Cerebral, Other Digital Mental Health Providers Face Ethical Questions

Prominent digital mental health start-ups that offer prescription medication, like Cerebral, have recently come under fire for allegedly over-prescribing stimulants like Adderall. The company is currently under criminal investigation for violating the Controlled Substances Act while also being the subject of a DEA probe.

Cerebral wasn’t the first digital mental health provider to come under scrutiny. For example, BetterHelp—which provides counseling services and is heavily marketed, like many of these companies, on social media—was subject to the internet’s ire in 2018 when consumers brought forward concerns about the service not matching its public values.

While BetterHelp doesn’t offer medications, the core question is the same: what are the ethical concerns at play when mental healthcare in the digital space is now so commonplace, and what effects can (alleged) poor or improper treatment have on patients? 

Dangers of Over-prescription

Much of the coverage surrounding possible over-prescription has focused on drugs like Xanax and Adderall in relation to conditions like ADHD. Dr. Benjamin Cheyette (MD, PhD), a professor Emeritus at the University of California-San Francisco and current director of ADHD services at Mindful Health Solutions, says that traditional barriers to mental healthcare are heightened for those with ADHD. 

“We don't have enough providers. The ones that we do have aren't available everywhere. And so there are a lot of patients who need mental health care who can't get it because they don't have access… That's true across the entire mental healthcare landscape. It is further exacerbated in the case of ADHD because ADHD has traditionally, especially in adults, not been well recognized or a subject of much training for medical providers.”

Alongside issues already facing the patient population, Cheyette points to the relaxing of restrictions contained in the Ryan Haight Online Pharmacy Consumer Protection Act of 2008.

This action, taken in early 2020, was made to allow more flexibility for drugs—like Adderall, which falls under the purview of the DEA as a controlled substance—to be prescribed to patients via telehealth. That decision meant, as Cheyette puts it, that “the genie was out of the bottle,” as much as some in the field may wish to return to previous norms two year late.

When it comes to the negative effects of (potentially) wrongfully prescribed medications, particularly stimulants like Adderall, Dr. Matthew Ruble, MD, says that a multitude of problems are on the table. 

“The risks of… over stimulation, and whether it's them precipitating anxiety, precipitating insomnia; or, a fear of mine in behavioral health, precipitating or unmasking undiagnosed bipolar disorder, and precipitating a manic episode or a psychotic episode.”

Alongside those possible side effects—as Cheyette says, “there’s no free lunch” when it comes to medications—is a real concern that when the appointments don’t have a fully formed patient-practitioner relationship attached to them, certain warning signs may be missed.

Without that in-person element tests related to blood pressure, EKG’s, and other tools meant to check for other drugs in a patient's system, are likely to go by the wayside. Despite these concerns, Cheyette believes that a portion of the dialogue around these platforms is absent. 

“They're meeting a need. There is a real value that they're adding by providing access to patients who can't get it, and that is getting a little bit lost in this conversation, perhaps. Why did this happen? Well, it's because there are patients out there who need help, who weren't getting it before.”

Cheyette believes that the responsibility now falls on broader organizations that oversee medical practitioners to formalize a set of standards for the online delivery of mental healthcare, 

"What should be appropriate standards of care, and management of patients on a virtual platform? That is a general medical question that I think all of American medicine and worldwide medicine has to now grapple with.”

The History of Telehealth

Dr. Ruble says it's important in any conversation about telehealth to first understand that the practice isn’t exactly as new as one might think. 

“I can't call it innovative because even when I was in medical school, which is going back into the 90s at the University of Iowa, we had a program that utilized telehealth pretty significantly.”

While that telehealth offering was mostly limited to providing access to rural Iowans, Ruble sees additional parallels between early telehealth options and today’s boom, especially when it comes to concerns about the over-prescription of medications. 

"When Prozac first was introduced there were very similar concerns, even though there was no existing telebehavioral health, about it being overprescribed. And I think we're riding a wave of tele- behavioral health, and are seeing because of increased access, another potential increase for overprescribing.”

Ruble says that companies that promise pain management or erectile disfunction medication are offering up the same ethical quandaries. For him, the focus needs to be on quality of care, including building relationships between clinicians and patients.

When asked how to build quality into a telehealth platform—the company Ruble recently started working for, Discovery Behavioral Health, has begun providing an online offering—the Harvard-trained psychiatrist says that the jury is still out on how to do that effectively. 

“Yeah, that's a great question. And I think it's one that none of the healthcare industry has figured out.”