It seems like making the app itself requires answering a lot of hard questions - you would need to read the textbook and figure out how to turn the therapist parts into an app. Also, how would we know if the app actually replicated the therapist well?
If there were clear answers to these questions, I bet it would be possible to find people who would be willing to make it (possibly even me).
You have approximately a million altruistic programmers in your reader-base. It might be highly valuable to point them/us in the direction of clinical instructions for CBT-i.
Do we have any reason to expect this won’t be piratable within the next 5-10 years? I ask because most things that I could ever want to download from 5+ years ago are illegally available online. Is there any reason to expect this not to happen for these sorts of apps?
And yes, obviously it will be illegal. But it does strike me as a good way to get access if you’re desperate, since by and large copyright laws don’t seem to be enforced against most individuals. Additionally, unlike black market pills that have some probability of killing you, it seems the worst risk here (besides law enforcement) would be a virus
CBT-I can be found in a terrific book called "Say Goodnight to Insomnia" by Gregg Jacobs written in 1998. It is the original CBT-I. $11.99 on Amazon, free on Audible. I suggest this book to my patients all the time. Also Kaiser Permanente has a 6-week CBT-I Sleep Class that is free for Kaiser members and others can take it for a nominal fee.
In case anyone's wondering, this is how you do CBT-i, according to this study [1]: The CBTi intervention consisted of six weekly 60 min sessions and included the following components: stimulus control, sleep restriction, sleep hygiene , relaxation training, and cognitive restructuring.
It's pretty much just CBT + standard insomnia tricks.
Stimulus control is only using the bed for sleep. Sleep restriction is not being in bed when you're not tired. Sleep hygiene is the normal "go to bed on time, wake up on time, no electronics". Relaxation training is the meditation sort of stuff. Cognitive restructuring is turning negative thoughts like "Damn it, I'm going to be exhausted tomorrow" into "I slept 6 hours last night. Pretty good!"
I think any sort of therapy app would do, here, as long as it had a sleep diary component.
If you buy the Dreem headband, which if you want an EEG headband is a good price just for the tech, you get their CBT-I app/system. Curious how it compares, but they went to great effort to get it FDA approved.
Related: I was diagnosed with asthma when I was 5, and I just turned 38. My asthma is moderate-to-severe, but luckily responds well to fluticasone/salmeterol. I am physically active / fit and have never had to go to the ER for my condition.
However, I dislike going to doctors, and they only seem to write prescriptions for 1 year. Thus to get my meds, I need to see the damn asthma doc 1x a year. I resent this. By the time I go to the doctor, I've typically been 2-4 weeks without the controller med (relying on my short-acting inhaler, albuterol, to keep breathing). While this is my fault, I really wish I could avoid this stupid process. Fluticasone/salmeterol isn't a drug of abuse, and no western pulmonologist would think that I shouldn't be on it. Why, then, do I have to go to the damn doctor (which can be expensive if I happen to be w/o insurance) to get this 'script refilled?
Going through the most recent iteration of this, I was excited to get my prescription refilled via Lemonaide Health (a telehealth startup). I payed them $75, answered about 30 questions about my condition online and then talked to an NP for 5 minutes, who refilled my prescription. Great!! But it turns out they'll only write me a **2 month** prescription (which they didn't tell me up front), after which I have to go through the same process again. While they tell me this is due to how telehealth practitioners are regulated and I assume they're telling the truth, this is seems like a regulation that benefits them at my expense. Yay, telehealth is so convenient, but you have to pay us $75 every 2 months to keep your prescription filled!
What makes me angry is that the medical system Moloch acts like they are gatekeeping my prescription for my own safety... as if I'm a disobedient child who must be forced to act in my own best self interest by leashing me with a limited duration prescription. But this is paternalistic bullshit. Medication adherence is a huge problem, from what I hear, and they should really consider the extent to which it is iatrogenic. I'd take my meds with near perfect consistency if they didn't make me jump through hoops to get it. And I say this as someone in a high income household. What a ridiculous and even deadly burden this must be on the bottom quintile.
You blame the US health care system, and the people who chose not to make 10 dollar apps. In that vein, you should probably also blame *consumers*. It is extremely difficult to sell apps in the range of 10 dollars, *especially* for health apps. Companies have tried with diabetes apps, digital health companions, etc, and mostly failed. You can offer a trial period, but since the benefit of CBT-i only accrues over time, it does not lead to much higher sales.
Even more importantly, consumers really really do not care whether the science behind your app is actually valid. So the virtuous thing to do, namely conducting a rigorous clinical trial for your app, makes almost no difference for your bottom line. It all blends into a ton of apps promising science proven techniques.
Interestingly it seems that the FDA is trying to lower the burden of or at least substantially change software certification.
It looks like Somryst was simultaneously assessed through the 510k pathway and some kind of lighter touch test regulatory procedure for apps from trusted vendors. Looks like they're currently running apps through both processes to compare the results (and presumably see if the new process misses anything disastrous).
Nice post, but the subtitle got my hopes up. When is Scott's "GHB: Much more than you wanted to know" coming?!
GHB ("Xyrem") is currently prescribed in the US as a treatment for narcolepsy. My understanding is that (some) narcolepsy is caused by low-quality sleep -- these narcoleptics fall asleep spontaneously during the day because they are in such a deep and long-term state of sleep deprivation. GHB actually increases sleep quality (whatever this means). The effect size here is huge in narcolepetics, and GHB is often a life-changing medication.
Besides its effects on sleep-quality, GHB does something else important and sleep-related. It makes it really easy to fall asleep -- for everyone, not just narcoleptics. It doesn't lead to a hangover and is quite safe. Holistically, it seems better than z-drugs or benadryl for inducing sleep. This leads me to wonder:
Is nightly GHB use a good treatement for people with insomnia (even in its milder forms)? Is occasional GHB use a good idea for people who occasionally have trouble falling asleep? GHB is a fascinating drug, and I'd like to see someone like Scott give it a real review and answer these questions.
