Cerebral stimulant suit

[Merovinge]

Yeah AHA guidelines recommend a cardiac exam and if you look at uptodate "cardiac evaluation of patients receiving pharmacotherapy for ADHD" it also recommends BP/P and cardiac exam. I just basically make sure they don't have a riproaring murmur/irregular/weird heart sounds and normal pulses and makes me feel like I'm actually examining patients

Impressive, I know of very few CAP who actually do that. Certainly family history and BP/P at every visit should be minimal standard of practice. I am so ridiculously bad at cardiac exam, I know it would not add to the treatment, especially given a PCP is listening at least yearly and would be approximately 1000% more accurate than I would be.

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[Celexa]

The damage done is grim and unfortunate, but I can't help the dark schadenfreude I feel every time some VC dingus or non-psychiatrist thinks 'simple' 'affordable' mental health care is low hanging fruit and then discovers after they've opened pandora's box the unending fountain of human misery contained within. I can only pray some of the execs see jail time.

 

[whopper]

Looking to make a new online therapy business that first does telehealth. The patient views a list of potential providers’ pics. Can interact with each of them for up to a few minutes and picks the one that he feels is the best match. Then the provider will visit the patient’s home to engage in intimidate sexual therapy.

Will need therapists. No education or license required. Please, however, provide a portfolio with at least 1 pictorial (CV not required, but please include your height, weight, and body measurements).

Providers will receive free healthcare and mandatory STD screening.

 

[VA Hopeful Dr]

Impressive, I know of very few CAP who actually do that. Certainly family history and BP/P at every visit should be minimal standard of practice. I am so ridiculously bad at cardiac exam, I know it would not add to the treatment, especially given a PCP is listening at least yearly and would be approximately 1000% more accurate than I would be.

You can probably get away with that for kids, but I don't think that was Cerebral's target audience

 

[Merovinge]

You can probably get away with that for kids, but I don't think that was Cerebral's target audience

AACAP does not recommend cardiac examination prior to starting stimulants beyond personal and family hx of cardiac concerns and vitals. This was based on the MacDaddy of CAP Dr. Biederman's research. I am aware of no research that suggests cardiac exam by CAP provides any benefit prior to initiation of psychostimulants and there is very real reason to expect it not to (e.g. most doctor's physical exams are notoriously terrible outside of a few exceptions here and there for specific fields and psychiatrists do not exactly get the most training or ongoing use of cardiac exam). There's nothing wrong with doing it, but I don't think our standard of care should be described as "get away with it".

 

[whopper]

I'm wondering if there's any cases of a kid being diagnosed with ADHD, starting a stimulant, then dying cause of then undiagnosed hypertropic cardiomyopathy. It's the classic board question of a high school kid joining a sports team and dying during practice.

A problem with stimulants is no one ever made an adult-standard for treating ADHD if the person has cardiac problems. I've had patients with moderate to severe ADHD with significant cardiac history. E.g. severe anxiety, insomnia, hyperactivity if not treated, person cannot maintain their job and will otherwise be homeless. It puts the cardiologist and I in a WTF situation. Either treat it with physical risk or don't treat it with psychological risk.

 

[VA Hopeful Dr]

AACAP does not recommend cardiac examination prior to starting stimulants beyond personal and family hx of cardiac concerns and vitals. This was based on the MacDaddy of CAP Dr. Biederman's research. I am aware of no research that suggests cardiac exam by CAP provides any benefit prior to initiation of psychostimulants and there is very real reason to expect it not to (e.g. most doctor's physical exams are notoriously terrible outside of a few exceptions here and there for specific fields and psychiatrists do not exactly get the most training or ongoing use of cardiac exam). There's nothing wrong with doing it, but I don't think our standard of care should be described as "get away with it".

Fair enough, my wording choice was not very good there.

Yes, if you are getting a thorough history before starting stimulants and getting vital signs at each visit and the patient is getting a CV exam yearly from their PCP that is definitely meeting standard of care.

My point still stands that Cerebral definitely wasn't getting vitals at each visit (because how would they) and kids are likely not their target market (since getting kids treated for ADHD isn't all that difficult most places).

 

[VA Hopeful Dr]

I'm wondering if there's any cases of a kid being diagnosed with ADHD, starting a stimulant, then dying cause of then undiagnosed hypertropic cardiomyopathy. It's the classic board question of a high school kid joining a sports team and dying during practice.

A problem with stimulants is no one ever made an adult-standard for treating ADHD if the person has cardiac problems. I've had patients with moderate to severe ADHD with significant cardiac history. E.g. severe anxiety, insomnia, hyperactivity if not treated, person cannot maintain their job and will otherwise be homeless. It puts the cardiologist and I in a WTF situation. Either treat it with physical risk or don't treat it with psychological risk.

Unless they get significant tachycardia on stimulants I'd be surprised if it increases risk of death from HOCM.

For adults I look at it like surgery clearance. If their cardiovascular function is optimized and is as stable as we can make it, barring significant pathology (bad CHF, CAD with frequent angina) then I will usually treat. The key there is optimized. CHF with maxim tolerated therapy, and bad valves have been replaced, CAD has been investigated and has been treated to the full extent that we can, you get the idea.

