ADHD drugs are convenient to get online.

For three days in July, Jenessa Barnes was tormented by voices. It was as if people were just out of sight examining her flaws, picking her separated, even when she was home independently. The morning of the third day she withdrew to her car, thinking she might feel safer in a remote, enclosed area. But the voices stayed. Something was going horribly sinful. She turned on some foreign-language pop music, attempting to drown out the voices amid lyrics she couldn’t comprehend. She started going.

At some point, she stopped and texted: “I absolutely feel like my mental health is getting more threatening, not better since I’ve started cerebral.”

Barnes, a 30-year-old former rehab manager working as a waitress in California, had been using the telehealth service Cerebral Inc., which she found through an Instagram ad. For $325 a month, she got access to a therapist, a psychiatric nurse practitioner, and what Cerebral calls a care coordinator—a gatekeeper for the other two professionals. That team was tasked with helping Barnes with anxious thoughts, the result of a combination of never-ending pandemic life and the bipolar disorder she’d been living with for years.

Her first video call was in May. She requested it at 2:17 p.m., was quickly connected with a nurse practitioner, and was done by 2:35, according to the medical records she provided. It felt even shorter, Barnes recalls, because the nature of the questions lent themselves only to yes or no answers. The nurse on the call confirmed her bipolar diagnosis and prescribed a five-month supply of Abilify. In her next appointment, Angela Rasheed, the nurse practitioner she’d see for the next six weeks, added major depressive disorder and post-traumatic stress disorder to her ailments. Rasheed prescribed Wellbutrin IR and later added two more prescriptions.

In the three months she used Cerebral, Barnes saw a nurse practitioner four times and was prescribed five medicines: three antidepressants, an anticonvulsant, and an antipsychotic. She also saw a therapist 11 times for an hour each visit—the best part of her experience with the company, she says. As an uninsured person, she would have paid thousands of dollars for comparable traditional care.

As she spiraled, Barnes exchanged a string of messages with her care coordinator, Eileen Davis. “This is very bad. It’s ruining my life,” she wrote. Davis promised to let her nurse, Rasheed, know. But Davis seemed confused, in particular about Barnes’s medication. It was a strange interaction—but texting with Davis was always a little odd, Barnes recalls, and, anyway, getting messages relayed to Rasheed was more important than whether her coordinator remembered every detail of the five scripts she’d been written.

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“Now you’re going to send me off? Like, ‘Oh, we broke it. Can’t do anything now.’” —Jeneesa Barnes, one-time Cerebral patient
Shutterbug: Maggie Shannon for Bloomberg Businessweek

There was a good reason for the confusion: Eileen Davis didn’t exist. That was a moniker given to hundreds of Cerebral care coordinators, who interacted with patients like Barnes under the pseudonym, former company insiders say.

The coordinator offered her an appointment with Rasheed in two days. But an internal chat log reviewed by Bloomberg shows that Rasheed decided before the session to terminate Barnes’s treatment. Her auditory hallucinations placed her in a new category; Rasheed’s notes say she required “in person psychiatric treatment/care.” For the first time in three months, a doctor weighed in on Barnes’s care to refer her out of Cerebral, the records indicate.

On the day she was scheduled to talk to Barnes for the final time, Rasheed logged on from her home outside Charlotte. She’d joined Cerebral 11 months earlier hoping to help address America’s mental health crisis at a company that promised the masses expanded access to care. She found something else, she says: a growth-obsessed startup targeting patients with social media ads and pressuring providers to dispense drugs after too-brief virtual sessions. In time, she says, she was seeing 30 patients a day—four an hour, from noon until after eight. It isn’t unusual for nurse practitioners who have psychiatric training to prescribe psychiatric medicine, rather than doctors. But 30 patients daily is twice the typical caseload, according to the American Association of Nurse Practitioners.

