Forging Psychiatry’s Technology-Driven Future – Dr. David Mou, Chief Medical Officer at Cerebral

Dr. Shiv Gaglani: Hi, I'm Shiv Gaglani. Today, on Raise the Line, I'm very happy to welcome Dr. David Mou, who's the Chief Medical Officer of Cerebral, a leading telemental health company serving hundreds of thousands of patients in all 50 states. David and I go way back to our college days, and it's been amazing to see his career trajectory and the impact he's made in psychiatry and digital health.

Previously, he was President, co-founder, and Chief Medical Officer of another company in this space, Valera Health, who's CEO, Dr. Thomas Tsang, was a previous guest on Raise the Line. Dr. Mou is on the faculty at Harvard Medical School, and is the Director of the Innovations Council for Mass General Hospital Psychiatry Department. His research interest is in using technology to predict and prevent suicidal behaviors. He earned his bachelor's degree and his MD and MBA from Harvard. David, it's so good to see you again.

Dr. David Mou: Likewise, Shiv. It's been a while, and great to reconnect. Congratulations again on the recent news.

Shiv Gaglani: Thank you. And you too, on Cerebral. There's a lot of news coming out of your space. I'd like to start first by learning more about you and what first got you interested in psychiatry. Obviously, I know a little bit more about this, going way back with you, but for our audience....

David Mou: Absolutely, yes. My interest in the brain started very early in college. I was a neuroscience major. I actually thought that I was going to be a lab rat. I was going to work in a wet lab for most of my life. After college, I spent a year in France, doing basic bench research and when I came back from med school, I just fell in love talking with patients. Out of all the rotations I did, it was very clear that psychiatry was the one where you had the privilege to sit down and learn about someone's life the most. Therefore, I chose psychiatry. I loved doing a residency at McLean and MGH. Now, I'm on the entrepreneurial side.

Shiv Gaglani: You've retained a lot of your research interests. I mentioned in your intro that you've done research on technology for suicide prevention. Can you tell us a bit more about your research background and some of the work you've done there?

Dr. David Mou: Yeah. One of the strangest things that I've known about the mental health space is how little we use data, period. If you have diabetes and you go to your endocrinologist, and they say, "Well, we don't follow outcomes. We don't measure outcomes," you would get a new endocrinologist. You would find a new doctor.

In mental health, that's not the case. Over 90 percent of clinicians just don't measure outcomes, and that's just the state of the field. It's not because we don't have outcome measures. We have outcome measures; we just don't use them as a field. When I first looked at the mental health space, I found these very empathetic people who would not measure outcomes, and would tell me, "We don't need to measure outcomes. We don't believe in evidence-based care." It was bewildering. It was strange. It was an odd set of emotions that I had. I became very interested in how we can measure care systematically on the research side as well as on the entrepreneurial side.

The research side is, how can we predict when someone's going to have suicidal thoughts and behaviors? I did some work with Matt Nock, who's the Chair of Psychology at Harvard, where he put these movement devices in so we can track people and how they move -- whether they're moving, whether they're shuddering, or whether they're pacing or not. We're also asking them how suicidal they are every few hours. One of the big findings in his lab is that suicidal ideation is not something that's static. Typically, we think about it as: "Are you suicidal or are you not?" We assume that it's static. But it changes hour-to-hour and day-to-day, which significantly affects how we should triage these patients and what we should do with them. That was the body of research that I was working on, and that's also the foundation of the data science that we're working with at Cerebral as well.

Shiv Gaglani: It’s fascinating. I remember close to a decade ago, getting excited about Ginger IO, which I'm sure you're very familiar with. And now, they're part of Headspace, or joined with them. And was it two years ago when Netflix got a little bit of heat. It had a funny, but also controversial, tweet about people who've been binge-watching the same episode. Netflix consumption behavior, I'm sure, can predict depression, anxiety, or those kinds of things. What data streams do you think are particularly effective at tracking mental health issues?