I'm curious, what does the app do, exactly, and how effective is it ? You say it works as well as a therapist, but how well does *that* work ? It must have went through the FDA approval process, so there must be public records of the studies they ran, right ?
On the one hand, I am somewhat skeptical that an app can fully replace personal instruction -- not to mention, prescription medicine ! -- to cure insomina; at least, if it claims to do so better than the natural remedy of counting sheep in your head.
On the other hand, if it's possible to make an anti-insomnia app for $10, would it be possible for a malicious (or even merely careless) actor to make e.g. a pro-insomnia app for free ? Or is there some process that prevents malicious apps from working too well ?
Have you looked at Fitbit Premium? It has a combination of guided programs to help improve sleep as well as metrics on how well you're sleeping so you can track progress.
I feel like a free/affordable version of this app would be less effective for two reasons.
1) For a similar reason to why some people LOVE Peloton more than other exercise bikes/treadmills, the insanely high price is a feature that enables people to feel more excited about the product.
2) If the app was affordable, lots of people would review the app; some of whom would say negative things and take away from from the app's mystique.
What happens if I just create a CBT-i app, skip the entire FDA process, and sell it exactly one would a meditation app?
* Yes, I know, I can't claim that "treats a medical disorder," so I would have to get a lawyer to take a look and avoid all the taboo words as needful. But it seems like it would be pretty easy to explain exactly what the app does without any of those taboo words.
* Yes, I know, doctors would not be able to "prescribe" it or get medical insurance to pay for it. But, umm, who cares? If it only costs $9 or whatever, insurance payment doesn't matter. And doctors could still recommend it, the same way they can recommend a dietary change or exercise.
It seems like sometimes we make this problem too hard by thinking inside of broken frameworks, when it's actually pretty easy to just ignore those frameworks and do the thing.
This seems remarkably us centric without mentioning that it's US centric. Like it is very soon and gloom about the whole system maintaining it's inadequate equilibrium without grappling with the 20+ other first world health systems that don't have this problem.
"the government regulates insurance companies to the point of effectively deciding what they have to cover,"
You are smart and well read enough to know that this is how every single first world country does it and it works better and is cheaper than in the US. The Us as is typical is in an unhappy medium where we decided that health insurance should be profit making, but that it needs to cover unprofitable conditions. The rest of the world is generally much better about making the priority universal coverage. This includes such socialist countries as Israel, Singapore and Taiwan.
It is what is very frustrating about the us healthcare debate.
"How can we solve problem x?"
"I don't know, it's impossible!"
"What about national single payer like Taiwan?"
"What about mandatory private insurance like Switzerland or the Netherlands?"
"What about whole sale government ownership of the medical system like the UK?"
You did your residency in Ireland right? How did their mental health system ration care and approve treatments?
Meta: I found this post much more informative and worthwhile to read than the last couple on online culture, and would prefer to see more posts like this one and fewer posts like those ones in the future.
I'm trying to schedule a psychiatrist appointment right now. The person in the office I'm emailing asked me to download an app for intake forms. It's for iPhone only. I don't have an iPhone. She says it's available as a desktop app. Not compatible with my computer. She says it's usable via a website. There's no website. She says to download the app for iPhone. Then she says to download on my computer. Finally she caves, and tells me she'll send it another way. Who knows what that'll turn out to be. Oh, and she also says my appointment will not be with the doctor I originally scheduled the appointment with (who's on my insurance) but with some other doctor who is not on my insurance.
I'm in the middle of a sleep-restriction program. I work with a regular CBT therapist, and I learned about sleep restriction online and in Gregg Jacobs's book, "Say Good Night to Insomnia" (which has already been cited many times in the comments). I track my sleep restriction using homemade worksheets (which I'd gladly share, if anyone's interested). Running a sleep-restriction program by app wouldn't be hard, and I think the VA app (which I used some years ago in an unsuccessful sleep-restriction effort) might do a lot of the data capture.
What I think might be challenging for an app is solving practical problems that arise. For example, in sleep restriction, as the sleep window expands, the awake window contracts. Early in sleep restriction, I had all this "free" time, and I filled it with puttering and reading and watching movies and Duolingo etc. The time is productive and relaxing. But I became attached to that time; I was reluctant to let it go, even though I was trading it for increased sleep quality and duration.
I've also learned that I'm incredibly sensitive to my environment. I used to use ear plugs only when the college kids in my neighborhood were loud, but then I'd be awake because of the unfamiliar feeling of ear plugs. Easy solution: wear ear plugs every night. But resolving my sleep issues has presented a series of things like this. Lately, I was sleeping poorly, and I didn't know why. Then I tried a weighted blanket, and my sleep improved. Then I put a fleece blanket on top of that and my sleep improved again. Both of these were guesses—I didn't feel cold or "unweighted," but it seems that I was.
There's a sense in which these environmental factors are anxiety-based, but they were easily cured by environmental change. Although environment is an important part of standard sleep-hygiene advice, solving environmental problems can be tricky, and I've yet to see a resource that addresses the things I'm talking about. Maybe one of those 75 CBT-i experts could have helped me.
Anyway, if anyone wants nonclinical advice on how to get through a sleep-restriction program, I'd be glad to share what I've learned through experience.
I'm somewhat surprised that the app-maker doesn't just quietly sell an ungated version of their app for $10.
This is what drug companies do, right? Like the fish oil pill maker can just sell off excess prescription gated fish oil pills as regular fish oil pills?
CPU manufacturers build only the highest quality CPUs they can make, and then they just gimp some of them to have a range of performance options available for consumers.
What companies really want is price discrimination, the ability to charge a customer as much as they are willing to pay. Only getting the highest payers in the market sounds nice, until the alternative is getting the highest payers *and* the lowest payers.
