Publication Date: 09/21/2026

Duration: 26 minutes, 34 seconds

Transcript:

KELLIE AIKEN: They wrote stimulant scripts as fast as their EMR would allow, until the Department of Justice got involved. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor-in-chief of the Carlat Report. And I’m Kellie Aiken, a psychiatric NP and a dedicated reader of every issue. Today, you'll learn how Done pioneered the genre of ADHD videos on TikTok, how they cut ties with the DSM and incentivized clinicians to prescribe more stimulants. We'll close with a research update on switching and stopping sleep medications. Here's the CME question for that one:

A. Eszopiclone

B. Quazepam

C. Zaleplon

D. Zolpidem

CHRIS AIKEN: When we left Ruthia He last week, she'd just set up a new business with a single mission: to make it easier for people with ADHD to get their medication. Her timing lined up with the COVID-era lockdown that transformed telehealth from a novelty to a necessity. Over the next few years, Done brought in more than a hundred million dollars in revenue, before it all came to a crashing halt. Today we'll look at the crimes they were accused of, with the caveat that we're not rendering any judgment on guilt or innocence. That’s already been Done. The core charge was a conspiracy to distribute controlled substances. Done built a system designed to make ADHD the diagnosis and amphetamines the treatment. The other charge was to make insurance pay for it – healthcare fraud.

[Done advertiement]

KELLIE AIKEN: That 1-minute pre-screen is a brief, six-question version of the ASRS adult ADHD rating scale. It's a controversial scale, since it emphasizes symptoms most people struggle with from time to time, like procrastinating on tasks that require a lot of thought, wrapping up the final details of projects, and remembering appointments.

CHRIS AIKEN: That’s how they screened patients. To screen employees, they crafted ambiguous case histories of people who didn’t clearly meet the DSM criteria for ADHD. If the job applicant said they didn’t have ADHD, they didn’t get hired. Once hired, if they denied the ADHD diagnosis, Done arranged a second opinion with a more lenient colleague.

KELLIE AIKEN: The ads went further still, suggesting people have ADHD if they pull an all-nighter to finish a paper, or stop to watch squirrels in the park.

[ADHD squirrels Ad]

Prosecutors accused the company of documenting ADHD diagnoses in patients who didn't meet the criteria. But that’s not a crime – it’s a common part of practice and why we have the unspecified diagnosis. It was the systemic practice, and other details we’ll get into, that made this a conspiracy to distribute stimulants for profit.

CHRIS AIKEN: Nor is there anything wrong about having a brief screening instrument on your website. The one Done used was endorsed by the World Health, and to their credit, one of the senior physicians at Done tweaked it, adding a question to screen out poor candidates for stimulants: "Have you had bipolar, psychosis, schizophrenia, suicide attempts, cardiac conditions, or any mental hospitalization in the past?"

The problem, prosecutors argued, was that these rule-outs were mostly for show. Done acted as though it was assessing and treating other disorders, but in practice they diagnosed ADHD in all comers. One Done analyst warned leadership that a well-run ADHD clinic diagnoses about 50% of adults with ADHD who present with cognitive symptoms. Done was diagnosing 90%. The 1-minute screen was followed by a 30-minute diagnostic interview. Beyond that, refills were plenty, and follow-up was scant.

CHRIS AIKEN: We spoke with Bryant Parson, a psychiatric NP who worked at another practice that came under pressure from the DOJ for overprescribing stimulants, Cerebral. Bryant left as the pressure to shorten visits increased.

BRYANT PARSON:  Realistically, you can't do an ADHD diagnosis in thirty minutes, especially if not for a brand-new patient just coming to care. Like, you can't do a good differential diagnosis in thirty minutes with a patient; you have to be able to spend the time to dig into who this person is, what their life has been like, get corroborating stories from other people, and all these other things. And then I think we owe it to the patients to do a better job of screening for all of the other things that this could be, because, you know, as I'm sure you know, like the overlap between ADHD diagnoses and sleep apnea is huge, you know, differentiating between borderline personality and bipolar disorder and having this ability to kind of talk with other providers in that patient's care also is really big, and that was something that didn't exist at Cerebral.

