Startups Prescribing A.D.H.D Drugs on TikTok Raise Diagnosis Concerns

Cerebral Inc., a telehealth start-up, emerged in 2020 and dangled the promise of quick, accessible mental health treatment. The company, whose services are entirely online, claimed to be able to provide prescriptions and counseling for conditions including depression, insomnia and attention deficit hyperactivity disorder, and gained traction after marketing aggressively across TikTok and Instagram.

But last week, after reports that the company pressured its clinicians to prescribe medications for A.D.H.D., Cerebral received a grand jury subpoena from the U.S. attorney’s office for the Eastern District of New York, which is investigating possible violations of the Controlled Substances Act, according to a representative for the company. Cerebral has more than 200,000 patients.

The investigation, which the representative said Cerebral intends to fully cooperate with, comes on the heels of accusations from former employees who said the company prescribed Adderall and Ritalin to treat A.D.H.D. without properly screening patients.

Several publications, including The Wall Street Journal and Bloomberg, have also called Cerebral’s practices into question. The issue now is whether the promise of being treated for mental health conditions entirely online is sustainable. Can a company like Cerebral make these medications more accessible while still following proper protocols?

The risks of overprescribing

Cerebral is only one of the dozens of mental health start-ups that took off in recent years. At the start of the pandemic, regulators relaxed rules around medical prescription of controlled substances, allowing clinicians to prescribe stimulants and other medications online without the need for an initial in-person evaluation, said Danielle Stutzman, a psychiatric pharmacist and spokeswoman for the College of Psychiatric and Neurologic Pharmacists, a professional organization of pharmacists.

Those changes made it easier for people with A.D.H.D. to get access to treatments during lockdowns — but also opened the door for companies to prescribe and market drugs without the protocols that can accompany an in-person visit. The Wall Street Journal reported that Cerebral visits typically took only 30 minutes, during which time some clinicians felt pressure to prescribe stimulants.

Over the past few decades, pharmaceutical companies have marketed A.D.H.D. medication more aggressively, and adults have become increasingly aware of symptoms, leading more and more people to seek treatment for A.D.H.D., said Margaret Sibley, an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. Researchers reported that the use of prescription stimulants to treat A.D.H.D. doubled from 2006 to 2016 in the United States.

The use of such drugs has increased significantly among women in particular: The Centers for Disease Control and Prevention found that the percentage of privately insured reproductive-age women who filled a prescription for an A.D.H.D. medication rose 344 percent from 2003 to 2015.

Also, during the pandemic, more people might have sought A.D.H.D. medication as they grappled with a lack of structure and increased stress levels, Dr. Sibley said. SingleCare, a company that offers discounts on prescription medications, reported a 16 percent increase in fills for generic Adderall in the past year. “This is a diagnosis people can relate to,” Dr. Sibley said. Discussion of the disorder has also become pervasive on social media, with people sharing their experiences with what they believe to be A.D.H.D.

These conversations created the perfect environment for mental health companies to advertise, said Olivia Little, a senior researcher at the nonprofit organization Media Matters for America. On TikTok, in particular, the companies jumped on viral trends, using popular sounds and memes in advertisements that often oversimplified complex symptoms of A.D.H.D., Ms. Little added.

“They’ll say things like, ‘Have you ever felt overwhelmed?’ ‘Do you ever not want to do your homework?’ Things that are very basic and universal,” she said. “Just take a short quiz. And you’ll be connected to a team of mental health professionals,” read one of Cerebral’s ads.

“I can’t tell you how much content I’ve seen where someone’s describing A.D.H.D., and it’s not actually A.D.H.D.,” Dr. Sibley said. These portrayals of the disorder lead people to identify with the diagnosis, she said, even if they would not meet the clinical criteria for A.D.H.D.

There are 18 symptoms of A.D.H.D., and in adults those can include frequently losing your keys or phone or struggling to follow a conversation at work. The average person meets at least one or two of these criteria, Dr. Sibley said, but the symptoms need to be severe enough to impair a person’s daily life in order to accurately receive an A.D.H.D. diagnosis. Children up to age 16 should have six or more symptoms of inattention or six or more symptoms of hyperactivity-impulsivity; those 17 or older need to have five symptoms from either category.

The majority of patients who are prescribed medication for A.D.H.D. will take stimulants like Adderall and Ritalin, Dr. Sibley said. The federal government classifies these drugs as controlled substances because of their potential for abuse and addiction.

When people who do not actually have A.D.H.D. take these medications, Dr. Stutzman said, they can “absolutely have health consequences,” including appetite suppression, cardiovascular issues and dangerous changes in blood pressure.

How to receive a proper diagnosis

There are a few things patients should look for to ensure they are getting an accurate diagnosis and treatment plan for A.D.H.D. A physical exam should be part of the diagnostic process, Dr. Sibley said, because thyroid problems, cardiac issues, concussions and other conditions could cause cognitive challenges that mimic the symptoms of A.D.H.D.

The typical standard of care is to interview a patient for no less than an hour and a half to make a first-time diagnosis, Dr. Sibley said. Ideally that would be an in-person visit, she said, though when that’s impossible — as it has been for many people during the pandemic — the interview can take place virtually. Clinicians typically spend a large portion of that time trying to uncover whether A.D.H.D. symptoms are signs of another mental health disorder, like anxiety.

Clinicians should also speak to patients’ relatives and partners or other people close to them, Dr. Stutzman said.

There are also nonstimulant medications for A.D.H.D. — like atomoxetine, sold under the name Strattera — which show a slightly lower clinical benefit, Dr. Sibley said, but which have a lower risk for abuse and addiction.

And medication isn’t the only option for treating the disorder. There are behavioral interventions for both children and adults, including cognitive behavioral therapy, and coaches who can help patients develop coping mechanisms like time-management strategies.

Patients should never feel pressured to start a course of medication for A.D.H.D. right away. Often, providers won’t even issue a diagnosis or prescription during a patient’s initial consultation, Dr. Stutzman said, because, particularly in the pandemic, it can be difficult to untangle whether symptoms indicate A.D.H.D. or something else.

“Is someone having difficulties with focus and attention because it’s A.D.H.D., or because of depression, or because they’re not sleeping as well?” she asked. “During the pandemic, we’ve all had shifts in our lifestyles.”

Potential patients should be skeptical of companies that offer speedy diagnoses, as Cerebral was accused of doing, Dr. Stutzman said.

“Where we see overprescribing is where there’s just a quick, one-off visit,” she said.

As for Cerebral, Kyle Robertson, the company’s founder and chief executive, sent a memo to his staff on May 4, announcing that the company’s clinicians would temporarily stop prescribing controlled substances to new patients for A.D.H.D. treatment.

This pause is “indefinite,” Cerebral’s president and chief medical officer, Dr. David Mou, said in an interview with The Times. The company will, however, continue to prescribe these drugs to established patients, as well as medications for other mental health conditions, like anxiety and opioid use disorder. “We are very judicious in how we prescribe medications,” Dr. Mou added.