Cerebral Exposes Cracks in Mental Health Apps

By: Smitha Gundavajhala

Consumers are increasingly using mental health apps to get their needs met. It can be challenging to find a clinician, navigate the triage process, and wait weeks just to be seen for a mental health condition. Apps such as Calm, Better Help, and Cerebral are helping patients get everything from meditations to diagnoses. These apps also help mitigate the stigma around mental health conditions, making it easier for individuals to engage with their mental health that would not otherwise do so. 

However, these apps run into problems because they are commercial products, not traditional clinical services. Many apps brand themselves as “wellness apps” instead of health apps to avoid having to seek FDA approval. They also undergo little rigorous clinical testing — a meta-review of 145 studies of mental health apps showed that there was little evidence of efficacy among most mental health apps. These services provide little clinical value, but one app actively caused clinical harm.

Cerebral is a newer app targeted toward younger users. The service claims to provide help for “anxiety, depression, insomnia, and ADHD.” It is marketed as a simple, accessible, one-stop shop for individuals to get diagnoses, care counseling, and prescriptions. However, one of Cerebral’s former executives, Matthew Truebe, is suing the company for over prescribing medications for Attention Deficit Hyperactivity Disorder (ADHD).

Studies have shown that most people abandon a mental health app within a few weeks — Cerebral is no exception. Truebe, Cerebral’s former Vice President of Product and Engineering, alleged that Cerebral planned to increase customer retention by prescribing stimulants to 100% of its ADHD patients. According to the complaint filed on April 27, CEO Kyle Robertson asked Cerebral employees to track the retention rates of ADHD patients who were being prescribed stimulants by Cerebral versus those who were not. Robertson then asked employees to find ways to prescribe stimulants to more ADHD patients to increase retention.

Under the Controlled Substances Act, clinicians can generally prescribe controlled substances online only after an in-person medical evaluation. However, this requirement has been relaxed since the former U.S. Secretary of Health and Human Services, Alex Azar, declared a public health emergency for COVID-19 on January 31, 2020. This emergency allowed Cerebral clinicians to prescribe stimulants to users with no face-to-face evaluation. While it can normally take weeks (or months) for clinicians to accurately understand a patient’s mental health condition, surrounding factors, and interacting health conditions before making a diagnosis or prescribing medication, clinicians working at Cerebral were expected to provide a prescription at the end of a 30-minute video call. Because of Robertson’s instructions, employees at Cerebral said they felt that Cerebral pressured clinicians to prescribe stimulants.

What’s more, ADHD medications such as Adderall are stimulants and are highly addictive. Cerebral’s plan to improve customer retention fed into the addiction. Truebe conducted his own analysis on August 5, 2021, and found around 2,000 duplicate shipping addresses in the patient database. The existence of these duplicate shipping addresses raised a red flag that some patients may have been attempting to get access to more medication than they were prescribed. 

The Cerebral case raises issues related to clinician liability — whether clinicians will be held liable for over-prescribing ADHD medication or whether Cerebral will be held accountable for instructing employees and pressuring clinicians to increase prescriptions. For now, Cerebral denies all allegations. However, this lawsuit could have repercussions for other mental health apps, especially those that allow consumers to obtain prescriptions remotely. While the federal public health emergency will not last forever, remote prescriptions may still continue because of the ease of access for consumers. However, Cerebral illustrates the need for serious guardrails before remote prescription becomes a permanent practice.

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