KELLIE AIKEN: The DSM criteria requires a bit more than screening for inattention. So let’s get into that. First, they require a positive score on either inattention or hyperactive symptoms, with a cut-off of 6 symptoms for children and 5 symptoms for adults. But symptoms are not enough. Forgetting appointments, missing deadlines, and feeling “on the go” are common human experiences, especially when people are juggling heavy demands. So DSM requires a few other elements: 

1. Ruling out other diagnoses. Done rarely did this. At one point, executives removed screening questions for other conditions from the intake forms because they created too much friction for patients. Cognitive problems are common in most chronic psychiatric disorders. They just aren’t listed in the criteria because they aren’t specific to any single one, and nor are they specific to ADHD. That’s why neuropsychological testing can’t confirm an ADHD diagnosis – people with bipolar disorder will score the same on those tests as people with ADHD.

2. Trace the symptoms back to childhood, ideally before age 6, and at minimum before age 12. More than half of Done's patients had no prior ADHD diagnosis, and many patients were first diagnosed after age 50. Done's ads suggested stimulants could help adults recapture the sharp attention they had as young students:

[Done advertisement]

CHRIS AIKEN: 3. You have to document significant impairment in at least two areas of life: home, school, work, or relationships. Significant enough to cause real problems: teacher conferences, poor grades, job loss or demotion, failed relationships; not just misplacing a wallet now and then. A patient who struggles with attention but compensates well enough to get by doesn't meet criteria for ADHD. Why? Because ADHD is in part a disorder of executive functioning, and if your frontal lobes are strong enough to compensate, you probably don’t have it. Compare that to this Done testimonial:

[Done advertisement]

KELLIE AIKEN: Done incentivized clinicians to refill medications without any follow-up. That may sound odd, as follow-up visits are how most practices generate revenue, but Done was operating outside insurance. It ran on a private-pay subscription model. Patients paid the same $79 a month whether they saw a clinician or not, so Done's strategy was to maximize subscribers, not visits. So they paid clinicians by the refill, not the appointment. As Charlie Munger said, "Show me the incentive, and I'll show you the outcome." The outcome was more subscription revenue, and the incentivized clinicians wrote for stimulants as fast as the EMR would allow, which was about one every 30 seconds if you skipped the chart review, which many did. Those who played along earned up to $700,000 a year. 

That’s a lot of money, so let’s break it down. They earned roughly $10 per patient for each monthly refill. Two refills a minute comes to $20 a minute, or $1,200 an hour; and that’s just the most an NP could make. Done was bringing in a lot more. With a monthly subscription fee of $79, the company was clearing around $8,000 an hour after paying the clinician’s salary.

CHRIS AIKEN: Not everyone went along with it. A lead NP complained that the policies were out of sync with every practice guidelines, and a medical director called Done a “pill mill” in a company email. But as clinicians pushed back, the chief physician, Dr. Brody, pressed on. At a Done holiday party held over Zoom, Brody told employees they were bringing stimulants to patients just like Santa Claus brings candy to children. Later, Brody refined the analogy, comparing Done to Coca-Cola, telling clinicians they should give everyone Adderall just like Coke dreamt of doing in their 1970s campaign.

[Ad: I'd like to give the world a Coke]

KELLIE AIKEN: Brody’s analogies stopped there, and we’ll spare you the Coke-Cocaine jokes. But there is an uncanny similarity between Coca-Cola, Done, and the Richwood Pharmaceutical Company that released Adderall in 1996. Did you catch it? Listen closely: Add-er-all. OK, I’ll spell it out: ADD for All.

CHRIS AIKEN: It was a bold idea. At the time, methylphenidate dominated the stimulant market, and amphetamines were rarely prescribed in the US. Doctors had learned to stay away from them after over-prescribing them in the 1960’s for energy, concentration, stress, and weight loss. Everyone from long-haul truckers to the president of the United States was taking them, usually with a legal prescription.

KELLIE AIKEN: John F. Kennedy started taking amphetamines while running for office in 1960, prescribed by a physician whose high-profile clients called him nicknamed Dr. Feelgood. A year later, Kennedy had to be restrained by his own Secret Service. The president had stripped naked at the Carlyle Hotel in New York and was running down the halls agitated and paranoid. Dr. Feelgood was called in to give Kennedy an antipsychotic. But nudity was not enough to stop the amphetamines. It took a nuclear crisis later that year to pull the plug. When Kennedy met with Soviet Premier Nikita Khrushchev in Vienna, the president’s drug-induced behavior nearly derailed the nuclear summit. Back in Washington, his staff barred Dr. Feelgood from the White House.

CHRIS AIKEN: The amphetamine habit spread through every level of leadership in the 1960s: Hugh Hefner, Nelson Rockefeller, Hollywood executives, Wall Street financiers. The party ended in a single day in 1970, when the Nixon administration reclassified stimulants as controlled substances. A few years later, medical societies spoke out against the last legitimate use left standing: weight loss. By the 1980s, weak sales forced Obetrol, a mixed amphetamine salt marketed for obesity, off the market.