Dr. David Mou: Just a piece of editorializing here: When you look at companies like Netflix, Facebook, or Google using these behaviors... your behaviors can be very predictive of your future behavior. Your current preferences or clicks, how long you scroll, how quickly you scroll, where do you stop scrolling, what are you staring at -- that's all very predictive of your future behaviors. What do they use that data for? For the most part, to get you to buy something, to sell you something or to market something to you. That's the principle.

The principle works, right? Why don't we use the same principle for good? Why don't we use that to predict when someone's going to respond to a treatment…whether they're going to respond to a certain medication or a set of medications, right? Maybe you could tell us that the dosage of medication isn't quite right. Or maybe this patient doesn't have the right diagnosis and needs a therapist, etc., right? The principle there certainly is true, which is that a very small set of data can predict quite a few things. We should just use that for good instead of using it to market to people. That's one thought.

What we find is that patients have to tell you how they're doing in mental health. Otherwise, you don't know how they're doing. Again, this is using the diabetes example. It's not like blood sugar where I can measure your blood sugar and know exactly how you're doing. We actually have to ask patients, “Are you feeling better?” And they have to fill out the survey. Just to get outcomes, you have to ask patients and get their engagement on this clinical service. That's a step harder than a lab value, frankly, so I can understand why it's been so challenging for the field to get there. 

But now that we have telehealth and we can send them a survey that's HIPAA-compliant through a digital app, it should be very simple, and that's what we've been able to demonstrate. We get much higher engagement with a digital app. We have over 80 percent of our patients -- hundreds of thousands of patients -- filling out these surveys on a regular basis. We have a very good understanding of who's benefiting from the treatment that they're getting and who's not, just as importantly, so that we can target those patients and make sure that they change their treatment plan so that they do get better.

Shiv Gaglani: It's fascinating. Let's transition to Cerebral. I would love to hear how that came to be and about the amazing scale that you all have achieved in such a short amount of time. Can you tell our audience a bit more about the company and your role in it? What makes it unique? How have you scaled so quickly?

Dr. David Mou:  I'm happy to talk about the journey. Frankly, I've been surprised by how quickly it's grown as well. I would say there are two major reasons. One is operations. It's being tight with operations. When you start a company, everyone has these objectives and key results. It's about sticking to those, operating against them, doing them very well, and moving very quickly with the market.

The other half of this is luck, to be honest with you. We started during a time when telehealth became open, and the pandemic hit so the demand skyrocketed. Just to give you a sense: before Covid, 90 percent of mental health professionals never used telehealth and only 10 percent had. Literally within a month, it was the opposite…90 percent of clinicians were using telehealth and 10 percent were not. That type of seismic shift, that type of crisis, invites a lot of opportunities. We were able to hit that in stride and that's how we've been able to grow so quickly. Where we differentiate ourselves is really on quality.

The Cerebral value proposition, I would argue, is one: access. We could get patients to care very quickly, within days. Two to three days is average. This is across all 50 states. We were able to get more than 2,000 clinicians now. We're launching in the UK as well.

The second part, I think, is where we really differentiate. It's quality. Like I mentioned earlier, we measure outcomes in all of our patients. We have industry-leading outcomes in terms of depression and anxiety. We look at ADHD as well. And when you focus on quality, it opens up a few new opportunities that I think are very unique. One, you can move into serious mental illness. I feel comfortable treating patients with bipolar disorder because, as you may know, bipolar disorder has some of the highest suicide rates of any diagnosis, period. We're able to do that because we have a very robust safety system built internally that's completely data-driven. Every safety response is audited. For example, any clinician who's dealing with a patient who's suicidal can activate this crisis line and within minutes, some internal specialist that just focuses on safety is on the same line, helping to triage the patient and making sure that the patient ends up somewhere safe…calls emergency contacts, etc. That's one of many examples. But the idea here is if you really focus on quality, it helps you play in arenas that others won't touch. If you look at bipolar disorder online treatment, you won't find anyone else. It's just us.

