I Can’t Believe I Have to Keep Defending Cerebral

... but the Wall Street Journal does some really irresponsible reporting, so here we are.

Dec 23, 2022

Look, I want to hate Cerebral just like the rest of you. What person above the age of 40 can tolerate TikTok ads? Who among us thinks that recently departed C-level Impact Officer Simone Biles has the medical pedigree to be a spokesperson for the future of psychiatry? Not this navel-gazing physician-journalist obsessed with appropriate regulatory standards, thank you very much. I’ve had to defend Cerebral—sorta, kinda—before, and I’d rather not have to do it again.

I’m a physician

for heaven’s sake. I just wanna be able to prescribe stimulant medications for people with honest-to-goodness ADHD

. Now I can barely send a stimulant script in without having to send it into five pharmacies in rapid sequence, because everyone is out of mixed amphetamine salts, methylphenidate, dexmethylphenidate, dextroamphetamine, etc. etc. etc. It’s really bad out there!

I would dearly love to be able to casually hate on dumb tele-health companies just as much as the next hyper-expert in bespoke and highly unscalable practices. I was hoping to write about how everyone should have a nine-hour private pay intake! I would like to opine on how all patients should be mailed a limited edition 8sleep e-couch to lay down on for their 4-times-a-week telemedicine analysis like Sigmund Freud intended. Obviously.

Can There Be No Rest for the Wonky?!

I listened to the Wall Street Journal’s unbelievably inappropriate

, and unethical coverage of Cerebral in their cringe-worthy podcast series. So now I’m stuck having to write this, instead of any of the more glamorous options mentioned above. As a public service to journalists everywhere, I am including an infographic

on how to responsibly report on suicide:

Episode three of Uncontrolled Substances: The Cerebral Story? It makes my blood boil.

A Synopsis

The third episode of the WSJ/Gimlet Media hit-piece features the story of a 17-year-old who died by suicide

, subsequent to having become a patient at Cerebral. The story features his grieving mother and a very sanctimonious narrator. Very little attention is paid to the fact that the kid’s life ended with the help of an unlocked firearm that his parents left around the home which functioned exactly as intended. Allow me to quote the transcript:

Kate Linebaugh: Instead, Anthony walked away from his mother, urging her not to follow. Wendi didn't realize until that moment that he'd brought a gun with him. It was hidden under his jacket. In a panic, Wendi called her husband.
Wendi Kroll: And then the sound of the gun went off.
Kate Linebaugh: Anthony had turned the gun on himself.

With the first mention of the actual cause of death, they violate journalist guidelines around reporting on suicide by describing the lethal means. Now, given that I am reporting on that reporting, I recognize there’s some conflict here, but I think the fact that we have the number one public health emergency being exacerbated by a major media outlet for the purpose of blaming a tele-health company for following appropriate standards means I kind of have to point out the problem.

The second mention of firearms in the story is similarly blasé:

She says she could have taken precautions, especially with regard to the family's guns.
Wendi Kroll: Could have known to put them away, not have them, give them to somebody else. I would've did that. That would've been fine by me.

Which sounds a lot like saying she didn’t take any precautions around the family guns. Let me reference national guidance from AACAP here:

The United States has the highest rate of gun-related deaths among developed countries. According to the Centers for Disease Control (CDC), guns are the leading cause of death for children and teens in the United States. Being able to easily get guns is the leading risk factor for youth death due to accidental shooting, suicide, and homicide. The best way to protect children against gun violence is to remove all guns from the home. If guns are kept in the home, there will always be danger.