When Rasheed told Barnes that Cerebral could no longer help her, Barnes became furious. She hung up the phone before Rasheed could give her the name of her replacement provider. “You guys are the ones who put me in this condition,” Barnes says. “And now you’re going to send me off? Like, ‘Oh, we broke it. Can’t do anything now.’  ”

Her therapist reached out, calling and texting to urge her to use the referral to another provider. In the internal medical record, the therapist wrote: “Therapist provided advocacy.”

Two weeks later, Barnes checked herself into a nearby hospital to be treated for her mental health crisis. She’s been unable to work since.

Americans’ mental health, already brittle, has taken a beating during the Covid-19 pandemic. Laid off, drifting, going to work and school via Zoom, they’ve become more isolated, depressed, and anxious. The traditional medical system hasn’t been up to the moment, but that’s no surprise. Even before the pandemic, geography and high costs kept millions from getting the help they need.

Hundreds of thousands of people with mental health issues have found solace in a new breed of telehealth companies that don’t just offer talk therapy but also prescribe medications after a brief online appointment. And not just antidepressants. Federal rules that had required in-person examinations before the prescription of addictive drugs—including amphetamines such as Adderall and benzodiazepines like Xanax and Klonopin—were relaxed in response to the health crisis.

No company in this business has grown faster or bigger than Cerebral, which operates in all 50 states and in two years has registered more than 200,000 patients. In interview after interview, Chief Executive Officer Kyle Robertson has touted a commitment to “increasing access to high-quality mental health care.” But 27 former executives, managers, nurses, and other staff say Cerebral is failing on the “high-quality” part of the goal. In its hunt for explosive growth, they say, it has made appointments too short, set follow-up sessions too infrequently, advertised too aggressively, pushed prescriptions too hard, and paid front-line staff too little. In some ways, the company, based in San Francisco and funded by venture capital, follows the classic Silicon Valley playbook: identify opportunities among changing rules, move fast, drive employees hard. In psychiatric telehealth, the stakes are heightened by the prospect of patients in crisis and the risks of addictive drugs. Buy Ketamine Crystals Online

Cerebral declined to make executives available for interviews for this story and said it wouldn’t be appropriate to discuss individual patients’ experiences. Through a spokesman, Don Campbell, it released this statement: “Given our commitment to quality and access to care, we strongly believe that we can serve almost all patients who suffer from mental health conditions. We have safety mechanisms in place that no brick-and-mortar clinic, much less other telehealth companies, have in place.” The company said in a statement that its policies aim to “try to reduce the number of controlled substances used and the overall reliance” on medications. It declined to disclose how many of its current patients receive prescriptions.

Demand for ADHD drugs is booming in the U.S. In the second quarter of 2021, amphetamine sales jumped more than they had in almost a decade. In addition to people with clinical ADHD, bleary-eyed students and overworked middle-aged professionals have turned to Adderall and similar drugs as salve. Colleges say abuse of the drug is rampant on campus, where students use it to power through both studying and partying.

Cerebral makes it easier than it’s ever been to secure first the diagnosis and then, in the states where Cerebral can prescribe stimulants, the meds. For the committed drug-seeker, it’s easy to find guidance online about how to answer any nurse’s screening questions. Like other telehealth companies, Cerebral has a relationship with an online pharmacy that can mail the drugs straight to your door.

Seven former nurses for the company say they worried that Cerebral wasn’t merely meeting demand but was also, by making access so easy, effectively creating it; they described a fear that they were fueling a new addiction crisis. One researcher, Stephen Wood, an acute-care nurse practitioner who worked in Massachusetts at the height of the opioid crisis, is even blunter. Looking at the Cerebral website, he notes in particular that nurse practitioners are referred to as prescribers rather than providers or caregivers. “It doesn’t sound like they care about your well-being,” says Wood, now a visiting researcher at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. “It sounds like they care about prescribing you these medications.” The company said it uses the term prescriber to minimize confusion among the varied services it provides.