I could talk about the positive effects of that. One, you take good care of these patients. These are the most disenfranchised and neediest patients, number one. Number two, the insurance companies begin to pay attention. Because insurance companies, for the longest time, they love the fact that anyone is helping them take care of mental health. But then, what they realized is the vast majority of companies only take care of mild or moderate depression or anxiety. They skim the easiest patients, and the second they say, "I have a substance use disorder. I have bipolar disorder. I'm suicidal," they refer them out. The insurance companies were thinking, "Well, we want someone who can take care of as many of our members as possible," and that's how we're able to get coverage with 80 million lives right now, with many of the major insurance companies, all within in a few months. That's what also helps us scale. When you focus on quality, it gives you access to a scale that otherwise would be very difficult.

Shiv Gaglani: That's incredible. We both got our MBAs at Harvard Business School. There's that talk about the triangle…it's speed, quality, and price. You can optimize for two of the three. I guess that begs the question, too, because you guys are amazingly quick at pairing patients with qualified mental health professionals.

By the way, I'm also curious how you recruit and train them. That's part of your role, I assume, as Chief Medical Officer, is to recruit and train these health professionals, especially given that there are so many digital mental health companies trying to go after the same set of professionals because we have a shortage. That's why we call this podcast Raise the Line. We need to train more healthcare professionals, social workers, mental health counselors, psychiatrists, and psychologists.

That's a two-part question. You've been able to optimize on quality and access. On price, I assume if you're doing the hard things, the insurance companies are hopefully happy to cover it because it's still telemental health so it should be a little cheaper to deliver than in person. But then, the second question is, how do you recruit and train? What's the value proposition for these healthcare professionals to join Cerebral versus Headspace or some other digital health company? Or maybe they do both?

Dr. David Mou: It comes back to quality. I'm going to sound like a broken record, but when you create a system built for quality, it helps out all of the stakeholders involved. Let me give you an example. If you're a clinician -- let's say you're a prescriber and you joined Cerebral -- you get a lot of clinical support. You're the most supported clinician, I would argue, in any mental health clinic.

Let me name what the supports are. First of all, everyone has access to what we call a curbside consult line. This curbside consult line is staffed by psychiatrists 12 hours a day, 7 days a week. At any point, you might run into a case and it's a challenging case. We don't care who you are -- you could be a psychiatrist; you could be a nurse practitioner -- if it's a challenging case, you could call this curbside consult line and get a response within an hour from another psychiatrist. It's a second opinion and it's almost always there. That's one pillar of support.

Another pillar of support is crisis response. Within minutes, you can have access to a crisis specialist to help you triage a case so it doesn't blow up your afternoon. Typically, as many mental health professionals would know, if I have a suicidal patient at 1 p.m., I've got to clear my own schedule. I clear it completely out in order to manage that and make sure they show up in the emergency room, etc. You don't have to do that. We have people to help you do that. These are crisis specialists, and they're coordinators on the other side to help you out. 

Third, I would say, is we have a lot of educational materials that are completely free to our clinicians. There are office hours. I actually hold an office hour every once in a while. We buy UpToDatefor everyone. It's not cheap, but we do it for everyone because we very much believe in evidence-based care. I think we are the only telehealth company that has an incident reporting and morbidity and mortality rounds that's taken from the hospital systems, where we go through cases where we could have done better. That's a helpful system for us to continually learn.

Probably the most important thing, I'll save for last, is this quality report that every clinician sees every month. It's not some generic non-actionable data. It's my specific patient panel and how they're doing. For the depressed patients that I'm treating, how are they doing? Or my anxiety patients, how are they doing? Not only that. We have the specific, "Here are the top 10 patients who are hot spotters, who started very depressed and remain very depressed. You should go talk to them."

