(Bloomberg) — Greg Grant knew he was in danger. Just fired from a freelance gig, the 51-year-old Texan responded by drinking heavily, beginning in the morning and continuing for hours. By the time he reached out to his mental healthcare provider, he was a dozen drinks in.
“I need help,” he wrote in a chat log set up by Cerebral Inc., a startup that offers online only psychiatric services and was treating Grant for anxiety and depression. “Alcohol poison.”
On the other side of that July 2021 chat, employees wondered how dire his situation really was. “I know 12 drinks is a lot, but I am trying to gauge if he needs immediate assistance or not,” a member of the company’s crisis team wrote to colleagues who were not licensed clinicians. No medical professional weighed in as team members opted to do what they’d done in dozens of other urgent situations: call the cops. Grant was taken by ambulance to an emergency room.
It was only afterward that a nurse practitioner in charge of Grant’s treatment informed coworkers that he had been prescribed medications that carried “risk of negative interactions” with alcohol. Mental health advocates say one of the drugs, an antidepressant, might increase suicidal thoughts in patients who drink. The nurse wrote: “Avoiding drinking or other illicit substance is always mentioned during the session and will be on [patient]’s risk.”
In interviews, Grant’s family members and a psychiatrist who treated him previously said he suffered from alcoholism, but his Cerebral medical records don’t include any mention of that condition. They do show that Grant’s Cerebral nurse practitioner had increased his dosage of the antidepressant four days before his binge.
Less than a month later, he was found slumped under a tree in his back yard, dead by suicide.
The potential for suicide or self-harm among patients presents complicated challenges for mental-health caregivers, whether they operate in brick-and-mortar settings or by telehealth technology. Grant’s case and others illustrate how Cerebral, once the fastest-growing startup in mental telehealth, was ill-equipped to treat some of its most vulnerable patients: those who don’t disclose their substance-use disorders.
As it grew, Cerebral took on a number of patients with complicated conditions, despite concerns that former members of its medical staff say they harbored. At least a handful of cases, like Grant’s, ended in overdoses and deaths, according to internal company records and interviews with dozens of current and former employees.
Those records and interviews show that tools frequently employed by addiction specialists, such as urine or breathalyzer tests, weren’t used by the telehealth provider even when addictive medications were administered. During appointments that clinicians say were often shorter than standard, the medical histories taken on some patients were incomplete — reflecting gaps that might have been closed if the nurse practitioners who serve as Cerebral’s prescribers had taken additional steps.
At a company that says it has treated about 200,000 people, it’s impossible to say precisely how many adverse outcomes have occurred, in part because it’s unclear how complete Cerebral’s records are. In Grant’s case and three others, Cerebral learned of an overdose or death only after a patient’s family member — or in one instance, a pharmacy — notified the company. In that case, a Cerebral nurse practitioner had prescribed Xanax to the man, according to internal records seen by Bloomberg News. The patient, who had a history of substance abuse, later died in a recovery home after overdosing on fentanyl, according to a medical examiner’s report.
Like other healthcare organizations, the company attempts to track patient deaths; a “mortality log” listed more than two dozen of them as of early this year. Some, such as a motorcycle accident, may well have been unrelated to the patient’s mental health or care.
Such documentation is crucial to what David Mou, Cerebral’s chief executive officer, described as a culture of constant improvement. Cerebral executives, citing healthcare confidentiality requirements, declined to discuss any individual patient’s case. But in an interview, Mou said Cerebral’s nurse practitioners are empowered to employ patient-safety steps, including ordering drug screens, when they think they’re needed. The company declined to say how long that has been the case or how often such tests are used.
“I think what is most important here is that absolutely every incentive that we have here is aligned to quality,” said Mou, who had been Cerebral’s chief medical officer. He took the top post in May after a tumultuous period for the company.
Cerebral quickly expanded last year by promising to make mental healthcare widely available at a time when the Covid-19 pandemic had cut off many who desperately needed such help. That promise, along with enthusiastic investors including SoftBank and persistent social-media advertising, helped Cerebral achieve a $4.8 billion valuation.
Controversy soon followed. As Bloomberg Businessweek first reported in March, clinicians at the company said they felt pressured to prescribe controlled medications for attention deficit/hyperactivity disorder. After that story appeared, the Drug Enforcement Administration interviewed at least two Cerebral employees about its handling of controlled substances. In May, a federal grand jury served a subpoena on the company, and its board ousted founder Kyle Robertson. Cerebral also announced it would stop writing prescriptions for most controlled substances.
Before that, a company spokesman had said Cerebral could treat “almost all patients who suffer from mental health conditions.” Since then, its executives have charted a course for Cerebral to continue offering substance-abuse treatment, even as it has gone through rounds of cuts. The most recent, which dismissed 20% of its staff, came in late October.