KELLIE AIKEN: A decade later, physicians had forgotten that history. DSM-IV loosened the criteria for ADHD, and new research was suggesting the problem kept up into adulthood. And in 1994, a small pharmaceutical company from Kentucky bought the company that made Obetrol. They relaunched the mixed amphetamine salts as Adderall for ADHD, earning approval for children in 1996 and adults in 2004.

CHRIS AIKEN: The approvals normalized amphetamines once again, and doctors no longer shied away from the medication. Before Adderall, methylphenidate accounted for 90% of stimulant prescriptions in the US and amphetamines for just 10%. After Adderall, the pattern reversed: Amphetamines now make up 62% of the U.S. stimulant market (MarketScan data), with methylphenidate at 38%. Other countries didn't follow this lead. Methylphenidate remains the top stimulant by a wide margin everywhere except in the US and Australia. In other countries, guidelines place amphetamines second-line, and regulators either restrict them tightly or ban them outright. That’s a tip you need to know. If your patient travels to parts of Asia or the Middle East, they could get arrested for carrying amphetamines, even if they have proof of a prescription.

KELLIE AIKEN: So have we reached peak amphetamine again? Not yet. By the end of the 1960’s, roughly 1 in 6 US adults were taking an amphetamine, which is about 2-3 times higher than estimates today. But the trend is there. Stimulant prescriptions rose steadily before the pandemic, increasing at a rate of 7% per year, and then by 30% per year after the pandemic. The combination of alprazolam and amphetamines is also on the rise, and most of this unfortunate combination is going to the wealthiest Americans who can afford a private pay physician. And just as 1960’s Manhattan had its Dr. Feelgood, most US cities have their feelgood equivalents. The Wall Street Journal recently profiled a Manhattan psychiatrist who said that 50% of his ADHD patients work on Wall Street. The doctor explained that [quote] “their high-octane jobs are nearly impossible to do unassisted" and then medicalized the problem, adding their “difficulties at work could be a sign of untreated ADHD.”

CHRIS AIKEN: And I have no doubt, there is some untreated ADHD on Wall Street. But is it a few people, or a few thousand? And what is the cost to all the wrongly diagnosed people who take this cardiotoxic and neurotoxic drug? Here’s what some of those Wall Street patients told the paper. Over time, the amphetamines made them withdraw socially. They couldn’t have normal conversations with others, because they felt rigid, hyperfocused, or perseverating on the amphetamine. “They made me robotic and highly transactional, unable to see the value in talking to others.” One trader felt Adderall was a miracle drug at first, allowing her to work in the office for 48 hours straight. It gave her the mental energy to analyze complex trends in the commodities market, but it also boosted her confidence, and she started making financially irresponsible decisions. She would take breaks at work to gamble her savings with penny stocks.

KELLIE AIKEN: It’s a myth that amphetamines are cognitive enhancers. Yes, they help mental alertness, speed, and energy, but cognitively they are a mixed bag. In one study, healthy subjects performed better on cognitive testing after taking a stimulant, but then performed worse the next day, probably because it worsened their sleep quality. In a study of professional chess players, stimulants worsened their performance, because they caused them to perseverate, second-guessing their moves. In meta-analyses of healthy adults on stimulants, most cognitive measures come up negative, or they only detect a difference in patients who are already impaired, such as from sleep deprivation or sedative use. All this data is useful, but it’s not what you’ll hear from patients. Because even when these studies turn up negative on objective measures, the subjects still believe that their performance improved.

CHRIS AIKEN: Done was operating in the most permissive country in the world for amphetamines, and still that wasn't enough. The company wanted to remove all friction between patient and prescription, and it incentivized employees to grease the wheels. When employees complained that the policies were illegal, Hu told them she'd give a free Tesla to the first person prosecuted.

KELLIE AIKEN: When incentives didn't work, Done used a stick. NPs who denied stimulants to a patient had to forward the case to a senior clinician for review. Employees who didn't readily prescribe stimulants got called in by management, and those who kept resisting got fired. In 2022, clinicians from Done and another telehealth practice, Cerebral, banded together to expose problems at their companies. They leaked their concerns to the Wall Street Journal, detailing how corporate leaders coached clinicians on optimizing stimulant prescriptions. The story, headlined "Startups Make It Easier to Get ADHD Drugs," put both companies in a blinding spotlight in the Spring of 2022, and that spotlight was only going to get brighter.