I suspect this will be the actual evolution of these products. An $899 prescription app, and a $10 ungated app that has a few minor inconsequential features removed, but basically does the same thing (and lots of advertisements in the $10 app suggesting you should upgrade to the prescription app).
I'm alarmed that Scott describes diphenhydramine ask "risky". My spouse takes diphenhydramine often for allergies; my two-year old son's doctor has us give him 6.25mg every evening; I'm an occasional user. Should I be worried?
All the lip service towards tackling health disparities, and this is the result: an app that will optimize treatment, but mostly for those who could already afford above-average care. The sad thing is that the novelty of these tools means that even those whose insurance providers will cover them have no idea they exist. For a year now, CVS has been partnered with ~10 different app-based services, providing guidance on proper nutrition, heart health, reducing anxiety, etc (Hinge Health is my personal favorite, at least as a concept). In that time, I've not met a single patient who has even heard of these apps, let alone used them. Of course, technological deficiencies are a huge hurdle to clear in the field. One can't reasonably expect somebody to find and use these successfully if it's a struggle to, for example, refill a prescription without calling. It's just a maelstrom of squandered potential.
I'm reminded of Captain Novolin, which was a video game released in 1992 intended to teach kids with type 1 diabetes how to manage their condition. It didn't require a prescription, but was only distributed through doctors and dietitians offices, usually for free or for the price of a commercial game. It wouldn't surprise me if someone released a similar smartphone app for this and charged much more.
I think this ignores the fact that placebos work better when the placebo is expensive and treatment compliance may be better when it is expensive too (sort of like 'I pay 100 bucks for the gym, I should go'). So 899 *may* not be as bad as it seems on the face of it.
Note: While I am not a big fan of it, I am not arguing CBT is pure placebo
Anyone with insomnia should try melatonin. It doesn't work for everyone, I think some people must metabolize it before it gets to the brain, but if it does work for you, congrats, your insomnia is solved forever.
That $899 may be designed to seem non-threatening to practicing therapists. Reading the comments (and the essay) there is a lot of less-than-positive experience with human therapists. If the app had a subscription fee of $20/month and people realized it worked better than in-person therapy and was also cheaper, who would get mad? The other therapists.
Being a good therapist takes training, dedication, willingness to reveal oneself during the training process, and a commitment to personal healing/growth which not everyone can pull off. I think there are many iffy therapists and it's too bad, but looking at what it takes to be a decent one, it's a lot. Well-designed apps may indeed be better at CBT specifically than many or most human therapists. "Tell me what I need to hear" may not have to come from another person. Bye-bye therapy industry although it may take decades. There are some things a therapist is still necessary for, subtle things that take years of practice, like trauma therapy. But there has been a massive increase in needing/wanting therapy and it all may be overdue for a course correction.
Good post and great exhortation to action. I've long thought about doing something in this realm after having comparatively severe insomnia thrust upon me from finasteride withdrawal--of all things--and having effectively solved it over time.
A coda I'd add is that CBT-i is actually fairly simple front to end; https://www.mdpi.com/1660-4601/18/6/2929/htm Fig. 1 here recapitulates the entire structure of a prototypical 12-week guided CBTi program. The more woolly issues come out in the later relaxation/cognitive phases, but it's still fairly straightforward to conduct an efficacious self-led CBTi program even in the absence of a guided app.
Noone made such app for 10$, because selling apps is a horrific lottery.
You can put thousands of hours and end with basically no sales - people will not trust you (for good reasons), people expect free or cheap side and app stores are overflowing with trash.
Maybe a better model would be to hire someone who is from a poor country and/or willing to get below market rates for interesting projects?
For example I would be willing to work as a programmer for 20$/h, as long as I consider project as worth existing.
But not willing to pour effort into something very likely to fail.
It might not make sense for someone to write a sleep app for money, but it could make sense for them to write it for themselves and/or friends and family, and then release it.
I could trivially write an app that claimed to do CBT-i, but unfortunately I might expand "CBT" correctly, as "Cock and Ball Torture", rather than in the weird way that the "therapy" people do. It probably wouldn't work on insomnia. Or I could try to do that weird "Cognitive Behavior Therapy" expansion, but get it wrong so it didn't work. How would the user evaluate whether I had done it right?
Same thing with fish oil pills. The supplement industry is notorious for not even being able to get the right herbs into herb capsules at all, let alone at the right dosages or stored under conditions that preserve their activity. Why would I trust their fish oil? They could easily have put snake oil in there instead. To be trustworthy, the supplement industry would have to be at least as reliable as the food industry, which probably means being as regulated as the food industry, which is actually pretty regulated...
Well, this is surreal - as employee #12 @ Pear Therapeutics and the product manager that launched reset & reset-O...I agree with your criticisms and I couldn't have said it better. I'm proud of the *work* I did there but the system that allows for the creation of such a company is a disaster and their incentives simply aren't aligned with improving people's health, but instead in creating a series of products that you can charge $1k for instead of, as you said, $10 for.
To state the obvious: There are other countries than America, and people in those countries also have insomnia. Also some of those people outside of America speak English and Spanish.
VPNing to another country and downloading a health app seems a lot easier than moving prescription drugs across the border.
If getting a prescription is so painful, won't there be a robust market for clones of these apps in Canadian/UK app stores. I'd pay $50 to avoid a trip to the doctors and I don't have an executive function disorder.
You say “This is part of why I am dedicating my life to building an alternative, non-insurance-based system of mental health care.” I say, how can I help you do that?
One thing to note about the cost structure, is that if you limit who can access a product, you have to charge more for it. If you sell 10,000 units at $10, you make $100,000. If you can only sell 500 units, you have to charge $200 each to get to $100,000. I'm looking at the $899 as a result of both the incentive to charge as much as possible, but also as a result of the need to charge more when you limit availability. Selling 10,000,000 units could be $1 and everyone would come out better, but you have to remove all of the gates on it.