For most of its history, the company delegated the delicate task of interacting with patients in emergency situations to front-line customer-care employees and mostly unlicensed personnel. In interviews, eight such employees, who asked not to be named in order to discuss internal company matters, said they felt ill-equipped to do their jobs. Company documents show that as of earlier this year, the time budgeted for their crisis training was about one hour, followed by a “condensed” 10-minute safety training video and a slide deck on managing suicidal clients.
Mou, a Harvard-educated psychiatrist, said the company has made recent improvements to address such issues. In April, it began shifting the responsibility for dealing with patients in crisis to a separate team of workers, who he said receive a week of training.
During the hour-long interview, Mou largely declined to discuss the company’s previous policies or his predecessor, Robertson, who oversaw Cerebral’s aggressive growth. “I don’t want to talk about the past,” he said. Mou said Cerebral has strived to improve during his time as top executive.
“All the evidence, I would say, would suggest that over the last five months, since I’ve been CEO, if you look at the things that have been done, we’re marching toward that at a speed that is very uncommon for healthcare companies,” he said.
But Mou’s 16-month stint as chief medical officer generated criticism too. Matthew Truebe, a former vice president, alleged in an April lawsuit that when patient overdoses or instances of suicidal ideation were reported, Cerebral was often slow to address the incidents and “sometimes failed to respond at all.” Truebe said in his lawsuit that he told the company’s former CEO that Mou “appeared more focused on business development than clinical safety.”
In a statement, Cerebral said Truebe’s claims were “unfounded.” But his allegations reflect a tension that dozens of other former Cerebral employees cited in interviews: They said the company’s executives emphasized rapid growth over the need to achieve the highest quality of care, leading to such outcomes as appointments that were too short and follow-up sessions that were too infrequent.
Cerebral has rejected those statements as well, saying it has always sought the best care standards. Now, executives are reallocating some marketing spending to “clinical quality and safety, to compliance, to other initiatives that help with clinical care,” Mou said.
He said the company’s performance exceeds standards of care practiced at the average brick-and-mortar mental health clinic. The company cited features that include a 24/7 crisis response team and pay incentives it has created for nurses to reach out to suicidal patients.
But a patient advocacy group said such services are typically offered by traditional providers as well. “While we appreciate efforts including regular audits of clinical guidelines, dedicated crisis response teams, and internal care coordination, we note that these aspects of care are routinely provided by psychiatrists and mental health clinics across the country,” Physicians for Patient Protection said in a statement.
The bigger issue is that patients can suffer from high-volume corporate medicine if adequate safeguards aren’t in place, said Alyson Maloy, a Maine-based psychiatrist and neurologist and a member of the advocacy group’s board. Maloy said she was speaking generally — not about any particular company.
“When corporations come in and they try to squeeze the practice of medicine into this corporate model of productivity and maximizing profit, there are many situations in which it doesn’t work,” she said. “And those tension points are where people get hurt.”
Greg Grant was the quietest one in a quiet family of hardworking Texans. He was often home alone, watching soccer with his rescue dog, Xena. But he could also be counted on to attend family gatherings, where seats next to Uncle Greg were prized for the chance to hear his soft-spoken quips. His sister Rhea Anne Teague describes him as kind, a good gift giver and fiercely loyal. Despite grappling with alcoholism and anxiety, he’d assembled a stable life, regularly seeing a psychiatrist he first met during a 2010 stint at an addiction recovery center. Grant worked as a live video engineer for an audio-visual company for more than two decades, a job that took him across the country to concert venues and conference centers.In 2020, he left that job and became a freelancer, just before the pandemic ended live concerts and conferences. By the end of the year, he’d sold his house and started renting. He dipped into savings from the sale, and his lack of income became anxiety-inducing, Teague said. In April 2021, he told his psychiatrist’s office he needed to take a break. He said he’d be back in six months.
That’s when Grant sought help from Cerebral. He got access to a prescribing nurse, medication deliveries by mail and check-ins with a “care counselor,” a sort of life-coach position that doesn’t require licensure, for $85 a month at the time. By comparison, the cost of a single appointment with a licensed therapist in the US frequently falls between $100 and $200, according to Psychology Today.
Patients with alcoholism can be challenging: In the worst cases, weaning them off alcohol can trigger seizures and even death, sometimes requiring round-the-clock monitoring. Cerebral’s model, with no physical offices or clinics, makes that impossible, prompting concerns among a number of employees about fielding alcoholic patients at all. Even in less-dire situations, the remote appointments that telehealth depends on can mean practitioners miss important clues about patients’ wellbeing, such as the smell of alcohol.