CHRIS AIKEN: Within months, the DOJ opened investigations into Cerebral and Done. In May 2022, major pharmacy chains like CVS and Walgreens stopped filling prescriptions for controls from these practices. Tens of thousands of patients scrambled for refills. Inside the companies, clinician turnover accelerated, causing patients to shuffle from provider to provider, with clinicians who'd never seen them tasked to bridge their prescriptions. Then, in October 2022, COVID-era supply chain problems hit stimulant manufacturers, triggering shortages that rippled into every practice.

KELLIE AIKEN: By the end of 2022, social media platforms had started blocking ads from Cerebral and Done. Simone Biles, an Olympic gymnast who was diagnosed with ADHD as a child, stepped down as a spokesperson for Cerebral. According to the Wall Street Journal, Cerebral pressured Biles the way it pressured its clinicians. It wasn’t enough for the gymnast to talk about ADHD; they wanted her to promote stimulants.

CHRIS AIKEN: Bryant Parson told us how those ads affected practice. He started at Cerebral fresh out of graduate school, and now runs his own practice in Virginia Beach.

BRYANT PARSON:  We would see these ads because, you know, we work there, so the algorithm knows us, and we would get these ads on Instagram. And the ads were essentially telling the patients the keywords that they needed to say to get an ADHD diagnosis. And so then those patients would see this on Instagram, and they would come to us and say these keywords. And yeah, I mean, they're the right words in the right order. Because of the 30-minute visits, you don't get really enough time to dig in and have them explain what they mean by X, Y, and Z. So, you know, when you say you're having executive dysfunction, what does that mean?

CHRIS AIKEN: In 2022, both companies were caught in the same quagmire, but the didn’t follow the same path. Cerebral did something about the problem, while Done pressed on and tried to cover it up. Cerebral’s board of directors ousted the founder, Kyle Robertson, a non-clinician, and replaced him with the Chief Medical Officer, psychiatrist David Mou. Dr. Mou had been with the company only a year and had kept his hands clean, lobbying internally for higher standards of care. Under his leadership, Cerebral secured a settlement with the DOJ that shielded the company from prosecution. The executives at Done would not be so lucky.

KELLIE AIKEN: Today's research update is an expert opinion on a common question: how do you stop sleep meds, or safely switch a patient off one sleep medication and onto another? This comes from Nathaniel Watson and colleagues, published in the Journal of Clinical Medicine. It's a clinical practice guideline — five sleep medicine specialists from the Alliance for Sleep reviewed the evidence on stopping and switching hypnotics. The authors have financial conflicts, and the guidelines were sponsored by the manufacturer of daridorexant, an orexin antagonist.

CHRIS AIKEN: Here's what they found. Benzodiazepines, z-hypnotics, trazodone, quetiapine, and gabapentinoids all need a gradual taper after two or more weeks of use. Lower the dose by 10 to 25% a week, and add CBT for insomnia if you can. The VA has a free app: Sleep Coach.

KELLIE AIKEN: But not every hypnotic requires a taper. Zolpidem and eszopiclone cause brief rebound insomnia, but the authors only recommend a 1-2 day taper to prevent it. Zaleplon/Sonata, however, doesn’t have rebound insomnia, a surprise, but it’s based on two large trials that compared it to rebound on zolpidem. So no need to taper zaleplon.

CHRIS AIKEN: And the newer agents — orexin antagonists, low-dose doxepin, ramelteon — don't show meaningful withdrawal or rebound. You can switch to those directly without special precautions. Trazodone, mirtazapine, and quetiapine, however, can cause withdrawal symptoms, including nausea, dizziness, and occasional rebound insomnia. Tolerance, however, isn’t the only thing that gets in the way when transitioning from z-hypnotics or benzos to newer sleep meds. The newer meds don't have that anxiolytic, "quiet the racing mind" feeling patients get from benzodiazepines and z-hypnotics. That subjective pull is part of why patients find it hard to switch. So why switch? The newer ones are safer, particularly in the elderly, with lower risks of tolerance, falls, and cognitive problems. And the older sleep meds don’t improve sleep quality, which the orexin antagonists may do. We’ve gathered 66 of the most clinically relevant trials of the past three years into a new book: Psychiatry Practice Boosters. Now in its Fifth Edition, Jesse Koskey and Zach Davis highlight the take-home points for each practice-changing study. Available at the Carlat Report.com.