This is very actionable data that clinicians would get, and then be able to reach out to certain patients. Within the same report, we have anonymized patient feedback. Within the same report, we randomly check charts and have psychiatrists give feedback on those charts. Within the same report, we have process things such as, "Hey, did you order the right labs for the bipolar patient who's on lithium, which requires lab monitoring?" It's all within one readable report that's less than two pages long, and we give it to them month on month on month. The idea here is that we empower clinicians with data to practice high-level medicine, and they like that. Clinicians like that. They don't want to do the work of scheduling. They don't want to be hampered by the current systems that prevent them from providing good care. That's how we're able to attract clinicians, and that's how we're able to keep them as well.

Shiv Gaglani: That's very compelling. There's a former Raise the Line guest who you may know, Dr. Richard Park from Ascend Partners, and before that he helped scale CityMD, those urgent care clinics in New York. It's one of my favorite episodes, in addition to this one now. It’s on how, as a chief medical officer or someone trying to scale care with quality first and then access as well—how you can do that? And having those reports, as you said, is essential because as Lord Kelvin said, "If you can't measure it, you can't manage it." You can't improve.

It sounds like that's what you guys are focusing on. Some of these are showing up clearly with how quickly you scale the results you have. Can you talk to us a bit about two of the big pieces of the news that came out of Cerebral in the last few weeks? One was the big round that you just raised and how you plan to use that and continue scaling because you're already in all 50 states. You have 80 million covered lives. That's amazing. You said you launched in the UK, so there’s probably some internationalization going on. And number two, your chief impact officer now is Simone Biles, so obviously that is big news. Congrats on bringing her on. Can you talk to us about her role and how she's shaping what you all do at Cerebral?

Dr. David Mou: Absolutely. I'll take the second question first. We're just so honored to have Simone on board as a chief impact officer. First off, Simone could have chosen any company. There were 20 mental health companies that were calling her. We just feel very privileged to be the one that she chose. It came down to quality. She looked at us and she looked at the outcomes. She actually is proudly a patient of ours as well, so this is not just something she signed-off on. She thinks it's good and she actually uses the service. I should say that she is one of the most wonderful people I've met. She is modest, kind, and open to learning new things. She's very curious about how to support certain efforts, and very passionate about this message for mental health. I was just blown away by her as a human being, and certainly as an athlete, like everyone. She's been absolutely fantastic and we're just very privileged to have that partnership.

In terms of the funding, it's been really interesting. We're at about a quarter of a million patients today, but we want to touch millions and millions, tens of millions of Americans, and be able to provide access to care for all of these people. The average wait time is still in the months, and this is for if you want to see a therapist or prescriber. It takes months for you to see someone.And not only that, it's not tailored care, right? It's the next man up or the next woman up. Whoever's available, we'll see you. 

We're trying to match you with someone. Let's say you come in and you say, "I want an African-American therapist who is trained in trauma-informed care and who is from the South." We can honor that, because we have data on our clinicians as we do on our patients. In order to scale that model up so that we can take care of tens of millions of patients, that's where most of the money is going to go towards. In order to manage the quality and manage the safety. That's certainly very important.

International is an important market for us. It's tied to quality as well. We showed this data to the chair of the NHS, the National Health System in the UK. He came over and we had a sit-down, and he said, "This is great. We'd love to help you guys expand into the UK." Now, we're doing that in a big way. We just won a grant there.

The other thing is what I mentioned earlier. We want to be in every behavioral health condition so that no patient has to be referred out. Just to zero-in on how traumatic that is when you have to refer someone out: they go to your service, they build a relationship with a therapist, they're spilling their guts in front of the therapist, and that therapist has been helpful. And all of a sudden, the patient says, "Oh, yeah, by the way, I had this thing.” And the therapist says, “Oh, that's a manic episode. You’ve got to go.”“Well, I'm sorry, where do I go?” And the therapist says,“I don't know, but it can't be here. This is a safety risk. I'm sorry. Goodbye. This is the last visit. I'm going to discharge you right now.”