Robertson launched Cerebral in January 2020. At the time the company treated only anxiety and depression, prescribing drugs like Lexapro and Prozac. When the pandemic hit, the U.S. Drug Enforcement Administration, recognizing that many patients could no longer get to their doctors, relaxed rules in the Ryan Haight Act, named for an 18-year-old who died of an overdose in 2001 after buying Vicodin online. The changes meant patients could get controlled substances without meeting a prescriber in person. Cerebral soon added ADHD treatment to its menu of services. In October, Simone Biles, the star Olympian who ignited conversations around mental health when she temporarily withdrew from the competition in last year’s Summer Olympic Games, was announced as Cerebral’s chief impact officer. Two months later investors led by SoftBank, the Japanese investor behind WeWork Inc. and Uber Technologies Inc., plowed $300 million into the company, and Cerebral was valued at $4.8 billion.

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Biles and Robertson
Source: Today Show NBC/YouTube

And it’s Uber that several former employees mention when describing the company’s attitude toward its workforce. “Counselors, providers, they feel like Uber drivers, and there’s a reason for that,” says one former manager. “They’re being paid less and being asked to do more.”

Cerebral runs on subscriptions. New customers are enticed with discounted rates—as little as $30 for the first month—and choose among three tiers of service ranging from $85 to $325 a month. The cheapest gets you an initial visit with a nurse practitioner who can prescribe drugs and monthly check-ins with a care counselor, a title that suggests some level of licensure but requires none. At higher price points the caring counselor is replaced by a licensed therapist. Initial appointments with Cerebral prescribers are normally 30 minutes, and 15-minute follow-up appointments are typically set three months out. The company says patients are also eligible for unlimited follow-up appointments to discuss their care.

The customer-is-always-right approach is laudable if you’re a car service or a grocer. If you’re a healthcare provider, it flips the basic tenets of medicine upside down. Doctors and nurse practitioners learn to make the best calls they can with the information they have, and that doesn’t always mean patients get the drugs they ask for. At Cerebral, choosing not to prescribe can leave clients irate, triggering bad reviews. When patients ask, the company will often pair them with a new prescriber, nurses and coordinators say. The company said it’s merely providing patients with an in-house option for a second opinion. “We do monitor the number of transfers requested by patients to minimize ‘doctor shopping,’ ” Campbell, Cerebral’s spokesman, said in an email.

In meetings with managers, Chief Medical Officer David Mou has said 95% of people who see a Cerebral nurse should get a prescription, according to two people familiar with his remarks. He was equally emphatic, according to the former employees, that the rate cannot be 100%—saying the company would be a “pill mill” at that rate. Campbell said the 95% figure “refers only to the subset of patients who have received a clinical mental health diagnosis that warrants a prescription as first-line treatment,” but the former employees say no such distinction was made. Cerebral said, through a letter from its lawyer, that it does not set any prescription target for its clinicians. “Regarding prescriptions,” the letter said, “the criterion for prescribing medical professionals is that they follow evidence-based and clinical-quality guidelines in making diagnoses and deciding whether medication is warranted.”

Campbell originally said that “less than half of patients are receiving prescriptions.” After subsequent questions, he later corrected that to say more than half have received prescriptions. He declined to be more specific or to say whether the figure referred to the company’s current roster of patients or to everyone who’s had an appointment since Cerebral’s launch when it couldn’t prescribe controlled substances.

Getting patients to come to Cerebral is as easy as posting on social media. The company markets on Instagram and TikTok, often with variations on the message, “Have you ever thought you might have ADHD?” Some ads suggest that symptoms as common as difficulty with multitasking, focusing, and stress, as well as poor planning, procrastination, and disorganization can all be symptoms of ADHD. (They can; they can also, as one former Cerebral nurse says, “simply be attributed to being an adult in 2022.”) In another ad, a woman shakes her leg; restless leg syndrome can be a symptom of ADHD. In a third, a woman is asked: “Yo, bro, who got you smiling like that?” She then begins dancing with a box of prescription pills. Campbell said, “The majority of patients coming in thinking they have ADHD are actually not diagnosed with the disorder, and therefore do not need to be treated with a controlled substance.”