I'm genuinely surprised how there are any depressed people receiving therapy, or drugs, or anything for their depression in the US. I myself have never been diagnosed with any kind of health issues whatsoever, but I *still* feel depressed, suicidal and homicidal (mostly the latter) each time I try to make an appointment with a doctor for a regular check up. And that despite me having a decent insurance and good job, so few hundreds dollars popping out of nowhere on the bill or having to leave for a couple of hours in the middle of the day is no big deal. How someone is supposed to go through this if they are poor, or not very intelligent, or depressed, or in pain or fever - I have no idea. And presumably the last three conditions are when you need doctors help the most!
Not app or sleep related, but related to missions to make the medical system suck less: the latest Wait But Why Post (https://waitbutwhy.com/2021/04/lanby.html) talks about Tim's wife's new project to create a primary care provider that solves many of the problems with the default.
Okay my Area Contrarian take on this is: Why am I supposed to do all this work instead of taking a Benadryl? I seem to remember reading that this bad for me in some way I can’t remember what it is though. [At least half joking] The site could really use a special ironic font to save a lot of confusion.
But seriously, I’m one of the million software engineers that read the blog and I’ll see if I can do anything to help
I'm the clinical director at a company that has been building these programs for alcohol and substance abuse for the last 15 years. We have cleaved to clinical science, building our tools with NIH SBIR grants as we go. Some of the programs we once offered at very low rates, or for free, we are now redesigning to become FDA-approved digital therapeutics. I find the views expressed here by the author very refreshing, and cathartic. Thank you.
I agree that the costs of developing one's app within an evidence base, and making it functional within our healthcare system, are expensive features that distinguish "wellness" apps from "digital therapeutics". I also agree it still seems like a bit of a money-grab, especially given the automaticity of the intervention and the scale of the eventual implementation.
That said, the costs will make more sense as technology progresses. Heretofore, as with the CBT-i app, tech based interventions have largely comprised adaptations of extant interventions. That's going to change: imagine real-time feedback via wearable sensors and cloud-computing AI, with both mobile and web versions of the same program integrated to optimize engagement, and you begin to see the picture. Qualitatively new interventions are coming.
There are incredible amounts of money sitting on the sidelines waiting to fund this leap in medical technology--as soon as clinical providers begin to get trained to use them and think in terms of them.
As great as CBT-i is, considering that a huge chunk of people with insomnia have it secondary to sleep apnea, I think it is a bigger deal that a lot of people who will be using Somryst won't first be getting a properly done and properly scored PSG. Half of AASM sleep clinics reported NOT using the scoring rules that are needed to properly diagnose sleep apnea, especially in those that are younger or are not obese (https://aasm.org/hypopnea-scoring-initiative-current-activities-future-plans/). Even those that do get a proper sleep study will have a difficult time getting PAP therapy properly titrated let alone adjusting to PAP the discomfort it can cause (this is where CBT-i for sleep apnea patients is great).
Medicine is a often joke and sleep medicine may be the worst of it.
one-off apps are not the way to market here. See MyStrength, which offers suites of mental health apps, or wait a year or so for Amazon to build a mental health marketplace. Amazon is clearly coming for inhome healthcare of all kinds - primary care, wellness, diagnostics, and mental health among others
I'm the cofounder/CEO at Shuni, where we've been consistently able to transform people's sleep through 1-on-1 coaching & therapy. Our team includes several of the world's top CBT-I and sleep experts. https://shuni.io/team
We currently have a free sleep information app, but I know that realistically, it takes a lot of self-directed reading and work if you want to move on insomnia. Though it is **definitely possible.**
I'd love to solve this accessibility issue. If there are any altruistic developers who want to help us take this app to the next level, please get in touch.
If anyone is interested, we've been working on the challenge of developing digital, evidence based apps for challenges like anxiety and depression that go direct to consumers (rather than through the insurance system). See or instance mindease.io which is our app for managing anxiety, and uplift.app which is for people suffering from depression. We also offer some free tools for mood on our site clearerthinking.org (e.g., a mood booster program based on a randomized controlled trial we ran to see what quickly boosts people's mood when they're feeling low, and a tool for building "happiness habits" that we also ran a randomized controlled trial on). We think there is a big opportunity to help people with these kinds of solutions.
I. In LA I had the opposite of Freddie DeBoer's experience finding a therapist in NYC. It took about 15 minutes to find a psychiatrist and schedule my first appointment through ZocDoc, and he was good, and I stuck with him for a few years until I felt like I didn't really need him anymore.
I also keep hearing commercials for BetterHelp teletherapy on the freakonomics podcast, which sounds convenient, but I haven't tried it.
II. By what mechanism is the insurance company prevented from refusing to cover Lovasa and offering reimbursement for identical OTC fish oil instead?
With a somryst prescription, I paid only $100 out of pocket, which will probably be reimbursed from my HSA. Even if it isn't, $100 was very reasonable to me.
What exactly goes into the app itself?
It seems like making the app itself requires answering a lot of hard questions - you would need to read the textbook and figure out how to turn the therapist parts into an app. Also, how would we know if the app actually replicated the therapist well?
If there were clear answers to these questions, I bet it would be possible to find people who would be willing to make it (possibly even me).
You have approximately a million altruistic programmers in your reader-base. It might be highly valuable to point them/us in the direction of clinical instructions for CBT-i.
Do we have any reason to expect this won’t be piratable within the next 5-10 years? I ask because most things that I could ever want to download from 5+ years ago are illegally available online. Is there any reason to expect this not to happen for these sorts of apps?
