Insider obtained can run the gamut from medication errors to a surgeon operating on the wrong leg, said Dr. John Bulger, Geisinger Health Plan’s chief medical officer.
Bulger, who previously headed up quality assurance for the Danville, Pennsylvania-based Geisinger health system, said that when prescribing problems surfaced through this kind of reporting at Geisinger, doctors were given resources to fix them.
“The question becomes what are they doing about it?” Bulger said. “Because some of this stuff is clearly going to happen.”
Yet at Cerebral, compliance initiatives languished.
Cerebral didn’t hire a chief for the department until March 2021, more than a year after it began treating patients. At times, compliance included just one or two people. (Childs said that Cerebral “more than doubled the size of the compliance team over the past year.”)
You’re sending me powerful neurological modifiers in a happy-colored box filled with Easter egg grass without doing the due diligence required to make sure none of these agents could kill me.
— Cerebral internal incident report, quoting patient complaint
In August, Cerebral discovered 2,000 duplicate patient profiles in its system, risking patients getting more than one treatment plan, a former senior employee, who had direct knowledge of the matter, said. Compliance wasn’t allowed to draft a plan to fix the issue, they said.
Childs said Cerebral, thanks to incident reports, has since implemented processes and technology solutions, such as automated checks, to prevent duplicate accounts.
Robertson mostly didn’t attend compliance meetings while CEO, another former senior employee said. “Kyle doesn’t care,” they said. “If it’s not about profit, he just doesn’t want to hear it.”
Leaders who did attend, including Mou, would typically spend a few minutes reviewing incident reports before growing overwhelmed and defensive and shifting to other topics. When urgent patient-safety matters were raised, the two former senior employees said, the executives refused to investigate.
Patients left in limbo
Care was further hampered by constant clinician turnover.
About twenty incident reports describe Cerebral switching patients’ providers, including therapists, three or more times. Providers who saw patients later in their journey at Cerebral were sometimes confused by the previous nurses’ treatment plans and had a hard time determining next steps with incomplete or contradictory medical notes, according to reports.
In February, Cerebral management directed a psychiatric nurse practitioner with 500 patients in Colorado to focus instead on treating patients in Florida, where he was also licensed, the nurse told Insider. In just a few days, the nurse, who no longer works for Cerebral, lost access to his Colorado patients’ medical charts.
The psychiatric nurse practitioner believed the move was dangerous, as many of his patients risked losing access to the medications he had prescribed. Most of the Colorado patients were on controlled substances to treat ADHD, he said, and at least some were switched to a provider who was unable to write prescriptions for controlled drugs. He only learned this when patients upset with the change contacted him outside the app, he said.
“Now your mental health may possibly crash or worsen after we’ve worked for months and months to help improve your emotional regulation and symptoms,” he said of his former patients. “But who’s to say the new medication is going to work? It’s like they’ll reverse that progress they made just because of a company thing, and I just felt like that wasn’t right.”
According to an October incident report, a patient who appeared to have bipolar I discussed hearing her sister’s voice at night. The patient was approved to be referred up to a more experienced clinician, but she then went two weeks without seeing a counselor or prescriber. “She feels she was erased or forgotten,” the nurse practitioner who filed the report wrote.
Just a month prior, a Cerebral patient was seen for the first time in eight months. She received medication refills the entire time without any appointments, a nurse practitioner said in a September report. The nurse was the patient’s fourth provider, and the patient said it felt “awful” to repeat her story to each of them.
The last time the patient had an appointment was two weeks after an overdose, the report said.
One patient saw three nurses, each of whom changed her medications, a Cerebral counselor said in a report from October.
“She’s had such a rough experience so far,” the counselor said.
At least 15 reports describe cases in which Cerebral clinicians found themselves treating patients in states where they were not licensed or lacked other required credentials, which sometimes led to disruptions in care. In one of them, a psychiatric nurse practitioner said it would be “tremendously helpful” if Cerebral would stop assigning her patients on controlled substances in locations where she was prohibited from prescribing them.
Childs said Cerebral was updating its system for matching patients with clinicians.
Previous prescriber left without notice and his new prescriber claimed his medical history was wiped.
— Cerebral internal incident report
Coordinators and providers were overloaded, hindering patient care. Cerebral clinical staff are required to respond to patient messages within 24 hours. But those messages sometimes hit a bottleneck. Coordinators, assigned to 1,000 patients or more, relay patients’ questions and complaints to providers. Slammed providers may leave messages unanswered while caring for patients back-to-back, or while away at other jobs such as their private practices.
Roughly 190 incident reports describe staff members canceling appointments or being unresponsive to patients, resulting in medication delays or patients left with unaddressed concerns, side effects, or full-blown crises.
According to a November incident report, a patient taking the antidepressant medication Zoloft wrote into the Cerebral app that she was pregnant and had a question about the medication’s safety during pregnancy. More than 10 days later, her care coordinator still hadn’t responded to her message or relayed it to a nurse practitioner.
Cerebral patients had trouble getting their prescriptions on time
The most common issue in the more than 2,000 reports reviewed by Insider was medication fulfillment. About 320 reports describe medication errors in which patients were sent the wrong drug, dosage, or quantity of pills. At least 120 reports document patients waiting around for their medication, and about 50 said patients ran out of their medication altogether.
For many of the medication errors and delays, the report authors blamed Cerebral’s technology and the mail-order pharmacy Truepill, which delivers prescriptions to patients’ homes.
Paul Vasquez, Truepill’s senior vice president of operations, said Truepill shipped the vast majority of its prescriptions within 24 hours but would delay fulfillment if it suspected clinical problems such as drug interactions, incorrect dosing, or clinical appropriateness.