Further, the AACAP facts for families guide, written under the leadership of authorial spouse and national committee co-chair Dr. Carlene MacMillan, M.D.,

provides these tips:

The following actions are important to lessen the dangers:
Store all firearms unloaded and decocked in a secure lockbox or gun safe. Only the parents/guardians should know where guns are located.
Store the guns and ammunition in separate locked locations.
Use a trigger lock.
While handling or cleaning a gun, never leave it unattended, even for a moment.
If you would like to surrender a gun, contact your local police department.
Advocate for the strict enforcement of laws around purchase, ownership, and storage of guns, as well as safety measures such as trigger locks, extended waiting periods, mandatory background checks, and other initiatives designed to protect children and reduce gun related violence.
Remember that the best way to protect children against gun violence is to remove all guns from the home.

It’s at this point that I will point out that I already wrote about how more children are shot to death than die by any other cause in the United States. It’s the leading cause of death.

If You Want Children to Not Die by Suicide, Experts Recommend: Don’t Have Family Guns

Guns are the leading cause of death in this episode of this podcast also. There is no indication that fluoxetine played any role in the death of the patient. There’s plenty of snarky implication, but no evidence or even expert opinion is presented. Just a, frankly, offensive narrator uttering insinuations.

Does this narrator spend time on why it’s common in America to have firearms just hanging out? No. No time was spent on that.

The WSJ spends a heck of a lot of time manipulating a grieving mother, addressing the evils of Prozac and the black box warning that the FDA has placed on it. A black box warning, which, if it were on a gun, would just be the instructions for use.

Let’s review their reporting on what actually happened in this investigation:

A young person lied about his age.

This young person was prescribed Fluoxetine in a 24-minute appointment. This sounds like efficiency. Given the severity of the symptoms the person was enduring, prescribing this medication for depression was a good choice. But you don’t have to take my word for it, we can just look at the actual standards of care, as depicted below:

Thanks, Consensus Guidelines.

The practice parameters published in the Journal of the American Academy of Child and Adolescent Psychiatry indicate the following about Prozac (generic name: fluoxetine):

Fluoxetine is the only medication to be approved by the U.S. Food and Drug Administration (FDA) for the treatment of child and adolescent depression, and it shows a larger difference between medication and placebo than do trials with other antidepressants.

Regarding the black box warning around increased suicidal thoughts, the experts note the following:

Given the small but statistically significant association between the antidepressants and suicidality, it is recommended that all of the patients receiving these medications be carefully monitored for suicidal thoughts and behavior.
9

But they further note:

It is important to emphasize that there are no data to suggest that the monitoring schedule proposed by the FDA or telephone calls have any impact on the risk of suicide.

Cerebral Prescribed the Best Drug for the Patient Even in the Context of Him Lying About His Age

It’s worth noting about the black box warning that it is a class-wide warning on every single antidepressant medication that exists. The risk is not higher for fluoxetine than any other medication. The black box warning is a source of controversy in the field, which isn’t addressed in the podcast’s questionable reporting. Also, it’s not clear if the trend occurs in the completed suicide rate for youth:

Notably, the analysis—carried out by the FDA on controlled clinical trials encompassing 2,200 children exposed to any of the nine FDA-approved antidepressants commonly prescribed at the time—could not highlight an overall difference in terms of suicide risk with antidepressants vs. placebo. Such analysis could not even highlight any difference across the appraised SSRIs or other types of antidepressants vs. placebo (13). Indeed, the FDA-conducted meta-analyses of 372 randomized clinical trials of antidepressants involving nearly 100,000 participants, which showed that rates of suicidal thinking or behavior were higher among patients assigned to antidepressants when compared with placebo. In a subsequent age-stratified analysis, it was shown that such increased risk was significant only among children and adolescents under the age of 18 years. There was no evidence of increased risk among adults older than 24 years.

The Increase in Risk Is for Suicidal Thoughts and Actions, Not for Completing Suicide!