And yes, obviously it will be illegal. But it does strike me as a good way to get access if you’re desperate, since by and large copyright laws don’t seem to be enforced against most individuals. Additionally, unlike black market pills that have some probability of killing you, it seems the worst risk here (besides law enforcement) would be a virus
CBT-I can be found in a terrific book called "Say Goodnight to Insomnia" by Gregg Jacobs written in 1998. It is the original CBT-I. $11.99 on Amazon, free on Audible. I suggest this book to my patients all the time. Also Kaiser Permanente has a 6-week CBT-I Sleep Class that is free for Kaiser members and others can take it for a nominal fee.
In case anyone's wondering, this is how you do CBT-i, according to this study [1]: The CBTi intervention consisted of six weekly 60 min sessions and included the following components: stimulus control, sleep restriction, sleep hygiene , relaxation training, and cognitive restructuring.
[1]: https://academic.oup.com/sleep/article/41/6/zsy069/4956251?login=true
It's pretty much just CBT + standard insomnia tricks.
Stimulus control is only using the bed for sleep. Sleep restriction is not being in bed when you're not tired. Sleep hygiene is the normal "go to bed on time, wake up on time, no electronics". Relaxation training is the meditation sort of stuff. Cognitive restructuring is turning negative thoughts like "Damn it, I'm going to be exhausted tomorrow" into "I slept 6 hours last night. Pretty good!"
I think any sort of therapy app would do, here, as long as it had a sleep diary component.
Found two iOS apps that seem alright:
https://apps.apple.com/us/app/night-owl-sleep-coach/id1044691086
https://apps.apple.com/us/app/cbt-i-coach/id655918660
https://support.dreem.com/hc/en-us/articles/360018006052-Sleep-Restructuring-Program
If you buy the Dreem headband, which if you want an EEG headband is a good price just for the tech, you get their CBT-I app/system. Curious how it compares, but they went to great effort to get it FDA approved.
Related: I was diagnosed with asthma when I was 5, and I just turned 38. My asthma is moderate-to-severe, but luckily responds well to fluticasone/salmeterol. I am physically active / fit and have never had to go to the ER for my condition.
However, I dislike going to doctors, and they only seem to write prescriptions for 1 year. Thus to get my meds, I need to see the damn asthma doc 1x a year. I resent this. By the time I go to the doctor, I've typically been 2-4 weeks without the controller med (relying on my short-acting inhaler, albuterol, to keep breathing). While this is my fault, I really wish I could avoid this stupid process. Fluticasone/salmeterol isn't a drug of abuse, and no western pulmonologist would think that I shouldn't be on it. Why, then, do I have to go to the damn doctor (which can be expensive if I happen to be w/o insurance) to get this 'script refilled?
Going through the most recent iteration of this, I was excited to get my prescription refilled via Lemonaide Health (a telehealth startup). I payed them $75, answered about 30 questions about my condition online and then talked to an NP for 5 minutes, who refilled my prescription. Great!! But it turns out they'll only write me a **2 month** prescription (which they didn't tell me up front), after which I have to go through the same process again. While they tell me this is due to how telehealth practitioners are regulated and I assume they're telling the truth, this is seems like a regulation that benefits them at my expense. Yay, telehealth is so convenient, but you have to pay us $75 every 2 months to keep your prescription filled!
What makes me angry is that the medical system Moloch acts like they are gatekeeping my prescription for my own safety... as if I'm a disobedient child who must be forced to act in my own best self interest by leashing me with a limited duration prescription. But this is paternalistic bullshit. Medication adherence is a huge problem, from what I hear, and they should really consider the extent to which it is iatrogenic. I'd take my meds with near perfect consistency if they didn't make me jump through hoops to get it. And I say this as someone in a high income household. What a ridiculous and even deadly burden this must be on the bottom quintile.
You blame the US health care system, and the people who chose not to make 10 dollar apps. In that vein, you should probably also blame *consumers*. It is extremely difficult to sell apps in the range of 10 dollars, *especially* for health apps. Companies have tried with diabetes apps, digital health companions, etc, and mostly failed. You can offer a trial period, but since the benefit of CBT-i only accrues over time, it does not lead to much higher sales.
Even more importantly, consumers really really do not care whether the science behind your app is actually valid. So the virtuous thing to do, namely conducting a rigorous clinical trial for your app, makes almost no difference for your bottom line. It all blends into a ton of apps promising science proven techniques.
ok I'll ask does a torrent tracker exist for prescription apps. if not it should.
Interestingly it seems that the FDA is trying to lower the burden of or at least substantially change software certification.
It looks like Somryst was simultaneously assessed through the 510k pathway and some kind of lighter touch test regulatory procedure for apps from trusted vendors. Looks like they're currently running apps through both processes to compare the results (and presumably see if the new process misses anything disastrous).
https://peartherapeutics.com/pear-therapeutics-obtains-fda-authorization-for-somryst-a-prescription-digital-therapeutic-for-the-treatment-of-adults-with-chronic-insomnia/
https://www.fda.gov/medical-devices/digital-health-center-excellence/digital-health-software-precertification-pre-cert-program
Nice post, but the subtitle got my hopes up. When is Scott's "GHB: Much more than you wanted to know" coming?!
GHB ("Xyrem") is currently prescribed in the US as a treatment for narcolepsy. My understanding is that (some) narcolepsy is caused by low-quality sleep -- these narcoleptics fall asleep spontaneously during the day because they are in such a deep and long-term state of sleep deprivation. GHB actually increases sleep quality (whatever this means). The effect size here is huge in narcolepetics, and GHB is often a life-changing medication.
Besides its effects on sleep-quality, GHB does something else important and sleep-related. It makes it really easy to fall asleep -- for everyone, not just narcoleptics. It doesn't lead to a hangover and is quite safe. Holistically, it seems better than z-drugs or benadryl for inducing sleep. This leads me to wonder:
Is nightly GHB use a good treatement for people with insomnia (even in its milder forms)? Is occasional GHB use a good idea for people who occasionally have trouble falling asleep? GHB is a fascinating drug, and I'd like to see someone like Scott give it a real review and answer these questions.