Grant’s own longtime psychiatrist, Lenae White, says her addiction patients take drug and breathalyzer tests on every visit, helping her gauge her clients’ health so she can treat them effectively. She also collects “collateral” information — patients’ prior medical records and even interviews with family and friends. Such information gathering should come from “a variety of sources” and “at a minimum, data should include current and historic substance use” and “substance-related treatment histories,” according to a guide on addiction counseling published by the Substance Abuse and Mental Health Services Administration.
Mou said taking a medical history in patient interviews is standard at Cerebral. But the broader information-collecting is not, several nurse practitioners told Bloomberg.
Grant’s Cerebral nurse merely asked him a few questions, and Grant wasn’t forthcoming about his alcoholism. During a 32-minute initial appointment — which clinicians have described as typical for Cerebral but is shorter than the standard at many physical clinics — Grant said he wasn’t suicidal, and that he had three or four beers a couple of times a month, according to medical records Cerebral furnished to Teague. The notes indicate that Grant was told his medication had a so-called black box warning stating that it was linked to “suicidal ideation.” He was advised against drinking while taking it and was given the drugs.
“Telehealth is terrible for addicts,” said White, who practices in both brick-and-mortar and telehealth settings. “They can lie to you and they can lie to themselves. Addicts assess the literacy of the person they’re dealing with and act accordingly. You can’t do these very short online appointments unless you’re very well-trained and very well-versed in the patient.”
But Grant’s new caretaker was unfamiliar with him and relatively new to mental health. He’d spent most of his working life as a dental technician before getting his psychiatric nurse practitioner license seven months earlier.
Similar blind spots in Cerebral’s system were evident when a man in his 20s with a history of substance-use disorder received a Xanax prescription from the company, according to internal communications and public records reviewed by Bloomberg News.
The incident raises questions about how effectively Cerebral and similar companies can screen out patients with drug-seeking behavior — and properly track them when things go awry. As with Grant, this patient’s family members were aware of his condition. It’s unclear how much his Cerebral clinician knew about it, but records show the patient was living in a recovery home while his Cerebral Xanax prescription was active.
Xanax, a benzodiazepine used to treat anxiety, can present what addiction experts describe as a high potential for misuse, especially for people with substance-use disorders in their histories, according to research compiled by the National Library of Medicine.
The patient, whose identity Bloomberg News is not disclosing at the request of his family, died from a fentanyl overdose in November 2020.
Cerebral only learned of his death when the patient’s pharmacy contacted the company. A nurse practitioner had issued a Xanax refill prescription for the patient about a month after his death, and the pharmacy feared that someone was using the name of a deceased person to obtain the controlled substance, which has a significant street value. In fact, Cerebral’s nurse simply didn’t know he had fatally overdosed.
The incident drew the attention of Cerebral’s executive suite after the pharmacy raised its concerns. “There’s no foul play involved?” asked Cerebral’s then-chief medical officer in an internal message. “Trying to understand if this could have been prevented.”
“I had no idea of the death,” the patient’s nurse practitioner responded. “Don’t think we can prevent a death.”
Another patient described to Bloomberg News how he used Cerebral appointments as part of a spiraling series of drug-seeking incidents that would eventually result in a non-fatal overdose in March of last year.
In the weeks leading up to that incident, the 36-year-old father, who suffered from bipolar disorder, was dealing with mounting financial stress, culminating in a joint bankruptcy filing with his wife.
The patient found Cerebral online after seeing an ad that promised medicines shipped to your door, and he took that to mean easy access to controlled substances. He described his experience as “customer-directed,” because he communicated what drugs he wanted, and got them.
“I knew what I was asking for, Ativan, and that hit a bit harder,” said the patient, whose prescription records indicate that he received a generic version of the benzodiazepine medication, a controlled substance that’s in the same class as Xanax, a week before he overdosed.
Still, he wanted more. A Covid-related downturn in work sent him to Craigslist for additional “benzos,” he said. He wasn’t sure what the Craigslist product he took was laced with, but he knows he responded to Narcan. He spent five days in a medically induced coma followed by 20 more in the hospital, he said.
Cerebral staff learned of the incident when the man’s mother, whose credit card he’d used to sign up for the service, messaged the company asking to cancel, saying he was in a coma. Though he wasn’t dead, staff turned to protocols for handling patient deaths, including canceling the service and refunding charges.
In yet another case, even when a patient disclosed his concerns about his medications, Cerebral failed to adequately address them, and he later suffered an overdose. The patient, a finance professional in his early 30s, reached out twice to Cerebral in the weeks before an overdose, concerned about the side-effects of his antidepressant medication, according to a voicemail he left for Cerebral, as well as communications and records reviewed by Bloomberg News.