 

[michaelrack]

I'm wondering if there's any cases of a kid being diagnosed with ADHD, starting a stimulant, then dying cause of then undiagnosed hypertropic cardiomyopathy. It's the classic board question of a high school kid joining a sports team and dying during practice.

A problem with stimulants is no one ever made an adult-standard for treating ADHD if the person has cardiac problems. I've had patients with moderate to severe ADHD with significant cardiac history. E.g. severe anxiety, insomnia, hyperactivity if not treated, person cannot maintain their job and will otherwise be homeless. It puts the cardiologist and I in a WTF situation. Either treat it with physical risk or don't treat it with psychological risk.

There arere alternatives to stimulants to stimulants for ADHD (and also for CNS hypersomnia disorders such as narcolepsy and idiopathic hypersomnia).
There is some older research showing the safety of low dose ritalin for older patients with severe MDD.

would definitely recommend cardiac problems if using stimulants in a person with diagnosed cardiac disease.

 

[littlefred]

would definitely recommend cardiac problems if using stimulants in a person with diagnosed cardiac disease.

Made me chuckle. Thanks.

 

[forchinet121]

I’ve never heard of a single psychiatrist that I know pulling out a stethoscope and putting it on a patients heart at any time stimulants or not, are you guys implying this is standard of care?

 

[docksan]

As somebody with pretty crappy ADHD Cerebral has long offended me by trying to drop ads on my social media pages everywhere I look, not even withstanding the sheer number of patient regimens that will need to be fixed as a result of this predatory prescribing.

I’ve never heard of a single psychiatrist that I know pulling out a stethoscope and putting it on a patients heart at any time stimulants or not, are you guys implying this is standard of care?

Literally part of my normal approach when I'm seeing hospitalized patients. Can't emphasize enough how many medical issues get missed because "it's a psych patient" made other providers overlook them.

 

[forchinet121]

As somebody with pretty crappy ADHD Cerebral has long offended me by trying to drop ads on my social media pages everywhere I look, not even withstanding the sheer number of patient regimens that will need to be fixed as a result of this predatory prescribing.



Literally part of my normal approach when I'm seeing hospitalized patients. Can't emphasize enough how many medical issues get missed because "it's a psych patient" made other providers overlook them.

I’m talking about outpatient clinic although we never did that on consults either

 

[brazilianpsych]

Funny anecdotal experience, but my attendings that do the physical exam are actually worse than the ones that don't.

 

[FlowRate]

I’ve never heard of a single psychiatrist that I know pulling out a stethoscope and putting it on a patients heart at any time stimulants or not, are you guys implying this is standard of care?

It's certainly not SOC here. Heck, most of our appointments are video anyway.

We do monitor BP+HR but usually via nursing appointments in the primary care offices.

 

[allantois]

It's certainly not SOC here. Heck, most of our appointments are video anyway.

We do monitor BP+HR but usually via nursing appointments in the primary care offices.

How? Are you integrated with primary care?

 

[FlowRate]

How? Are you integrated with primary care?

Well it's a very large multispecialty group. Patient just arranges an appointment with an RN through our web portal. (Psych RN's will remind/prompt patient to do so if they forget.)

 

[PikminOC]

Cerebral sends me an offer of employment about once a week. I have blocked them.

 

[PikminOC]

It's really funny to read that whole article. The psych np is making all the same arguments against the fnp regarding knowledge, training, etc that psychiatrists make against midlevels. But when we do that it's called turf wars...

 

[Stagg737]

Uh oh, looks like more trouble in the pipeline for Cerebral...who could have guessed?

Cerebral Treated a 17-Year-Old Without His Parents’ Consent. They Found Out the Day He Died.

The telehealth startup treated a 17-year-old and prescribed him an antidepressant without his parents’ consent. The company said the treatment was appropriate and the case was an outlier.

www.wsj.com

 

[randomdoc1]

Uh oh, looks like more trouble in the pipeline for Cerebral...who could have guessed?

Cerebral Treated a 17-Year-Old Without His Parents’ Consent. They Found Out the Day He Died.

The telehealth startup treated a 17-year-old and prescribed him an antidepressant without his parents’ consent. The company said the treatment was appropriate and the case was an outlier.

www.wsj.com

paywall. any where we can see whole article?

Edit:
Also included link to article with no paywall!

NCR News: Latest News, Viral News, Local News, India News

NCR News: Read the Latest News, Viral News, Local News, India news, Health news, finance news, business news, technology and auto news.

www.newsncr.com

 

[VA Hopeful Dr]

paywall. any where we can see whole article?

Cerebral Treated a 17-Year-Old Without His Parents’ Consent. They Found Out the Day He Died.

The telehealth startup treated a 17-year-old and prescribed him an antidepressant without his parents’ consent. The company said the treatment was appropriate and the case was an outlier.

www.wsj.com

See if that works

 

[Orgone]

Cerebral Treated a 17-Year-Old Without His Parents’ Consent. They Found Out the Day He Died.