In the largest pooled data that we have, for individuals who say they are 19 years old, not only would Prozac be the best treatment for the actually 17-year-old child in question, but it would’ve been an appropriate choice for a 19-year-old as well. It could and would have placed a 19 year old at no increased risk. The nurse practitioner working for Cerebral had the responsibility to inform the patient of the black box warning around the risk, which the reporting indicates very much was the case:

But then Wendi discovered something alarming about the medication Anthony was on. She found it in his car.
Wendi Kroll: It was actually in the console, closed.
Kate Linebaugh: Inside was the fact sheet that came with the drugs.
Wendi Kroll: So when I found that, I'm like, "Oh my goodness. What's a black box warning?"
Kate Linebaugh: A black box warning is the strictest type of warning the FDA can require for a medication. It's usually on a printout with the medication, and it's meant to draw attention to serious side effects and life-threatening risks. And although Fluoxetine, generic Prozac, is not a controlled substance, it still carries one of these black box warnings. One that's especially relevant to teens like Anthony.

When a risk factor is relevant to an individual, what that means for the doctor and patient is that the risks and benefits need to be addressed, and the benefits need to outweigh the risks. In this case, informed consent was obtained, as was evidenced by written documentation of that informed consent process, found in the glove compartment of the car the patient was driving.

So let me break down what happened to here, absent the snark and unprofessionalism of the Wall Street Journal:

A person presented to a tele-health platform for care, specifically for their depression. That person lied about their age to access care.

The company went above and beyond regulations, in terms of attempting to identify and verify the identity of the person. They missed the age verification, which is not a standard of care that they were held to.

Comorbidities were assessed, in keeping with the best expert guidelines:

Wendi Kroll: They said that he had general anxiety, but he had anxiety, and they did say depression.

The patient, who claimed to be 19 years old, reached out in crisis, subsequent to that initial appointment. A crisis evaluation was done, and a safety plan was formulated:

Notes from that meeting revealed that he mentioned that he was feeling suicidal. On that call, the counselor and Anthony established a safety plan.
Wendi Kroll: Reasons for living. Step four of their safety plan. Number one, family, two siblings in particular, places to go to distract myself, take a drive and go to the lake.

It is a brutal tragedy that the child’s death occurred at that lake. It is also a documentation by the WSJ of a standard of care being followed to a high degree of adherence. What is a miracle is that a young person could access psychiatric care. Affordably. I wish that care had been more effective, and I wish that young person had stayed alive. And absent access to loaded guns, this very well might have been a story of triumph, not tragedy. It’s worth noting that the patient did follow the safety plan.

In keeping with the standards of care, the patient also met with a therapist for combined treatment of his symptoms with both medication and psychotherapy (also from the episode transcript):

Kate Linebaugh: Psychiatric groups and experts recommend involving parents and family when suicidal patients seek treatment, and to make sure they don't do anything to hurt themselves. This means removing lethal means from the home. On December 29th, the day after Anthony picked up the pills, he spoke with Cerebral again. This time rather than meeting with a nurse practitioner, Anthony spoke with a counselor. Notes from that meeting revealed that he mentioned that he was feeling suicidal. On that call, the counselor and Anthony established a safety plan.

Here, however, the reporter misrepresents the guidance of experts. Although it is true that lethal means should be removed from the home in the case of someone who is experiencing suicidal ideation, it is the actual guidance that there be no guns in a home in the first place:

Being able to easily get guns is the leading risk factor for youth death due to accidental shooting, suicide, and homicide. The best way to protect children against gun violence is to remove all guns from the home. If guns are kept in the home, there will always be danger.

Cerebral followed the standard of care. The WSJ ignores reporting on life saving guidance from every professional society—including the NRA—around gun safety.

Everything presented in the story indicates that Cerebral, given the information they had, provided care in keeping with standards. In a minor miracle, it was care in keeping with what would’ve been the standard of care had they known his age.

Anthony was assessed for presenting symptoms, assessed for co-morbidity, a diagnosis was made, a treatment was prescribed, it included medication and therapy, it was the first line pharmacological treatment, there was an assessment of suicidal ideation, safety plans were made, a standard of care was followed and exceeded. Despite all of these things, a bad outcome occurred.