Laura Loray, a psychiatric nurse practitioner and clinical therapist based in New Jersey, is on TikTok as ThatPsychNP, dispensing information about ADHD, anxiety, and prescription drugs to her 95,000 followers. She says she’s been inundated with videos created by Cerebral and by influencers on the company’s behalf. She falls squarely into one of Cerebral’s target demographics: a woman with ADHD, diagnosed later in life, and extremely online.

“Initially, my impressions were, if this is a good company, this could be very beneficial,” Loray says. “We don’t see education telling people how to access these services. I was happy to see that initially.”

Loray’s opinions of the service soured after she saw a viral video posted by another TikTok creator, Katie McAleer, who says she was refused a refund after the app was unable to match her with a prescriber in her area, as was required in her state. The video tallied 270,000 views, and a follow-up was seen 2.4 million times. She received a refund after the first post went viral. McAleer’s video appears high in a search for “Cerebral” on TikTok, as does a sponsored post from influencer Samantha Swanson. Swanson does a tumble onto her bed, discusses her mental health, and then recommends that her 1.2 million followers check out Cerebral. When the company pays creators like Swanson for content, the videos are delineated with a small “#cerebralpartner” disclosure in the caption of the post. One ADHD content creator, Reece Palamar, has posted about a half-dozen Cerebral-related videos to his almost 600,000 TikTok followers. Swanson didn’t respond to an emailed request for comment, and Palamar declined to comment for this story.

The spots starring Biles are about anxiety or about mental health in general. Her decision to temporarily withdraw from the competition in the Summer Olympics, saying she had to put her mental health first, was a clarion call for a world devastated and exhausted by the pandemic. In the following days, Cerebral ran a “Summer Olympics Sale,” a mobile campaign that blasted phones with an offer of as much as 70% off the first month of the service. Campbell said in his email that it’s “absurd and offensive to suggest that this promotion had ANY connection to Ms. Biles’ personal participation.” Biles declined to comment.

When the company announced Biles would be joining as chief impact officer in October, many former employees, already concerned about the Cerebral model, expressed dismay. “I cried real tears when she became the face of the company,” says one former care coordinator, who is Black and who was already disillusioned after being asked to engage clients under the White-presenting Eileen Davis avatar. “Some little Black girl who idolizes Simone Biles will see her face on Cerebral’s stuff and want to get health care and end up not getting the help she needs.” Speaking of the Eileen Davis avatar, Cerebral said through Campbell, “While we regret that it made an employee feel uncomfortable, it has been updated and fixed.”

Kyanna Dixon, a care counselor for four months in 2021, wonders whether Biles knows what the company’s services actually look like. “It’s not doing what it needs to do,” Dixon says. “These people are like, ‘Cerebral is amazing,’ and I’m like, ‘Do you even know?’ ”

Disconcerted staff can be found at every level of Cerebral’s organization. Several former employees who expressed concerns declined to speak on the record for fear of retribution or because of concerns about violating non-disparagement agreements. All of them believe that telehealth has a vital role to play in filling the gaps in America’s healthcare system but contend that Robertson has ditched a serious mission to chase growth.

Others shared their thoughts openly. Carlen Zhu joined the company as a coordinator in August, just as Cerebral was retiring the Eileen Davis alter ego. “It is pretty bizarre to make people believe they’re talking to someone they’re not talking to, and it was strange to introduce myself to clients acting like I was ‘taking over’ from Eileen when she wasn’t a real person,” Zhu says. She had a roster of about 1,000 patients and was so overwhelmed on her first day that she cried. On an average day, she estimates, she fielded about 100 inbound messages; in a typical week, she heard from at least a few people in crisis.