The telehealth startup treated a 17-year-old and prescribed him an antidepressant without his parents’ consent. The company said the treatment was appropriate and the case was an outlier.

www.wsj.com

See if that works

"The prescription bottle, with 14 pills left, has a label listing the nurse practitioner and Michael Boggs, a psychiatrist who is also Cerebral’s director of clinical safety.

Dr. Boggs said Anthony wasn’t his patient. “If my name was on a prescription bottle for a patient in Missouri, it should not have been,” he wrote in an email.

Dr. Boggs said he had been the nurse practitioner’s collaborating physician in Illinois and Oklahoma, but not in Missouri. State records show Dr. Boggs was issued a license in Missouri on July 22; the company said he applied for it about a year earlier.

Cerebral said its prescribing software only allowed for one supervising doctor to be associated with a nurse practitioner. The company has since upgraded its software. Cerebral said the nurse practitioner was working with another physician licensed in Missouri, whom it declined to name."


The tech company didn't make software that could accurately put the "supervising" physician's name on a subscription. Disruptors, indeed.

 

[medium rare]

Cerebral Treated a 17-Year-Old Without His Parents’ Consent. They Found Out the Day He Died.

The telehealth startup treated a 17-year-old and prescribed him an antidepressant without his parents’ consent. The company said the treatment was appropriate and the case was an outlier.

www.wsj.com

See if that works

First rule of thumb if you’re treating a minor is to verify parental consent. I actually don’t think I’ve ever had a minor request services on their own, it’s always been the parent(s) who schedule the intake.

Hard to conceive that the prescriber didn’t think to verify parental consent when they wrote a Rx for a minor; that’s pretty basic stuff.

From the way this article reads, I’d say Cerebral is pretty much f@#%*d.

 

[calvnandhobbs68]

First rule of thumb if you’re treating a minor is to verify parental consent. I actually don’t think I’ve ever had a minor request services on their own, it’s always been the parent(s) who schedule the intake.

Hard to conceive that the prescriber didn’t think to verify parental consent when they wrote a Rx for a minor; that’s pretty basic stuff.

From the way this article reads, I’d say Cerebral is pretty much f@#%*d.

I mean you should be aware of the laws in your state certainly (Missouri, as the article states, has a cutoff of 18yo), but for instance in my state the cutoff is 14yo for "mental health" treatment which includes medications. Realistically, this never happens without the parents actually knowing about it but at least I can change a 17yo prozac dose when he drives to appointments by himself and just tell the parents to call if they have any questions.

I don't loveee this article (I honestly don't love articles in general where they make it a point to emphasize the very controversial black box warning....) but absolutely the parents should have been involved in this case. Huge issue here too if they didn't ask about firearms and access to firearms. Really rough story, sounds like he shot himself in front of his mother.

 

[medium rare]

…Realistically, this never happens without the parents actually knowing about it but at least I can change a 17yo prozac dose when he drives to appointments by himself and just tell the parents to call if they have any questions.

I’ve done this as well with a 17yo but only after having established care with one or both of the parents present and I inform the parent(s) after the appointment of the changes (if any) made.

 

[calvnandhobbs68]

I’ve done this as well with a 17yo but only after having established care with one or both of the parents present and I inform the parent(s) after the appointment of the changes (if any) made.

Right but you don't legally have to "verify parental consent" that's the point. They can be annoyed about it if you don't tell them if they want but you aren't circumventing parental consent because no parental consent is required.

I also don't do this after the appointment, especially with virtual appointments, because it's been so annoying to me the number of teenagers whos parents are not present in any way or available during the virtual appointment. I always tell people I expect the parent to be available to talk during the appointment if they want to talk. If the parent is not immediately available and the kid is over 14, I'm not hunting them down outside of the time to talk about med changes, they can be available and present at the scheduled time just like if they were bringing them into the office.

 

[medium rare]

Right but you don't legally have to "verify parental consent" that's the point. They can be annoyed about it if you don't tell them if they want but you aren't circumventing parental consent because no parental consent is required.

My state is 18yo for no parental consent. I would not schedule an intake, let alone prescribe, for a minor without parental consent.

 

[randomdoc1]

Right but you don't legally have to "verify parental consent" that's the point. They can be annoyed about it if you don't tell them if they want but you aren't circumventing parental consent because no parental consent is required.

I also don't do this after the appointment, especially with virtual appointments, because it's been so annoying to me the number of teenagers whos parents are not present in any way or available during the virtual appointment. I always tell people I expect the parent to be available to talk during the appointment if they want to talk. If the parent is not immediately available and the kid is over 14, I'm not hunting them down outside of the time to talk about med changes, they can be available and present at the scheduled time just like if they were bringing them into the office.

lol, this discussion reminds me of when I was in high school I asked my PCP to rx OCPs for acne and he wanted nothing to do with it lololol

 

[calvnandhobbs68]

My state is 18yo for no parental consent. I would not schedule an intake, let alone prescribe, for a minor without parental consent.

Correct…which is why you have to do what you described above for a 17yo. I don’t.