The patient’s script was still active at the time of the event because a customer care specialist failed to turn it off, according to former employees familiar with the matter. The overdose wasn’t fatal, and it isn’t clear what caused it. The patient didn’t respond to requests for comment.
The nurse practitioners who provided care to the four patients featured in this article were all fully licensed by their state nursing boards, and public records don’t show any disciplinary actions or grievances filed against them. None of these incidents triggered litigation; Cerebral patients are required to sign arbitration agreements that keep disputes out of court. A company spokesman said such agreements are standard in the industry.Cerebral’s operations are set up so that liability for any mistakes would fall largely on the nurse practitioners, who are independent contractors putting their own licenses on the line. Dozens of them have left the company in recent months, with many citing the liability issue as their reason. (Cerebral also employs psychiatrists, though they do not see patients. All prescribing is done by nurse practitioners.)In a July 2020 presentation prepared for investors, Cerebral had touted a corporate structure that “mitigates legal risks” as a selling point for potential backers. That presentation was accompanied by a chart showing how money flows through Cerebral while the actual process of providing appointments and prescriptions is undertaken by an affiliated medical group.
Before Cerebral can help patients in crisis, it needs to know they’re going through one. But until May, the company had no automated system for escalating inbound messages from patients in danger. Some of them could languish in customer care queues alongside more mundane queries about refills and scheduling for 24 hours or longer — in effect, leaving some patients to manage crises on their own.
Employees say that pleas to create an engineering fix — such as moving requests with crisis keywords to the top of queues — were ignored for months. Truebe, the former executive, alleged in his lawsuit that his product engineering department was instructed to focus exclusively on projects that boosted the company’s client base, at the expense of other endeavors. Cerebral disputed Truebe’s claims.
A fix to escalate crisis queries was rolled out in May, and it revealed the extent of the problem. Out of as many as 10,000 daily messages, about 400 were flagged as highly urgent, according to a person familiar with the figures.
The Cerebral spokesman said the “crisis escalation mechanism is far beyond the standard of care at a mental healthcare facility.”
That change came long after Greg Grant’s exchanges with Cerebral’s crisis team last year.
By July 13, 2021, his symptoms were growing worse. “I have anxiety about my anxiety,” he wrote to Cerebral, “and not sure I can handle it.” He initially received a response from “Answer Bot,” an automated feature that suggested articles including “Is Cerebral for Me?”
During a 15-minute appointment four days later, Grant’s nurse had an opportunity to reassess his patient’s relationship to alcohol when Grant described crippling anxiety attacks that would hit before he left for work, causing his hands to shake. To cope, Grant said, he would drink a can of beer before heading to his job.
The records don’t reflect any reassessment, follow-up questions or comments from the nurse about that revelation. They show instead that the nurse increased the dosage of Grant’s antidepressant.
It was the last time Grant met with his nurse. His binge-drinking episode came four days later.
In internal chats following the incident, Grant’s nurse practitioner still showed no sign of rethinking his patient’s situation and suggested that Grant had to police himself.
On July 30, Grant met with his unlicensed care counselor, who specialized in dance therapy, according to LinkedIn. Notes from the meeting give no indication whether the binge-drinking incident was discussed at all. One focus of the session was coping strategies for anxiety, including naming football teams or identifying colors in the room. Grant denied that he was currently contemplating suicide, according to the notes. While declining to comment on the case specifically, Mou said care counselors have access to patient records. (In early October, Mou told staff that Cerebral would discontinue its care counselor services.)
About two and a half weeks later, Grant received a message from “Eileen Davis,” a pseudonym that Cerebral’s customer care staff members were using at the time to engage with patients. The company has declined to discuss why its workers used the fake name, but in effect, it presented continuity to patients who were actually dealing with different workers. “Eileen” wrote to let Grant know she would “be shifting you over to another one of our coordinators,” part of Cerebral’s effort to retire the false identity.
Details from a medical examiner’s report suggest that Grant was almost certainly dead by the time that message was sent. His body was found two days later, on Aug. 18.
“He signed up with them, they sent him some meds — it just seems so easy,” Teague, Grant’s sister, says now. “It struck me as colossally not a good situation for Greg.”
A coroner informed Cerebral of Grant’s death on Aug. 20, but the company’s messages continued to flood Grant’s phone and email. Over 23 days, according to documents Teague received, the company sent her brother nine missives, including four inviting him to check in. The last, a cancellation email, arrived on Sept. 12 with a farewell message: “Sorry to see you go!”
More stories like this are available on bloomberg.com
©2022 Bloomberg L.P.