This is the reality of medical practice. We need better first line treatments paid for. But the best expert guidance was followed. It led to a young person getting care that did not prevent him from ending his life. This is in the context of easily accessible highly lethal loaded firearms. They were stored in the home by parents without appropriate safety measures. This is a completely predictable outcome of not storing guns safely.

And we are subjected to a podcast, perplexingly, about how following the standard of care wasn’t good enough (?!?). The only deviation from appropriate standards in this case was that of the reporters from the Wall Street Journal, in their deeply inappropriate reporting on the suicide of a young person for their professional and financial gain.

What Does Their Lust for Shoddy Journalism Bring Us?

The WSJ demonizes a tele-health company, in service of the ambitious goal of providing more access to mental health care.

In their attempt to create sensational journalism, they document a standard of care, and create a standard of hopelessness, which increases the risk for listeners and non-listeners alike.

It’s briefly worth mentioning that the story about the completed suicide is in the context of a broader story around over-prescribing stimulant medications (according to the Wall Street Journal). This listener is left to wonder: Why the hell didn’t they have some article or episode about a bad outcome with a stimulant medication, and instead had to resort to inappropriate and sensationalistic coverage of a completed suicide, a story in which these supposedly demonic and dangerous controlled stimulants play no role whatsoever? And they couldn’t bring themselves to interview a single actual expert on the topic of child and adolescent psychiatry once in the entire story?

As such an expert, I am now forced to chime in: Dear Wall Street Journal: You should be ashamed of yourselves. You violated journalistic ethics, and put patients further in jeopardy.

—O. Scott Muir, M.D.

Share The Frontier Psychiatrists

Of note, I heard a lot of nurse practitioners interviewed in the Wall Street Journal podcast, but not a lot of, or in fact any, physicians, at least in the episode I’m writing about here. I understand that nurse practitioners prescribe medication, but if you’re looking for expertise around the standards of care for young people who are at risk for suicide, maybe you might want to find someone who has done some academic work on the topic? I might know a few:

I did a child and adolescent psychiatry fellowship in order to spend the additional 30,000 hours necessary to be able to do so, with a high degree of expertise. That’s a total of six years of post-graduate training, none of which is held by anybody who works at Cerebral, but whatever. The Wall Street Journal didn’t interview any child psychiatrists either.

We have previously written on the topic of responsible journalism around the reporting of suicide, which I will reference here. The very short summary is that reporting graphically about means by which one can kill themselves, which is what the Wall Street Journal was doing, is a way to get more completed suicide, not less. It’s a problem. They didn’t follow appropriate journalistic guidelines. What the hell are you doing, Wall Street Journal?

Which only doesn’t include a reference to 988 because it was done before 988 existed, which tells you something about how long I’ve been writing about this topic.

See what I did there? I followed appropriate journalistic guidelines around reporting on suicide. It’s not that hard, Wall Street Journal.

A plausible expert, who could’ve been interviewed by The Wall Street Journal as the chair of the committee, that writes all the guides for families about the appropriate care of children with psychiatric conditions for the American Academy of Child and Adolescent Psychiatry.

Now, I wrote this column in less than a day, and in all fairness I am pretty quick writer. But they had months to work on this thing, and they could’ve looked up any of the things I looked up, or contacted any of the experts who wrote any of the papers referenced. But they didn’t do any of that. Because they weren’t interested in journalism, they were interested in sensationalism and selling advertisements on a podcast. At the cost of hopelessness and death for people who are suffering.

This happens all the time. I’ve seen minors admitted to adult inpatient psychiatric units after lying about their age. I have walked into the Bellevue children’s psychiatric emergency department at 2 AM to do an evaluation of an adult who lied about his age, claiming he was a minor. Identity verification is not a standard of care. They even admit in the story that it’s not a standard of care.

Which is exactly what happened, according to the reporting.

If this is your style, you might as well work at the NY Post. But I guess Rupert Murdoch owns the WSJ publication also…