That's what happens to thousands of people who were on these platforms where they only treat mild and moderate illnesses. There's no referral pattern. I've seen that first-hand. I have seen a lot of patients who come to us who were traumatized by that, and they would ask questions like, "Are you going to abandon me?" Where did that come from?"I got abandoned earlier by this service or that service." I won't name names, but the idea here is that in order to be a truly quality-driven service, you have to treat substance abuse disorders, you just have to treat serious mental illnesses like bipolar disorders or psychotic disorders, you have to treat children and adolescents who are suffering a lot. If mom and dad are depressed and it's coming from a lot of family issues, to not treat that is to turn a blind eye to where the real problem is. A lot of our research will be invested in expanding those service lines.

The last piece is clinical trials, I'm happy to talk about that, but that's a little bit off the path, so I'll leave it at that for now.

Shiv Gaglani: No, I'd love to hear about that. That's very compelling. I'm sure our audience would be very interested.

Dr. David Mou: We are the first telehealth company that is running a clinical trial. We are running a clinical trial with a biotech company. And you have to imagine, why would a pharmaceutical company want to partner with a telehealth company when they can partner with Harvard or Stanford or these very well-renowned brick-and-mortar clinics? Again, it comes down to quality. We have metrics on our patients. We have metrics on how our clinicians act process-wise that are so high resolution that we can recruit patients faster and engage them at a higher level so they drop out of these trials at a lower rate. This is music to pharma companies. When they hear that, they're very interested in working with us.

Again, as I told you, I'm going to sound like a broken record: when you focus on quality, it opens up all of these different business lines and opportunities for you to grow. Certainly, I can't say that I had the foresight to say, "Hey, we're going to provide good telehealthcare, and then we're going to run a clinical trial in nine months." That wasn't the idea.

But certainly, once we had the infrastructure to do that, it became a no-brainer. We're doing the first clinical trial that's fully decentralized. We go to the patient's home. We’re not asking the patient to go up to the clinic. We put EEGs and get blood tests. We're giving them Fitbits to measure their activity in order to see whether this specific drug for depression really works for a subset of the population. This is the first step towards precision psychiatry. Instead of carpet- bombing your entire population with one drug and hoping to see a small effect, the idea here would be to find one sub-population -- based on all of those diagnostic data -- that really, really benefits from the intervention and then targeting that specific sub-population for FDA and for clinical trials going forward.

Shiv Gaglani: That's extremely exciting. And since we brought up clinical trials in psychiatry, one thing that's emerging in the mental health space, as you're well aware is interest in MDMA-assisted therapy. My board member Mitch Rothschild’s wife is Rachel Yehuda, who is with the National Academy of Medicine and Mount Sinai. She runs the PTSD treatment for veterans. One thing that she and many other clinical trials are actually doing is bringing back psilocybin, things that I'm sure you guys are familiar with. I don't know if this has reached telehealth yet in terms of a clinical trials, but maybe just you as a psychiatrist, or you wearing the Cerebral hat…what are your thoughts on this re-emergence of psychedelic-assisted therapies?

Dr. David Mou: In a word, I'm very bullish. Full disclosure: I am an adviser to COMPASS Pathways, and I'm also on the Neuroscience Executive Council for Janssen -- the Johnson & Johnson company that made Spravato (esketamine). I’m very bullish. I would just put it this way. If you think about a new antidepressant, the signal effect size of the antidepressant versus placebo is always small. For psychedelics, it's massive. It's absolutely massive. The question for those business models is not in the effect size, it's in commercialization. How do to commercialize that in a correct manner?

It is certainly something that we’d love to engage in a safe way. There are ways to do it safely, and there are ways to do it unsafely. These are also medications with certain side effects. I would argue that it's not just a med…it's also the setting and the presence of a guide or presence of experts to manage rare situations that should be there for these clinical trials. But definitely, I'm willing to engage. As a matter of fact, we have some announcements in the coming weeks that may have something to do with this.

