Managing Treatment

The Tattered Promise of ADHD Telehealth

In 2020, telehealth services like Cerebral and Done promised to revolutionize mental health care for patients unable to pursue diagnoses and treatment in person due to lockdowns, distance, and long waiting lists. Today, allegations of medical and legal violations are dominating headlines. Can telehealth still be used to help patients with ADHD? Should it?

May 24, 2022

It took just 30 minutes for Allison, 31, to receive a dual diagnosis of ADHD and anxiety from a psychotherapist on Cerebral. She joined the mental health subscription platform during the pandemic because the wait time to see an in-person clinician for an ADHD evaluation was long — too long for the mother of three children, two preschoolers and one 10-year-old with ADHD. Within one week of her diagnosis, a prescription for the antidepressant Wellbutrin was mailed directly to her home in Illinois. What followed was alarming.

“I began having suicidal ideations,” she told ADDitude. “I let the provider know. They wanted me to keep taking [Wellbutrin] for the three months until my next appointment with them. I found a new psychiatrist right away and quit trusting them with my care.”

Jessica began to suspect she had ADHD during the pandemic and likewise signed up for Cerebral after seeing it advertised on Reddit. She, too, received an ADHD diagnosis following a 30-minute interview with a nurse practitioner. Shortly after that, a prescription for Wellbutrin arrived in her mailbox in Maryland. Jessica said her primary care physician was never notified of her new diagnosis or medication.

“I was told I had obvious depression. I’ve been in therapy for years; I have no signs of depression,” she said. “When I asked about something more specific to treat the ADHD, I was sent Strattera, which caused sudden depression, extreme apathy, and uncontrollable crying. I then went through the drawn-out cancellation process, got confirmation my Cerebral subscription was cancelled, and I was still billed for the next month. I had to fight for a refund.”

Susan* stuck with Cerebral a bit longer, but not much. Following her ADHD diagnosis by a nurse practitioner, the 56-year-old struggled to achieve the continuity of care needed to fine-tune her new prescription for Adderall XR.

“I had a revolving door of care providers — three in the three months that I used the service. It was unsettling every time I was transferred to a new provider and had to basically start over,” she said. “No one seemed willing to adjust my medication or to try a different medication option. Their motto seemed to be: Take one Adderall a day and call me never.”

[Dr. Thomas E. Brown on the Building Blocks of a Good ADHD Diagnosis]

Allison, Jessica, and Susan were among the 872 ADDitude readers who recently shared their experiences with telehealth services in an ADDitude survey about ADHD treatment during the pandemic. Of the 484 American adults who answered the survey regarding their own personal care, 57% reported using telehealth services and/or mental health apps in the last two years. Among those individuals, the most popular diagnosing and/or prescribing telehealth services included Teladoc (18%), Cerebral (16%), and ADHD Online (10.5%).

Telehealth and the Promise of Mental Health Care Access for All

Telehealth services surged in popularity during the pandemic due to lockdowns, extended waiting periods with providers, and relaxed federal regulations for prescribing stimulant and other medications remotely. A recent analysis of U.S. Census data shows that 22 percent of Americans have used telehealth services recently. Before the pandemic, telehealth visits accounted for less than 1 percent of all outpatient visits.

ADDitude readers reported subscribing to telehealth services to access three primary services: evaluation of symptoms, prescription of new medication, and renewal or adjustment of existing medication. On the first count, some ADDitude survey respondents reported questionable, confusing, or troubling diagnostic experiences.

“I had a 30-minute interview with a psychiatrist that was sloppy, short, and only consisted of a dozen or so questions. I was then offhandedly thrown a diagnosis of bipolar disorder, a serious disorder that has never, in my 30 years of off-and-on therapy and different SSRIs, been considered. This felt like malpractice,” wrote one woman in Connecticut who did not specify the telehealth service she used. “I sought another opinion and was given three days of in-person, comprehensive, and thorough neuropsychological testing, evaluations, questionnaires, and interviews and then discussed the resulting clinical diagnosis of ADHD.”

[Free Guide: What Every Thorough ADHD Diagnosis Includes]

A thorough ADHD evaluation typically lasts several hours and begins with a clinical interview to understand the patient’s daily symptoms and medical history, including any diagnoses of ADHD and/or its comorbidities in the family, according to leading ADHD expert William Dodson, M.D. The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V), stipulates that ADHD may be diagnosed only if an adult patient demonstrates at least five out of nine symptoms of predominantly inattentive ADHD and/or five out of nine separate symptoms of predominantly hyperactive-impulsive ADHD, and only if those symptoms are consistent, persistent, and impair functioning in two or more settings — for example, at work and at home. To make this determination, clinicians often interview loved ones, colleagues, teachers, and friends as well as the patient.

But complaints of cursory evaluations and knee-jerk prescriptions were common among users of Cerebral, Done, and other prescribing services, according to the ADDitude survey. Only 52% of all telehealth users said their evaluation included “taking down the patient’s family medical history.” Two-thirds of respondents said their evaluation lasted less than an hour, and just 17% said information about their new diagnoses or prescriptions were transmitted by the telehealth service to their in-person doctor.