The expectation was that every customer would hear back from Cerebral within 24 hours; failure to meet that was considered a “breach” by the care coordinator. For Zhu, that meant weighing, in each interaction, “whether I should prioritize a quick response or a quality response.” She lasted three months. “How can you expect us to deliver quality care to 1,000 people?” she asks. “There was such a disconnect between the people on the ground and what the higher-ups were doing. They were making decisions that weren’t in the best interests of the people making the money for them.”

For Dixon, the last straw came when she heard the company was expanding into treatment for even more complicated conditions, including substance abuse issues. The idea of dealing with patients going through withdrawal, virtually, was too much. “You can literally die from alcohol withdrawal,” she says. “That’s when I was like, ‘I do not want to do this at all.’  ”

As a recruiter of prescribers for Cerebral, Stephanie Leonard saw how nurses struggled under the company’s model and, as a member of its headquarters staff, worked closely with Robertson. “The company would be much better off outside of his hands,” says Leonard, who left in June. “He just wants to make money. That’s his end goal. Whenever he talks about ‘providing quality mental health care,’ his eyes are dead. He does not care.” Campbell said Robertson would like to address the criticism in an interview, then declined to make him available. In a statement, Robertson said he is working with an executive coach. “I am constantly looking for feedback from the people around me, so that I can improve as a leader for Cerebral,” the statement said.

Robertson, who’s 30, grew up with three sisters in a sprawling Tudor-style home in Cincinnati. He was one of four valedictorians at his high school; another, Claire Bernard, remembers him as “a pretty goofy guy and just naturally smart.” They’ve remained friends, and she says her father invested in Cerebral as soon as that was possible.

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Robertson with his parents in a promotional video.
Source: Cerebral/YouTube

After graduating from Columbia with degrees in East Asian studies and business management, Robertson did a stint as an intern with the Obama White House’s National Economic Council before becoming a management consultant at Accenture. From there he went to the Wharton School of the University of Pennsylvania. There, Robertson launched StartU, a publication that profiles startups at top universities. It was an early opportunity to run a remote enterprise and gave him a window into high-growth companies. “Kyle is a flame and constant source of energy,” says Matthew Wozny, who ran StartU at Harvard.

In Robertson’s telling, Cerebral’s genesis is rooted in his own struggle with anxiety and depression as a gay man. “Finding the right care was nearly impossible,” he says in a Cerebral TV ad, sitting on a couch between his psychiatrist father and psychotherapist mother. “As mental health professionals, we could help him navigate the system,” says his mom, Rita Robertson. “Not everyone has that,” Kyle chimed in, adding that Cerebral cuts patients’ wait times and provides affordable service, with the ability to get medication prescribed and then delivered to a client’s door.

Robertson founded the company with Ho Anh, a medical doctor who previously worked for Hims & Hers Health Inc., the Viagra-by-mail company. Former employees attribute the Cerebral aesthetic—tastefully branded pill bottles, snugly packed in tidy boxes—to Anh’s time at Hims & Hers. He was gone by February 2021. Anh didn’t respond to multiple requests for comment.

The pace of departures is stunning, considering the company’s rapid growth. Cerebral quadrupled its valuation from June to December 2021 alone. Internally, conversations center on when the company will list on public markets, not if. And yet in early 2022, Cerebral has lost its vice president for clinical operations (a tenure of 18 months), senior manager for clinical operations (13 months), and compliance manager (14 months), postings on LinkedIn shows. Employee turnover information is confidential, Campbell said.

Former employees often attribute exits to Robertson himself, describing him as condescending, incapable of fielding criticism, and prone to showing up unannounced to video meetings to dress down employees. Because he has no medical background, the habit especially bothered licensed clinical staff. Some employees told their managers they wanted less face time with Robertson; in an effort to improve morale, some managers tried to oblige.