I loved the Alexander Pope quote
I'm curious, what does the app do, exactly, and how effective is it ? You say it works as well as a therapist, but how well does *that* work ? It must have went through the FDA approval process, so there must be public records of the studies they ran, right ?
On the one hand, I am somewhat skeptical that an app can fully replace personal instruction -- not to mention, prescription medicine ! -- to cure insomina; at least, if it claims to do so better than the natural remedy of counting sheep in your head.
On the other hand, if it's possible to make an anti-insomnia app for $10, would it be possible for a malicious (or even merely careless) actor to make e.g. a pro-insomnia app for free ? Or is there some process that prevents malicious apps from working too well ?
Have you looked at Fitbit Premium? It has a combination of guided programs to help improve sleep as well as metrics on how well you're sleeping so you can track progress.
I feel like a free/affordable version of this app would be less effective for two reasons.
1) For a similar reason to why some people LOVE Peloton more than other exercise bikes/treadmills, the insanely high price is a feature that enables people to feel more excited about the product.
2) If the app was affordable, lots of people would review the app; some of whom would say negative things and take away from from the app's mystique.
Here's a question I never see addressed:
What happens if I just create a CBT-i app, skip the entire FDA process, and sell it exactly one would a meditation app?
* Yes, I know, I can't claim that "treats a medical disorder," so I would have to get a lawyer to take a look and avoid all the taboo words as needful. But it seems like it would be pretty easy to explain exactly what the app does without any of those taboo words.
* Yes, I know, doctors would not be able to "prescribe" it or get medical insurance to pay for it. But, umm, who cares? If it only costs $9 or whatever, insurance payment doesn't matter. And doctors could still recommend it, the same way they can recommend a dietary change or exercise.
It seems like sometimes we make this problem too hard by thinking inside of broken frameworks, when it's actually pretty easy to just ignore those frameworks and do the thing.
Try SSRI. I had severe insomnia and it has worked for 3 decades. Risk reward so good that it should be first line
This seems remarkably us centric without mentioning that it's US centric. Like it is very soon and gloom about the whole system maintaining it's inadequate equilibrium without grappling with the 20+ other first world health systems that don't have this problem.
"the government regulates insurance companies to the point of effectively deciding what they have to cover,"
You are smart and well read enough to know that this is how every single first world country does it and it works better and is cheaper than in the US. The Us as is typical is in an unhappy medium where we decided that health insurance should be profit making, but that it needs to cover unprofitable conditions. The rest of the world is generally much better about making the priority universal coverage. This includes such socialist countries as Israel, Singapore and Taiwan.
It is what is very frustrating about the us healthcare debate.
"How can we solve problem x?"
"I don't know, it's impossible!"
"What about national single payer like Taiwan?"
"What about mandatory private insurance like Switzerland or the Netherlands?"
"What about whole sale government ownership of the medical system like the UK?"
You did your residency in Ireland right? How did their mental health system ration care and approve treatments?
Meta: I found this post much more informative and worthwhile to read than the last couple on online culture, and would prefer to see more posts like this one and fewer posts like those ones in the future.
I'm trying to schedule a psychiatrist appointment right now. The person in the office I'm emailing asked me to download an app for intake forms. It's for iPhone only. I don't have an iPhone. She says it's available as a desktop app. Not compatible with my computer. She says it's usable via a website. There's no website. She says to download the app for iPhone. Then she says to download on my computer. Finally she caves, and tells me she'll send it another way. Who knows what that'll turn out to be. Oh, and she also says my appointment will not be with the doctor I originally scheduled the appointment with (who's on my insurance) but with some other doctor who is not on my insurance.
I'm in the middle of a sleep-restriction program. I work with a regular CBT therapist, and I learned about sleep restriction online and in Gregg Jacobs's book, "Say Good Night to Insomnia" (which has already been cited many times in the comments). I track my sleep restriction using homemade worksheets (which I'd gladly share, if anyone's interested). Running a sleep-restriction program by app wouldn't be hard, and I think the VA app (which I used some years ago in an unsuccessful sleep-restriction effort) might do a lot of the data capture.
What I think might be challenging for an app is solving practical problems that arise. For example, in sleep restriction, as the sleep window expands, the awake window contracts. Early in sleep restriction, I had all this "free" time, and I filled it with puttering and reading and watching movies and Duolingo etc. The time is productive and relaxing. But I became attached to that time; I was reluctant to let it go, even though I was trading it for increased sleep quality and duration.
I've also learned that I'm incredibly sensitive to my environment. I used to use ear plugs only when the college kids in my neighborhood were loud, but then I'd be awake because of the unfamiliar feeling of ear plugs. Easy solution: wear ear plugs every night. But resolving my sleep issues has presented a series of things like this. Lately, I was sleeping poorly, and I didn't know why. Then I tried a weighted blanket, and my sleep improved. Then I put a fleece blanket on top of that and my sleep improved again. Both of these were guesses—I didn't feel cold or "unweighted," but it seems that I was.
There's a sense in which these environmental factors are anxiety-based, but they were easily cured by environmental change. Although environment is an important part of standard sleep-hygiene advice, solving environmental problems can be tricky, and I've yet to see a resource that addresses the things I'm talking about. Maybe one of those 75 CBT-i experts could have helped me.
Anyway, if anyone wants nonclinical advice on how to get through a sleep-restriction program, I'd be glad to share what I've learned through experience.
I'm somewhat surprised that the app-maker doesn't just quietly sell an ungated version of their app for $10.
This is what drug companies do, right? Like the fish oil pill maker can just sell off excess prescription gated fish oil pills as regular fish oil pills?