“My evaluation was impersonal, and my diagnosis was based on an online survey,” said a mother of two in California, who was prescribed Adderall following a 30-minute evaluation on Done. “While I answered honestly and trust the results, I can imagine how easy it might be for someone to abuse the system to get controlled prescription meds.”

Some users of Cerebral said they simply completed a questionnaire and then participated in a 30-minute clinician interview before receiving their diagnosis, which happened within one week of joining Cerebral for 72.5% of ADDitude survey respondents. Of those Cerebral users, 83% were diagnosed with ADHD, 51% were diagnosed with anxiety, and 29% were diagnosed with depression.

Telehealth and the Danger of Shallow Diagnoses

A rushed, and potentially incomplete, diagnostic evaluation can carry serious consequences. As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder, making it critical that providers screen patients for symptoms of anxiety, depression, learning disorders, and more. “Even if a patient does exhibit symptoms of ADHD, clinicians should still rule out alternative explanations as part of the evaluation. Changes to the patient’s home environment and circumstances, for example, could influence symptom severity and presentation,” said Theresa Cerulli, M.D., in an ADDitude webinar in June 2021.

Though rare, ADDitude reader reports of telehealth providers who disregarded or failed to seek information regarding patients’ existing conditions and medication red flags were disturbing.

“Even though I told the prescribing nurse practitioner that I had high blood pressure, she prescribed a stimulant,” wrote one woman diagnosed with ADHD and prescribed Adderall on ADHD Online. “My pressure spiked, and I had to have it managed by my primary care physician, who prescribed a nonstimulant. My pressure is on track and I’m doing great with the ADHD nonstimulant now.”

“I mostly felt as though the professionals I saw were short on time and eager to get done talking to me so they could move on to the next patient,” said Susan, who was diagnosed with ADHD on Cerebral and prescribed Adderall XR.

A whopping 97% of the Cerebral users diagnosed with ADHD reported receiving a new prescription, according to the survey. Roughly 59% of those respondents were prescribed Adderall; 34% were prescribed Wellbutrin; and less than 10% were prescribed Vyvanse, Strattera, or Ritalin each.

“It seemed like a pill shop,” wrote one woman diagnosed with ADHD, depression, and anxiety by a Cerebral provider who prescribed her Adderall. “It was very impersonal. I could have come in and said any symptoms and they would have given me drugs.”

The Rise and Fall of Cerebral

Earlier this month, Cerebral came under investigation for possible criminal violations of a federal law that regulates the distribution of controlled substances, including stimulant medications like Adderall. The U.S. Drug Enforcement Administration (DEA) also recently interviewed former Cerebral employees as part of an apparent probe, according to a news report by Insider.

That investigation came just two months after Bloomberg reported that 95 percent of Cerebral patients received a prescription, that care coordinators were assigned as many as 1,000 patients at a time, and that 27 former employees believed Cerebral was prioritizing pills and profits over people. “In its hunt for explosive growth, it has made appointments too short, set follow-up sessions too infrequently, advertised too aggressively, and pushed prescriptions too hard,” Bloomberg reported about Cerebral.

Cerebral’s rise was, indeed, meteoric. Founded in January 2020, the San Francisco startup was quickly touted as a mental health savior for offering virtual diagnosis and prescription services to hundreds of thousands of Americans cut off from in-person doctor visits during a global pandemic and mental health crisis. Within its first year, Cerebral had landed $300 million in funding. Esteemed clinical advisors, and the appointment of Olympic gymnast and ADHD role model Simone Biles as chief impact officer, lent credibility to Cerebral’s subscription service. In March 2020, Cerebral’s virtual prescription services became available as the DEA temporarily lifted consumer protections and allowed “practitioners to prescribe schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation.”

Among the most common controlled substances are the stimulants used to treat ADHD, namely Adderall, Ritalin, Concerta, and their competitors. Suddenly, patients were no longer required to meet in person with prescribers of these drugs — and, just as quickly, Cerebral amassed a user base of 200,000 and a valuation of $4.8 billion.

“The venture capital models that prioritize profits seem to hit challenges in the health care sector, which prioritizes patient safety,” said Margaret Sibley, Ph.D., of Seattle Children’s Hospital in response to news of the Cerebral probe. “The two goals are hard to simultaneously balance, which means that profits are not maximized when one takes the proper steps to stay in compliance.”

Last week, ousted Cerebral co-founder and CEO Kyle Robertson accused the company’s board of directors of pressuring its prescribers to write scripts for Adderall, according to the Wall Street Journal. Former Cerebral Vice President Matthew Truebe has made similar claims. In April, Truebe filed a lawsuit alleging that its chief medical officer, David Mou, M.D., instructed employees to prescribe stimulant medication to all patients with ADHD.