Leonard says her job, hiring providers to fuel Cerebral’s expansion, was a constant struggle, because dozens of new hires departed before training was finished and dozens more fled amid concerns about the company’s prescribing practices. Robertson, unhappy with her team’s progress, had been checking their calendars and asking managers about gaps in their schedules, Leonard says. Another executive eventually advised the recruiters to fill their calendars with appointments even if they had no interviews scheduled. Leonard left after nine months.

In early August, Robertson decided the company needed to strip salaries and benefits from more than 200 therapists and moved to make the changes rapidly, over the protests of some executives. Therapists who didn’t quit were now paid by the session—$40 to $45 per patient. The company’s head of HR, hired just a week before, quit immediately when the cuts were announced.

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“It’s all about: We’re going to prescribe the most medicine to the most patients so we get the most patients.” —Angela Rasheed, former Cerebral nurse practitioner
Photographer: Travis Dove for Bloomberg Businessweek

Angela Rasheed, Jeneesa Barnes’s prescriber, had been among Cerebral’s top earners, reflecting her demanding schedule. She was terminated in September amid a dispute over her billing practices. She’d billed for the time she spent on paperwork during the windows when patients canceled and for writing prescriptions on behalf of other nurse practitioners who evaluated patients but lacked the necessary licenses to prescribe. The company called her billing fraudulent. The assertions befuddled Rasheed, who’d been paid a retention bonus six days earlier. She says that her manager encouraged her to bill the company in such a manner and that Cerebral never quantified or attempted to collect the money it alleged she owed.

Her critique of the company matches that of many other former employees: “You cannot effectively diagnose somebody with ADHD in a matter of 30 minutes,” she says. “It’s all about: We’re going to prescribe the most medicine to the most patients so we get the most patients. It’s just about quantity and not quality of care.” Cerebral characterizes her as a disgruntled ex-employee and an unreliable narrator.

Cerebral works effectively for patients with existing diagnoses who are seeking quick and easy online care, like Kristen Pearson, a graphic designer based in North Carolina. She was able to get help for anxiety related to her ADHD—she’d been diagnosed years earlier—when she didn’t have insurance. She initially planned to see an in-person psychiatrist, but the app offered a speedier process. For $85 a month, she got a care counselor she clicks with and a nurse who spent almost an hour on her initial visit. Pearson recently obtained health insurance through the Affordable Care Act marketplace. She plans to leave Cerebral soon because her nurse practitioner will be joining a local in-person medical office, where Pearson’s appointments will be covered by insurance.

Trustpilot Inc., a review website, features a slew of positive reviews from customers happy with their Cerebral experience. So does TikTok. In one post, a woman gleefully opens a medication in her car, rifling through the cute packaging.

This year, the biggest threat to Cerebral’s continued growth might be the possibility of the DEA eventually reinstituting pre-pandemic rules around prescribing controlled substances in person. That wouldn’t hurt only Cerebral; it could leave many patients of telehealth services functionally stranded, unable to get refills. But even before the pandemic, there were discussions about changing the Ryan Haight Act, and telehealth companies, among other interested parties, now see an opportunity to make some of the rollback permanent. Cerebral has joined more than 300 other companies and organizations in calling for Congress to extend the telehealth waivers for two years. Telehealth is effective for patients “who have a condition that warrants the prescription of a controlled substance,” Campbell said. “We feel strongly that providers need to be able to use their independent professional judgment to prescribe medications as needed, including controlled substances when clinically appropriate.”

Cerebral critics don’t disagree. That includes Barnes. She now relies on in-person psychiatric care after getting insurance through California’s public marketplace, and her mental health is under control. Cerebral eventually refunded the $829 she’d spent with the company, then politely asked her to consider removing a scathing review she’d posted. “If you would be willing, we sincerely appreciate you updating or removing your Trustpilot review,” a coordinator wrote. Barnes has left the review up.

Although her experience was harrowing, she believes telehealth fills an important need, and she feels a kind of sympathy for the Cerebral staff who worked with her. “If you send someone to do a job and you don’t give them the right tools,” she asks, “how are they going to be able to do it?”

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