The Business of Mental Health

For a number of years, I have subscribed to the Wall Street Journal.  Not because I actually have interest in Wall Street or investing, but because I have found that by following the business of technology, I can often have up to date information on the ways that technology can be abused in the realm of my work: addiction and forensic psychology. 

For fun, I thought I would start a monthly recap of the business side of mental health from the WSJ.

Cerebral

Oh boy have they been in the news all month.

First, if you have not heard of Cerebral, here is a little recap: Cerebral is a mental health company that really capitalized on the telehealth trend that exploded during the pandemic. Cerebral has a network of doctors all over the United States that will do telehealth appointments and prescribe medications. According to their website they treat anxiety, ADHD, Depression, Insomnia, and bipolar disorder.

From the outside, this really looks fantastic. Many people cannot access psychiatrist. For example, in my geographic area the wait for a psychiatrist can be months. So having nearly instant access to a psychiatrist can really open up care and convenience for a lot of people. 

However, it has not all been sunshine and roses. 

The WSJ initially ran a story in March about some prescribers who worked for Cerebral feeling as though they were pressured to prescribe stimulants to patients and that they did not feel the 30 minute patient evaluation was a long enough period of time to accurately diagnose an individual and get a good history. 

Some major chain pharmacies stopped filling prescriptions that were prescribed by Cerebral’s doctors.

In the beginning of May, the company received a subpoena from the Federal Prosecutor’s office. From what I have seen, there has been no official statement made from either side. The main issue was the prescribing of medication for ADHD, which is a stimulant and a controlled substance.

By the end of May, many major chains such as Walmart and CVS decided to stop filling controlled substance prescriptions that were made by Cerebral prescribers.

Presumably as a result of all of the bad press, questionable practices, and investigation by the Federal government, the company replaced CEO Kyle Robertson, in a move that he calls illegal. At the same time, the company stated it would stop prescribing most controlled substances.  

This story continues to unfold and continues to be featured in the WSJ. It will be interesting to observe the outcome. 

When the government started to address the opiate epidemic, one of the things they did was to increase oversight of the prescribing practices of doctors. 

No one is claiming that there is an Adderall epidemic, but those in the field know that this is a medication that can be and is frequently abused. While it is nice to see that the government is taking its oversight of prescribing practices seriously, the result is that many people are back in a position where they do not have easy access to address their mental health issues and need for medication.

Anti-Addiction Medication

In the middle of May, the WSJ published an article that looked at the use of injectable drugs for mental health conditions such as Vivitrol for alcohol addiction or antipsychotic medications for bipolar disorder or schizophrenia. 

The injectables are often used with individuals who may be prone to miss appointments, not be consistent with a pill medication regime or are prone to stop taking necessary medication abruptly. From a business perspective, the injectables cost significantly more than the same medications in pill form.

Thousands of dollars more.  

Scientific research indicates that the use of the injectables reduces risk of hospitalization or relapse significantly but does not have any better effect on outcomes such as quality of life and cognitive function that the pill form of the same medication does. 

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Again, due to access to healthcare during the pandemic and what feels like a shortage of mental healthcare availability, many doctors are turning to injectable medications as opposed to pill forms. From a business perspective, this is costing insurance companies significantly more money and it is not really certain that the benefits fit the extreme different in cost. 

Psychiatric Assessments Questioned

The last article from May in the WSJ I am going to discuss is a bit near and dear to my profession. As someone who conducts psychosexual evaluations, I use risk assessment measures often as well as various and sundry other psychological tests

On May 20th, in response to the horrific shooting in Buffalo, New York, the WSJ ran an article discussing the fact that the shooter had been evaluated for mental health issues at a hospital and was not held on an involuntary commitment.

According to various news sources, last year in school, the shooter had made a comment in an online class stating that he wanted to kill himself and others. As is both legally mandated and necessary, he was brought to a hospital for an evaluation to see if he was a risk to himself or others. The shooter claimed that the statement was a joke and was released, not being deemed a danger. 

The fact that he went on to follow through on his threat to hurt others has many people questioning the assessment he received in the hospital last year. Perhaps in defense of my profession, what most people do not know is that we cannot invoke an involuntary mental health hold on a person unless they meet certain standards. While these vary from state to state, they all have some similarities.  

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There is one landmark ruling that all mental health professionals are familiar with: the Tarasoff case which dictates duty to protect requirements. This is actually a case from 1976 from California, where a client told his therapist that he intended to kill Ms. Tarasoff. The psychologist did not warn Ms. Tarsasoff and she was later killed. When the case finally had its final ruling (after appeals) it was found that a therapist has a duty to warn an individual that is threatened by a patient. However, that individual must be identifiable. So, I can surmise, that the Buffalo shooter’s statement that he was going to kill people did not meet the Tarasoff ruling as there was no identifiable victim.  

As to determining someone’s risk of harm to themselves or others, as the doctor’s quoted in the article state, it is an inexact science. 

We have no assessment, test or measure that can accurately predict this. Many clients can learn the right words to say to avoid commitment. With due reason, doctors are not allowed to indiscriminately hold people in the hospital on a psych hold without defensible cause as this would be a violation of their human rights. 

Since there is no true test of dangerousness to self or others and we cannot simply detain people because we want to, we are left in the unsatisfying position of letting potentially dangerous people go home. 

Sometimes this has catastrophic consequences.