CPU manufacturers build only the highest quality CPUs they can make, and then they just gimp some of them to have a range of performance options available for consumers.
What companies really want is price discrimination, the ability to charge a customer as much as they are willing to pay. Only getting the highest payers in the market sounds nice, until the alternative is getting the highest payers *and* the lowest payers.
I suspect this will be the actual evolution of these products. An $899 prescription app, and a $10 ungated app that has a few minor inconsequential features removed, but basically does the same thing (and lots of advertisements in the $10 app suggesting you should upgrade to the prescription app).
I'm alarmed that Scott describes diphenhydramine ask "risky". My spouse takes diphenhydramine often for allergies; my two-year old son's doctor has us give him 6.25mg every evening; I'm an occasional user. Should I be worried?
Levels of CBT in water supply rising fast
All the lip service towards tackling health disparities, and this is the result: an app that will optimize treatment, but mostly for those who could already afford above-average care. The sad thing is that the novelty of these tools means that even those whose insurance providers will cover them have no idea they exist. For a year now, CVS has been partnered with ~10 different app-based services, providing guidance on proper nutrition, heart health, reducing anxiety, etc (Hinge Health is my personal favorite, at least as a concept). In that time, I've not met a single patient who has even heard of these apps, let alone used them. Of course, technological deficiencies are a huge hurdle to clear in the field. One can't reasonably expect somebody to find and use these successfully if it's a struggle to, for example, refill a prescription without calling. It's just a maelstrom of squandered potential.
I'm reminded of Captain Novolin, which was a video game released in 1992 intended to teach kids with type 1 diabetes how to manage their condition. It didn't require a prescription, but was only distributed through doctors and dietitians offices, usually for free or for the price of a commercial game. It wouldn't surprise me if someone released a similar smartphone app for this and charged much more.
I think this ignores the fact that placebos work better when the placebo is expensive and treatment compliance may be better when it is expensive too (sort of like 'I pay 100 bucks for the gym, I should go'). So 899 *may* not be as bad as it seems on the face of it.
Note: While I am not a big fan of it, I am not arguing CBT is pure placebo
Anyone with insomnia should try melatonin. It doesn't work for everyone, I think some people must metabolize it before it gets to the brain, but if it does work for you, congrats, your insomnia is solved forever.
That $899 may be designed to seem non-threatening to practicing therapists. Reading the comments (and the essay) there is a lot of less-than-positive experience with human therapists. If the app had a subscription fee of $20/month and people realized it worked better than in-person therapy and was also cheaper, who would get mad? The other therapists.
Being a good therapist takes training, dedication, willingness to reveal oneself during the training process, and a commitment to personal healing/growth which not everyone can pull off. I think there are many iffy therapists and it's too bad, but looking at what it takes to be a decent one, it's a lot. Well-designed apps may indeed be better at CBT specifically than many or most human therapists. "Tell me what I need to hear" may not have to come from another person. Bye-bye therapy industry although it may take decades. There are some things a therapist is still necessary for, subtle things that take years of practice, like trauma therapy. But there has been a massive increase in needing/wanting therapy and it all may be overdue for a course correction.
Good post and great exhortation to action. I've long thought about doing something in this realm after having comparatively severe insomnia thrust upon me from finasteride withdrawal--of all things--and having effectively solved it over time.
A coda I'd add is that CBT-i is actually fairly simple front to end; https://www.mdpi.com/1660-4601/18/6/2929/htm Fig. 1 here recapitulates the entire structure of a prototypical 12-week guided CBTi program. The more woolly issues come out in the later relaxation/cognitive phases, but it's still fairly straightforward to conduct an efficacious self-led CBTi program even in the absence of a guided app.
Noone made such app for 10$, because selling apps is a horrific lottery.
You can put thousands of hours and end with basically no sales - people will not trust you (for good reasons), people expect free or cheap side and app stores are overflowing with trash.
Maybe a better model would be to hire someone who is from a poor country and/or willing to get below market rates for interesting projects?
For example I would be willing to work as a programmer for 20$/h, as long as I consider project as worth existing.
But not willing to pour effort into something very likely to fail.
It might not make sense for someone to write a sleep app for money, but it could make sense for them to write it for themselves and/or friends and family, and then release it.
So here's the problem with that.
I could trivially write an app that claimed to do CBT-i, but unfortunately I might expand "CBT" correctly, as "Cock and Ball Torture", rather than in the weird way that the "therapy" people do. It probably wouldn't work on insomnia. Or I could try to do that weird "Cognitive Behavior Therapy" expansion, but get it wrong so it didn't work. How would the user evaluate whether I had done it right?
Same thing with fish oil pills. The supplement industry is notorious for not even being able to get the right herbs into herb capsules at all, let alone at the right dosages or stored under conditions that preserve their activity. Why would I trust their fish oil? They could easily have put snake oil in there instead. To be trustworthy, the supplement industry would have to be at least as reliable as the food industry, which probably means being as regulated as the food industry, which is actually pretty regulated...
Well, this is surreal - as employee #12 @ Pear Therapeutics and the product manager that launched reset & reset-O...I agree with your criticisms and I couldn't have said it better. I'm proud of the *work* I did there but the system that allows for the creation of such a company is a disaster and their incentives simply aren't aligned with improving people's health, but instead in creating a series of products that you can charge $1k for instead of, as you said, $10 for.
To state the obvious: There are other countries than America, and people in those countries also have insomnia. Also some of those people outside of America speak English and Spanish.
VPNing to another country and downloading a health app seems a lot easier than moving prescription drugs across the border.
If getting a prescription is so painful, won't there be a robust market for clones of these apps in Canadian/UK app stores. I'd pay $50 to avoid a trip to the doctors and I don't have an executive function disorder.
You say “This is part of why I am dedicating my life to building an alternative, non-insurance-based system of mental health care.” I say, how can I help you do that?