Cerebral’s Childs said an analysis of Truepill errors for Cerebral patients showed an error rate below the national average, but added that dispensing errors were a “top priority for Cerebral’s new leadership.” Last month, he said, the startup sent Truepill a letter with a request to review plans for reducing errors.
Client has had issues with medication delivery every month since he enrolled with Cerebral.
— Cerebral internal incident report
Danielle Logan, a phone coordinator who left Cerebral in April, said she was directed to take upwards of 30 patient calls each day after her first month at the company. On average, she told Insider, roughly half of her calls were related to medication delays, and upward of five each day were from patients going through withdrawal. Coordinators had no way to fast-track a resolution for patients other than messaging their providers on Slack, she said.
“Essentially everything about the job was stressful, exhausting, and not fulfilling in any way shape, or form,” Logan said.
Consequences from delayed medication could range from minor inconveniences to hospital stays. One patient was committed to a psychiatric ward for suicidal thoughts because Cerebral ordered her medication four days late, a coordinator wrote in October 2021. The patient asked not to be charged for her subscription going forward and requested a refund for that month.
Cerebral offered her 50% off.
That’s one of about 120 reports that describe people who ended up in the hospital, emergency department, or other inpatient care, such as psychiatric wards, while Cerebral patients. Not all hospitalizations were related to Cerebral’s care. Some patients were hospitalized for suicidal thoughts or attempts or panic attacks. Other reports describe patients who were hospitalized because of reactions to Cerebral-prescribed medications, withdrawal symptoms, or overdoses.
Logan and three other current and former coordinators said the job was overwhelming between the steady stream of crises and sheer volume of emails and calls. More than 10% of the roughly 2,000 reports involve patients who had been suicidal or attempted suicide at some point. More than 90 of them attempted suicide while Cerebral patients; at least six died by suicide.
All four coordinators said they did not feel adequately trained to handle suicidal patients.
“It feels like a factory sometimes,” Heather Valmy, a phone coordinator who also left Cerebral in the spring, told Insider. “We’re just trying to churn people in and out.”
Cerebral has “full confidence” in the ability of its coordinators, who complete a clinical safety and crisis training when they join Cerebral, to triage crisis situations, Childs said. Cerebral also implemented a crisis response team over a year ago to help with emergencies, he said.
Cerebral faces investigations
Cerebral’s explosive growth was built on the shaky foundation of temporary regulatory waivers triggered by the pandemic. Early on, the DEA relaxed restrictions related to prescribing controlled substances online, and state waivers allowed nurse practitioners to work beyond their usual scope of practice without as much doctor supervision.
But Cerebral executives didn’t create solid plans for how to adapt the business once rules tightened up again, documents suggest.
An internal agenda document covering a period of months in 2021 and 2022 shows corporate employees tracking state-level requirements that Cerebral wasn’t in a position to meet. In it, they debated what to tell the startup’s clinicians about the risks they were taking on, according to a copy of the document reviewed by Insider.
Notes from an October meeting identified physician-supervision issues in Missouri, Mississippi, and Tennessee. In Tennessee, for instance, a doctor would need to visit the physical location where the nurses practiced once a month once COVID-era waivers expired, the document said.
“We cannot meet these requirements as a telemedicine company,” a note in the agenda said.
Agenda notes indicate Cerebral was struggling for months with the implications of its virtual workforce and lack of brick-and-mortar clinics. On applications for licenses to prescribe controlled substances, the DEA requires providers to supply the address where they work. Cerebral clinicians were instructed to use WeWork addresses the company set up. DEA offices in various states began rejecting that approach as early as October, according to the agenda.
Cerebral’s lack of physical infrastructure was a red flag for the DEA, indicating that Cerebral had no plans to comply with the Ryan Haight Act, one of the former senior employees said. The federal law requires patients to see a clinician in person before obtaining a prescription for a controlled substance. The DEA temporarily waived that requirement as COVID-19 surged. The waiver is set to expire with the end of the federal public-health emergency, though the emergency period was recently extended beyond mid-July.
An internal company memo shows that Cerebral’s legal team mulled how the company could meet the “spirit and intent” of the law without providing in-person patient visits. That could be enough, the memo argues, in the absence of a special registration process for telemedicine providers that the DEA was directed to create by Congress but hasn’t.
Cerebral noted in the memo that this strategy risked setting up its providers to violate the Controlled Substances Act, the federal statute that regulates the distribution of such drugs, and lose their individual DEA licenses. The memo also notes that any public disputes with the DEA could cause Cerebral “significant reputational harm.”
Childs said Cerebral contests the accuracy of Insider’s reporting about the startup’s compliance with telehealth laws, adding that the company takes legal compliance very seriously.
As state-level COVID-19 waivers expired, Cerebral rushed to comply, disrupting patient treatment in the process.
In April, for instance, the company moved all Missouri patients to the care of physicians, from nurse practitioners, following the reinstatement in December of a requirement that nurses practice within 75 miles of a supervising doctor. One nurse practitioner who still works at Cerebral told Insider she lost roughly 500 Missouri patients, who would have to wait as long as six weeks to see a doctor.
By April, the DEA was interviewing former Cerebral employees about the company’s rules for prescribing controlled medications, its processes for verifying clinician licenses, and other topics.
In May, the Justice Department issued a grand-jury subpoena to Cerebral, demanding the company turn over a slew of documents related to its prescribing of controlled substances as part of an investigation into possible violations of the Controlled Substances Act.
Cerebral said it would stop prescribing controlled substances soon thereafter. In a FAQ about the change sent to employees, the company blamed the DEA and Congress for not creating a permanent pathway for telehealth prescribing of the medications.
“Unfortunately,” the FAQ said, “the permanent actions required by the DEA and Congress did not come to pass as necessary.”
Megan Hernbroth contributed reporting.
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