Days after that lawsuit was filed, Walmart pharmacies, TruePill, CVS, and others said they would no longer fill prescriptions for stimulant medications like Adderall prescribed by certain telehealth providers, including Done and Cerebral. Cerebral then announced it would stop writing new prescriptions for controlled substances used to treat ADHD, effective May 9. It also confirmed it would stop prescribing all controlled substances to new patients on May 20 and to existing patients in mid-October. Mou denies any wrongdoing by Cerebral and says this policy change is needed to prepare for the expiration of the temporary DEA suspension of drug rules.

“It is acknowledged that there is an extreme shortage of experienced clinicians who are willing to diagnose and treat ADHD, especially in adults,” said Dodson, one of the first practitioners to specialize in adults with ADHD three decades ago. “Most MDs and nurse practitioners get little, if any training, in ADHD even though 20% of mental health patients have ADHD. Easily accessible and affordable care for ADHD is desperately needed. This poor start [in telehealth] will probably set back much needed change for many years.”

Can Telehealth Be Saved?

Among those Cerebral patients losing prescription services this year are many ADDitude survey respondents who shared their experiences with the startup. Despite recent controversy and criticism for its practices, Cerebral earned generally high satisfaction scores from ADDitude survey respondents, who rated the service 4.07 out of 5 for its evaluation and/or diagnosis services; 4.06 out of 5 for its prescription services; and 3.93 out of 5 for its access to telehealth appointments with a doctor.

“After years of struggling to be seen by mental health experts, I gave up following the traditional route and went looking on my own. I am so glad I did; it’s been life-changing!” wrote one woman in Washington. She was diagnosed by Cerebral with ADHD, anxiety, obsessive compulsive disorder, and sleep disorders, and was prescribed methylphenidate ER.

Some ADDitude survey respondents reported great success using a telehealth service like ADHDOnline to diagnose their symptoms, and then taking that diagnosis to their primary care physician. This solution, they said, was more efficient and cost-effective than waiting months to see a specialist, many of whom are not covered by insurance.

Survey respondents’ primary motivations for using a telehealth service over the last two years were:

  • Convenience: 60%
  • Ability to receive care without leaving the house: 56%
  • Ability to receive and/or renew prescriptions remotely: 39%
  • Privacy: 18%
  • Cost: 18%
  • 24/7 access: 14%

For many of these users, access to telehealth evaluation and prescription services meant the difference between receiving mental health care during the pandemic and being cut off from all support. Most ADDitude survey respondents said they found their chosen telehealth provider through an online search (31%); their health care provider (29%); Facebook (12%); Instagram (8.5%); or a friend (6%).

“The practice of telehealth restored my sanity,” wrote one woman in Maryland who used the service Doxy. “I have struggled for decades with mental illness, especially with undiagnosed ADHD. At 67 years of age, I feel better than I have for many, many years.”

This sentiment was echoed by many survey respondents, especially women, who often battle false ADHD stereotypes and unhealthy societal expectations when seeking an ADHD diagnosis later in life.

“I was able to finally get a diagnosis with less shame and stigma,” said a 44-year-old mother of three in New York who was diagnosed with ADHD using Cerebral. “I find the telehealth interface less uncomfortable and much more streamlined than a traditional provider. The providers are specialists and there was no referral delay. Also, the team assigned to me checks in to see how my experience is going.”

“Telehealth made taking the first step so much more accessible. I was never diagnosed as a child, and as an adult, I’ve heard so many stories of dismissive doctors, long waiting lists and expensive evaluations. For so long, it was all too overwhelming to even start looking for help,” said a 27-year-old woman in Florida diagnosed using Klarity. “I do see it as a starting point… I would like a more thorough evaluation eventually, partially because I also want to be evaluated for other conditions like sensory processing disorder and dyscalculia that weren’t really addressed in the telehealth session. But the access I have to treatment now means I can afford to take the time to find the right fit while I learn more about what works for me.”

ADDitude survey responses like these suggest that the benefits of continued access to telehealth services outweigh its risks for many patients with ADHD and its comorbidities. It is not yet known when the government will reinstate consumer protections on the prescription of controlled substances and require in-person evaluations once again.

“Both amphetamine and methylphenidate were over-the-counter medications or schedule 4 (the least restrictive category) for 20 years without significant abuse. While there is misuse in college students, true abuse is very uncommon,” Dodson said. “The pandemic was a once-in-a-lifetime opportunity to move the legal restrictions on the stimulants back to something that does not obstruct care. The chance for reform is likely to be much harder due to the sloppiness of the first online clinics.”

Even among users who said they benefit from telehealth prescription services, there was some acknowledgment that government regulation could help the industry grow in a smart, measured way that better balances medication with other ADHD treatment options such as cognitive behavioral therapy.

“The proliferation of apps providing unfettered access to drugs without requiring talk therapy or ADHD coaching is detrimental not only to the people using these apps, but it’s also giving the whole field a black eye,” said one Headspace user diagnosed with ADHD, depression, and anxiety and prescribed Wellbutrin and Adderall. “These conditions are real and can’t be solved with a few pills. You need behavioral follow-through.”

Cerebral & ADHD Telehealth: Next Steps

*not her real name

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