One thing to note about the cost structure, is that if you limit who can access a product, you have to charge more for it. If you sell 10,000 units at $10, you make $100,000. If you can only sell 500 units, you have to charge $200 each to get to $100,000. I'm looking at the $899 as a result of both the incentive to charge as much as possible, but also as a result of the need to charge more when you limit availability. Selling 10,000,000 units could be $1 and everyone would come out better, but you have to remove all of the gates on it.
I'm genuinely surprised how there are any depressed people receiving therapy, or drugs, or anything for their depression in the US. I myself have never been diagnosed with any kind of health issues whatsoever, but I *still* feel depressed, suicidal and homicidal (mostly the latter) each time I try to make an appointment with a doctor for a regular check up. And that despite me having a decent insurance and good job, so few hundreds dollars popping out of nowhere on the bill or having to leave for a couple of hours in the middle of the day is no big deal. How someone is supposed to go through this if they are poor, or not very intelligent, or depressed, or in pain or fever - I have no idea. And presumably the last three conditions are when you need doctors help the most!
Not app or sleep related, but related to missions to make the medical system suck less: the latest Wait But Why Post (https://waitbutwhy.com/2021/04/lanby.html) talks about Tim's wife's new project to create a primary care provider that solves many of the problems with the default.
Okay my Area Contrarian take on this is: Why am I supposed to do all this work instead of taking a Benadryl? I seem to remember reading that this bad for me in some way I can’t remember what it is though. [At least half joking] The site could really use a special ironic font to save a lot of confusion.
But seriously, I’m one of the million software engineers that read the blog and I’ll see if I can do anything to help
I'm the clinical director at a company that has been building these programs for alcohol and substance abuse for the last 15 years. We have cleaved to clinical science, building our tools with NIH SBIR grants as we go. Some of the programs we once offered at very low rates, or for free, we are now redesigning to become FDA-approved digital therapeutics. I find the views expressed here by the author very refreshing, and cathartic. Thank you.
I agree that the costs of developing one's app within an evidence base, and making it functional within our healthcare system, are expensive features that distinguish "wellness" apps from "digital therapeutics". I also agree it still seems like a bit of a money-grab, especially given the automaticity of the intervention and the scale of the eventual implementation.
That said, the costs will make more sense as technology progresses. Heretofore, as with the CBT-i app, tech based interventions have largely comprised adaptations of extant interventions. That's going to change: imagine real-time feedback via wearable sensors and cloud-computing AI, with both mobile and web versions of the same program integrated to optimize engagement, and you begin to see the picture. Qualitatively new interventions are coming.
There are incredible amounts of money sitting on the sidelines waiting to fund this leap in medical technology--as soon as clinical providers begin to get trained to use them and think in terms of them.
We used our anger while it's hot: https://www.cato.org/white-paper/drug-reformation-end-governments-power-require-prescriptions.
If Twitter were prescription-only, that might make the world a much better place.
you often write epistemic status before you post a horrifying scifi story, but there is none here, so this is real, right?
As great as CBT-i is, considering that a huge chunk of people with insomnia have it secondary to sleep apnea, I think it is a bigger deal that a lot of people who will be using Somryst won't first be getting a properly done and properly scored PSG. Half of AASM sleep clinics reported NOT using the scoring rules that are needed to properly diagnose sleep apnea, especially in those that are younger or are not obese (https://aasm.org/hypopnea-scoring-initiative-current-activities-future-plans/). Even those that do get a proper sleep study will have a difficult time getting PAP therapy properly titrated let alone adjusting to PAP the discomfort it can cause (this is where CBT-i for sleep apnea patients is great).
Medicine is a often joke and sleep medicine may be the worst of it.
you can download the www.ionamind.com app for free. It's i-cbt and really helpful
one-off apps are not the way to market here. See MyStrength, which offers suites of mental health apps, or wait a year or so for Amazon to build a mental health marketplace. Amazon is clearly coming for inhome healthcare of all kinds - primary care, wellness, diagnostics, and mental health among others
I'm the cofounder/CEO at Shuni, where we've been consistently able to transform people's sleep through 1-on-1 coaching & therapy. Our team includes several of the world's top CBT-I and sleep experts. https://shuni.io/team
We currently have a free sleep information app, but I know that realistically, it takes a lot of self-directed reading and work if you want to move on insomnia. Though it is **definitely possible.**
Here are our recommendations: https://www.shuni.io/blog/2021-3-25-vfhe6bm9u7wfjrpc348lzz9tiujn8q
I'd love to solve this accessibility issue. If there are any altruistic developers who want to help us take this app to the next level, please get in touch.
If anyone is interested, we've been working on the challenge of developing digital, evidence based apps for challenges like anxiety and depression that go direct to consumers (rather than through the insurance system). See or instance mindease.io which is our app for managing anxiety, and uplift.app which is for people suffering from depression. We also offer some free tools for mood on our site clearerthinking.org (e.g., a mood booster program based on a randomized controlled trial we ran to see what quickly boosts people's mood when they're feeling low, and a tool for building "happiness habits" that we also ran a randomized controlled trial on). We think there is a big opportunity to help people with these kinds of solutions.
I. In LA I had the opposite of Freddie DeBoer's experience finding a therapist in NYC. It took about 15 minutes to find a psychiatrist and schedule my first appointment through ZocDoc, and he was good, and I stuck with him for a few years until I felt like I didn't really need him anymore.
I also keep hearing commercials for BetterHelp teletherapy on the freakonomics podcast, which sounds convenient, but I haven't tried it.
II. By what mechanism is the insurance company prevented from refusing to cover Lovasa and offering reimbursement for identical OTC fish oil instead?
With a somryst prescription, I paid only $100 out of pocket, which will probably be reimbursed from my HSA. Even if it isn't, $100 was very reasonable to me.