This interview has been edited for length and clarity.
MindSite News: The last few years have been pretty meteoric for you – explosive growth and a somewhat dizzying decline. What lessons have you learned, and how will they affect your practices?
David Mou: First, consider how broken the system is right now. If you want a psychiatrist or therapist, you wait for months. Once you get to them, the vast majority don’t measure any outcomes. The vast majority of psychotropic medications are actually written not by psychiatrists but by primary care doctors and family nurse practitioners during 15-minute visits. That’s the system today.
We did a lot of things right: getting access down from months to days, measuring outcomes very carefully, making sure our clinicians are apprised of data and clinical guidelines, and improving access as we prioritize quality. In terms of lessons learned, I would say our prior marketing strategy was distasteful. Since I’ve been CEO, I’m very clear: Our asset is our clinical quality, how quickly we can get patients to care and follow clinical guidelines and encourage the data science behind all of this. Let’s make that the lead for our marketing campaigns and our reputation. We want to be seen as a high quality, high performing mental health system. We’re doubling and tripling down on clinical quality.
The second thing I would say is that generally speaking, we need to improve meeting patients where they are. Right now in brick-and-mortar psychiatry, when you have depression, you drive to an office, you sit with other patients who suffer from mental illness. You wait for the doctor, the doctor calls you back – it’s clinician-centered. We want to flip that on its head so it’s as convenient for the patient as possible. That means telehealth and making sure patients can come in and out of care easily. If you have depression, you might need care for a few months, then you don’t, then you need care for three months again. Tailoring the user experience to adjust for the rhythm of mental illness – that’s something that I’m focused on improving.
You mentioned that some of your marketing was distasteful? What were you getting at?
I understand the need to meet patients where they are on social media. We also need to get creative on how we communicate that. We can take good care of your depression, your anxiety, your ADHD or bipolar disorder. We can take care of patients who are dumped by [other] companies. I’m not a marketing person. I don’t know how to make that pithy, but we should look like a well-respected mental health system. That’s where I want to take our marketing.
I’m sure you saw the Business Insider article on incident reports. All top healthcare systems have an incident reporting system to encourage their staff and clinicians to report things that could have been better. I took a lot of policies from Harvard’s Mass General Hospital because it’s the best way to continue to improve. I’m proud of the fact that having treated 400,000 patients – 1.8 million clinical visits – we have over 2,000 reports. Our clinical safety team looks at the [reported incidents] and improves, but this was used as almost an attack on us – the fact that we have an incident reporting system and that reports were leaked.
Were any changes made after reported incidents to correct things?
Absolutely. The incident reports are when something could have happened or happened that was away from our standard operating procedures. Some were systemic. We meet with the doctors regularly and ask them what things are you hearing about? They’ll say, “Sometimes we see that people need to be on the appropriate dose of an antidepressant. Can we encourage clinicians to follow FDA guidelines?” So we began to look at patients internally. We send out an email to each clinician saying, “Hey, you might want to take a look at these patients’ medications. And here are the FDA guidelines.”
Now that Cerebral is not prescribing controlled substances, what is the company doing to help its ADHD patients who rely on medications like Adderall?
We stopped prescribing controlled substances because we heard that October is likely the drop-dead date for [the rule that temporarily allowed telehealth prescribing of controlled substances]. It takes two, three months sometimes for patients to find a new prescriber. So we made the decision to stop doing controlled substances going forward. We can help get a letter to their new prescriber and make that transition. If they want to switch from a controlled to a non-controlled substance – we offer that but we’re explicit that it may be less effective. Lastly, some of them say alright, I’m gonna get my controlled substance from someone else, but I want therapy here.
Since you made that decision in mid-May, how has your subscriber base changed?
It hasn’t changed much. ADHD has always been a minority of our patients – the vast majority have depression or anxiety disorders. A lot have both ADHD and depression. In that case, first-line treatment is not a controlled substance, it’s the antidepressant bupropion. Some have substance use disorders and ADHD, in which case first line treatment is atomoxetine. It’s worth mentioning that two-thirds of our patients have never had the privilege of accessing mental health care prior to coming to Cerebral. And the average salary of our patients is below the national average. So this is democratizing access to care to people who otherwise never had the privilege to get care.
The Wall Street Journal reported that ADHD was about 20% of your business. How much of a blow to your revenue is this going to be?
I won’t provide exact numbers here. I’ll just say that this is not majorly impactful of our business. There are still millions of people who need this care and we’re still seeing very serious demand.
Some patients have told us they’re not spending enough time with providers. Do you plan to increase appointment lengths?
There’s an unlimited number of appointments. We tell the clinicians not to rush toward diagnosis on the first visit. If it’s a complex case, and they need more time, they can schedule follow-ups. There’s no limit on that because we understand that care is personalized. The second thing is we have unique supports for these clinicians – clinical guidelines used by by the Harvard hospitals, Stanford hospitals, all the top academic institutions. We also have a curbside consult line so prescribers can get a second opinion from a psychiatrist in 20 to 25 minutes, 12 hours a day, seven days a week.
Do you have some data on the time your clinicians spend with patients? And if you think the perception is wrong, where did it go off?
We have data on outcomes. We have really good outcomes in terms of depression and anxiety. For example, if you have bipolar disorder, a serious mental illness, some of the medications require regular blood draws to make sure the levels are safe. We track whether patients get that and if they don’t, we send the clinicians an email, we nudge them. We have 100% compliance with labs. Suicidal ideation – for patients with a specific type of suicidal thinking, we email the clinician and pay them, incentivize them, to give an extra phone call to those patients in between visits. Why do we invest in all of this? The eventual goal is to get to value-based care to show insurance companies, to show employers, that we’re taking care of their members and employees so well that they should build a deeper relationship with us.
