The three years since Cerebral launched have been a whirlwind. With a promise to expand access to mental health care and medication online, the company received an impressive $462 million in funding from the end of 2021. But in the summer of 2022, the company came under intense pressure as its prescribing and business practices tailed off test by federal agencies and prosecutors.
As Cerebral navigates the fallout of these investigations and a rapidly changing telemedicine landscape, the CEO emphasized that Cerebral is working to improve the quality of mental health care.
“I’m really confident about the clinical side of what we’ve done and what we’re going to do in the future,” David Mou, a doctor who took over chairman of the embattled company in May, said Wednesday at the STAT summit.
When Cerebral launched in 2020, the San Francisco-based startup attracted clients with a subscription-based approach to mental health care that targeted conditions like anxiety, depression, and attention-deficit hyperactivity disorder. But in May it was reported that the company was examined by the Drug Enforcement Administration and was subpoenaed for possible violations of the Narcotics Act. Pharmacies including Walmart and CVS no more filling out prescriptions for controlled substances from Cerebral and the following month, The Wall Street Journal reported The Federal Trade Commission investigated whether the company engaged in fraudulent or unfair practices.
Around the same time, Cerebral stopped prescribing controlled substances like Adderall and Ritalin online, citing the fact that the drugs “have become a distraction from our focus on democratizing access to mental health services.” But Mou framed the change as a clinical decision instead, pointing to the forthcoming return of pre-pandemic regulations this would restrict purely telemedicine prescription of controlled substances.
“We have heard that Ryan Haight will be back in the coming months,” Mou said, referring to the 2008 law that requires an in-person consultation before prescribing a controlled substance in most cases. “We didn’t want to play and … have a month to wean all of our patients, hundreds of thousands of patients, off these drugs.”
Mou also resisted the idea that Cerebral’s business model could make doctors feel pressured to prescribe drugs, like reports over his clinical practices to have recommended. “We encourage people to follow clinical guidelines,” said Mou, who added that providers would not be given quotas on diagnoses, drugs, types of drugs, or dosages. “And that’s been from day one since I was there,” said Mou, who first joined Cerebral in February 2021 as chief medical officer, replacing co-founder Ho Anh.
“I think there’s a great intersection here between what’s good for business and what’s good for the patient,” he added.
Cerebral’s challenges have raised questions about how behavioral health care can be delivered safely in a virtual environment and what care is better delivered in person. But Mou resisted drawing a hard line between the two. “I don’t think it’s telemedicine versus brick and mortar,” he said. “I think it’s about evidence-based care versus non-evidence-based care, quality care versus non-quality care. I actually see the future as both brick and mortar and telemedicine, and this patient is able to move seamlessly between the different continuums.”
Mou has repeatedly invoked the idea that existing face-to-face care for patients is inadequate — and not just because patients may prove difficult to access mental health care and therapy, a common refrain from telemedicine advocates. Instead, he pointed to a lack of standardization in existing behavioral health practices, both in prescribing and tracking outcomes.
“This is a big mental health problem, but we don’t have a gold standard,” Mou said. “It’s not like diabetes, where we have a hemoglobin A1C and all clinicians agree that this is the standard.” With platforms like Cerebral, more standardization is possible.
“Telemedicine can be very, very useful for measuring clinical outcomes and important process outcomes,” Mou said. As an example, he cited Cerebral’s efforts to track metrics such as suicidal tendencies, emergency room admissions, and hospitalizations.
But when asked if his internal metrics were established benchmarks of clinical quality, Mou acknowledged they were a work in progress. “You have to start somewhere,” Mou said. “In short, we need to agree as a field on what that is. But in the meantime we will measure everything we can.”
Mou also described novel tools at Cerebral that can be used to identify patients who need additional support. “We have one of the most proactive suicide prevention programs,” he said, citing the text messages patients send to providers. “Some say I want to kill myself. I don’t want to go on anymore and I don’t want to wake up anymore. We use machine learning to identify these instantly.” He also described a program under development to similarly identify signals of domestic violence in text messages.
Mou said a data-driven approach is key to scaling Cerebral’s business, which is facing economic headwinds: the company announced in late October second round of layoffs This year saw an additional 20% reduction in staff across the Operations, Support and Clinical Care teams. He described how the company uses a set of criteria to identify high-risk patients and matches those selected users with a complex case manager. “Because we have this data, we can focus on the patients who actually need them and we offer them a high level of support,” Mou said. “It comes back to data science, to really knowing our patients and using our resources to optimize clinical outcomes.”