Shiv Gaglani: That's exciting. We'll definitely watch this space. I know we're coming up on time. If you have time for two more questions…COVID has been very difficult. We call this Raise the Line because we can’t just focus on flattening the curve and helping people avoid COVID and other sorts of diseases and disorders. We also have to strengthen healthcare capacity, which includes training more healthcare workers but also keeping the ones already in practice in the space. We've known for many years that there's a lot of burnout. Unfortunately, there’s a lot of suicide among physicians and other healthcare providers. As a clinician, w,hat are your thoughts on addressing that? I'm sure a lot of them are Cerebral patients as well.

Dr. David Mou: Yeah, it's a great question. It's such an important issue Shiv. One of the saddest things that got me quite upset and angry was that I remember that there were suicidal residents who would call me and they couldn't get care. They couldn't get time off work to seek care. They were going to work suicidal. This is not coming from the hospital where I trained, but I got these calls. And I said, "Can't you say something?" And they said, "I've tried. They don't care. They just don't care. They said go on."

Even in this group that would have access to care, they wouldn't seek it for a very good reason. At first, I said, "Well, you have care. Why don't you seek it?" The answer was it's in the same health system. The person that they're seeing may be a co-resident or a resident in a different program, but they might run into each other during lunch. There's a good reason why the care for physicians and healthcare professionals, in general, is hard to access. It's a real problem because their insurance is covered by their hospital system. There is a real challenge here, I would argue. To tell them to go find someone in a different hospital is a little bit unfair. 

I, frankly, just have not seen this problem solved at scale. I'm open to solutions here. We're thinking about donating a certain amount of care to underprivileged people first, but then eventually, maybe health professionals would be the next good target. But that's not a scalable solution, frankly, so I'm open to ideas. If your listeners have ideas here, this is personal to me. I've seen my friends suffer pretty badly from this. And each time, I have to go out and find an individual clinician who refers them into Cerebral, which shouldn't have to be the case if they’re physicians, right? But I don't have an answer to that, unfortunately.

Shiv Gaglani: Yeah, it's consistent. I mean, as you know, I was in med school, too. A lot of my friends who went onto med school residency -- not just for mental health conditions, but everything from Orthopedic to OBGYN -- have these issues pop up. It's a really perverse incentive for sure. Hopefully, our listeners will have ideas. Maybe they can contact you or others and talk about this.

Speaking of our listeners, my last question… we have many people who are entering careers in healthcare who are listening to Raise the Line and are followers of Osmosis. What advice would you give to them? Is there anything else that you want them to know about you, Cerebral, or the space that you'd like to leave as final words?

Dr. David Mou: I would say, right now, it's an unprecedented time in healthcare innovation. It's a great time to get involved. Regardless of what specialty you're interested in, spaces are getting disrupted at an alarming pace. Some for good and some for bad. I hope that when you, as good clinicians, come on board, it's geared towards good in every specialty. I would say this is a particularly good time to get involved, and involvement doesn't mean jump off full time. This could be advising. This could be going to events and just talking to people who are in this space. I advise that more so than jumping off and doing your own thing at the very beginning. And then, once you get a feel for the space, you can begin to become an entrepreneur like Shiv and take it from there.

I would say this is just an unprecedented time. For those of you who are interested in behavioral health, specifically, we have one of the most active job boards out there. If you just look up Cerebral -- go to Cerebral.com -- you can look at the job descriptions. If you want to work in a very fast, growing mental health company, we welcome great clinicians across the board. Psychiatrists, especially, but we actually take primary care docs as well. As you know, we're moving to substance abuse disorders and other illnesses as well, where primary care doctors have a lot of experience. Thank you, Shiv, for having me on. This has been a lot of fun.

Shiv Gaglani: David, thanks so much again for joining us, and more importantly, for the work that you're doing to raise the line. I appreciate your time. It's really good to reconnect. And with that, I’m Shiv Gaglani. Thank you to our audience for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.