We’re building out a clinician decision support system that encourages clinicians to practice based on those guidelines. If your mom had heart disease and you take her to see a cardiologist who doesn’t follow the clinical guidelines, you would want to know why. If the doc gives a reason your mom is not getting that, that’s great – you want them to give a rationale. I don’t see why psychiatry should be different from cardiology.
Why do you think some physicians and patients have expressed these concerns? And are physicians incentivized to spend more time with patients?
There are absolutely no incentives for diagnoses or what percentage of patients are on controlled substances. I’ve sent out repeated emails where I say, don’t rush to a diagnosis. If it’s not enough time, schedule a follow-up appointment. I was brought in a year ago to institute clinical safety and quality programs. We have a psychiatrist who runs clinical safety and another who is director of clinical quality. Their only incentive is to think through how can we make this system safer and higher quality? Are we perfect? Absolutely not. This is why we have these processes in place. I want to know where the minority of people deviate and to get better on that front.
The lawsuit filed by Matthew Truebe says the goal at one point was to prescribe stimulants to 100% of ADHD patients. Is that true?
It’s never the goal. One month after I came in, I said we are following clinical guidelines. And that is our North Star. And at no point can we deviate from that. So all we did was encourage people to follow clinical guidelines. If you think, ‘Why be so maniacal about this?’ It’s about getting to our next business model which is value-based care. So there’s a business reason for this.
Even before Cerebral strict stopped prescribing controlled substances, some patients faced delays getting their meds. What has Cerebral done to address that?
We are continually reviewing our processes and making them better. When people come to us, they can choose to work with our partner pharmacy or their local pharmacy – the CVS or Walgreens. We want we want our clinicians to respond quickly – it’s one of my priorities.
Patients have said they’ve been cycled through multiple providers and a former employee told us there’s high turnover. With layoffs coming, how are you going to support your base with fewer people?
This is a phenomenon that’s happening across healthcare, and all companies. And really, the focus going forward is sustainable growth and focusing on reducing our scope. Previously we were looking into other fields like international expansion or primary care. We’re putting that on pause. The idea is focus on getting our core services at an even higher performance level.
Would it be fair to say that Cerebral had a Silicon Valley-type “move fast and break things” kind of ethos, and has that shifted?
I would say growth was important at the founding of the company – it’s important for any company. When I came in, my mandate was clinical quality, clinical safety, build out a system that would be industry leading. I was given infrastructure that’s unique because we have our own EMR [electronic record] and didn’t have to depend on third-party data. That was my playground. You’ll see in the coming weeks that we’ve got a number of projects that have a strong potential for completely changing mental health care delivery. One example: We’re very invested in precision psychiatry – provide the right dose of medication for the right patient based on their demographic, at the right time. We know when our patients are dosed with what medications, we know their demographic data, we know geographically where they are. So we can use data science to better inform clinical care in a way that no other clinic can because they don’t have the scale or the technology.
I’ve been CEO for a little bit over a month. The clinicians have taken over. I’m really excited about the things to come. We have so much data – hundreds of thousands of data points. We can come up with new subtypes of depression based on treatments and outcomes. We can reinvent the boundaries between mental illnesses. The algorithm today for depression is start any antidepressant because one isn’t better than the other. What a weird treatment algorithm, right? Well now, we can – based on that data – suggest that maybe this medication is better for this patient at this time. That’s the kind of thing that gets a lot of experts in mental health excited. That’s where we’re headed.
Data is important, but mental health is also about relationship. If people feel untethered and unconnected, data isn’t a substitute for human relationship and connection you would have with a caring therapist.
That’s a really important point. Psychiatry is the only field of medicine where, if you look at the broad studies, telehealth is just as good as in-person care. It’s not true for primary care. Not true for any other specialty – maybe radiology is the one exception. You make a very important point. One of the most important strategic pillars going forward in my mind is focusing on therapy. We need holistic care. There’s evidence that meds are helpful for major depression, therapy is helpful, and both together are more helpful and actually gets the patient better faster. So how can we bring in more holistic care? You’re right, it is relationship based. Also, different patients are different. When they come to us, they have a choice between therapy only, meds only, or therapy plus meds. There’s research to show that patients who think meds are going to be helpful — they tend to orient that way. Others don’t want to be on meds; they want a therapist. We are meeting the patient where they are. There are exceptions: If they have bipolar disorder, therapy-only is not appropriate. But the idea here is that patient preference matters. The relationship with that caretaker does matter.
One thing we heard from patients was that they were opting for the prescription-only model partly because it was less expensive.
Because we care about holistic care, the medication plan comes with a care counselor – like a health coach who would meet with the patient on a regular basis to just check in and see how everything’s going. But you raise a really important point: Therapy is expensive. So we want to work very closely with insurance companies because that’s the best way for people to get care covered. We measure the outcomes, share that data back with the insurance companies: These are your members, here’s how much better they’re getting. We send that to them on a regular basis. Down the line we’re very interested in the Medicaid population – the mission here is to democratize access to care for everyone. That’s where the need is even greater.
We want to get to value-based care. Probably my most exciting project right now is when patients are categorized as high risk, we give them extra support at basically no extra cost. Let’s say they get hospitalized, they go to the emergency room. We have someone getting in touch, making sure they have the right meds, and if they get sent to an inpatient unit, we make sure they’re on the right meds to get the right history immediately. And when they’re about to get discharged, we make sure they get a follow up within days – giving them white glove service. That’s obviously good for patients and their families, but it’s also good for insurance companies. There’s a great story here for creating high quality care for specific types of patients. Hard to do, because most healthcare systems don’t have enough data to say who’s high risk and who’s not. Well, we have that data. We want to share data with the payers. We want data back from them as well. We can build out that system. I think that’s the future.