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May 12, 2021
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Thanks, this is helpful!

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May 13, 2021
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I loaded this onto my iPhone and have poked around a bit it looks promising. Good for UW!

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omg - thanks so much

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Heads up: this no longer seems to be free on Audible. At least, it appeared to cost one credit when viewed in my premium account.

Fortunately, the audiobook was available online at my local library.

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There are multiple versions of the e-book hosted at b-ok.org for free download if you don't mind book "piracy" (of course if the e-book changes your life for the better you should buy a copy)

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This is the same program that Scott links to above, described as "a $50 CBT-i course/workbook." I don't know what the difference is between the $50 course and the original book, but they are both by Gregg Jacobs.

Incidentally, I purchased Say Goodnight to Insomnia and the associated electronic coursework around when it originally came out. The program is simple but not necessarily easy in the same that losing weight is simple but not easy (just eat less). It also worked.

At the time I thought, "Someone should make an app for this."

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...You thought "someone should make an app for this" in 1998?

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No, around 2009 or so. Sorry if I misread the publish date of the book. I thought it was mid-2000s.

Also, I was kind of eliding a longer story. What I really thought was, I should make an app that does this. I am actually a software...start-up guy (it feels pretentious to use the e-word). I thought at the time that CBT-based protocols seemed scripted enough to lend themselves to automation, which would potentially open up mental health services to a much broader group of people.

And I was right! Not that this was particularly hard to see. And 2009 was probably a bit early.

Anyway, I didn't pursue it because that's the default option: I have tons of ideas and I can only pursue a small handful of them in one lifetime. Perhaps when my current startup goes bust or boom...

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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).

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Check out the Veterans Administration's "PTSD Coach." I heard about this recently and downloaded it from the app store. It sounds like the VA has a few of these coach apps and you can see how it works. They have a head start on replicating the therapist.

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They even have CBT-i Coach!

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And they have insomnia coach! for free! not only a treatment companion app!

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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.

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What you really need is a CBT-i expert to act as project manager - the guy who goes "okay, we need to do this this and this" and then programmers go and do it, show it to him, he either goes "this is shit, do it over" or "this is good, this and this need to change."

Hey, I at least am down if someone wants to give this a shot. I'm not an app guy but I'm an experienced programmer. I'll work for cheap if it's an altruistic project (~$600 month?)

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I was hoping someone would say that! I think what you want is the aforementioned "Say Goodnight To Insomnia" book, but the really high-value thing would be for you to get in touch with Gregg Jacobs (the guy who wrote it) and see if he is on board with helping. Needless to say I would give so much free advertising to anyone who did this.

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May 13, 2021
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Right but how do I know you work? Got any independent studies to verify it works? What about my data and how qualified are your “coaches”?

I’ll take a hard pass…

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Monthly fees boo. More monthly fees than netflix also boo.

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I think their model included human coaching - not sure how you expect that to cost less than Netflix

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By having an option to not have human coaching.

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This is actually what I'm experimenting with in Dozy! Going fully automated is tricky though, lots of edge cases & unique obstacles (some discussed elsewhere in these comments)

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Alternatively, you could just have a whole bunch of people randomly working on different parts in the "bazaar" sense of "the cathedral and the bazaar".

I was going to suggest you make a github repository and see if anyone shows up, but then I decided to make one myself here: https://github.com/mwacksen/iCBTi . So there's your Schelling point, knock yourselves out.

I'm happy to give control of it away as soon as possible and don't really intend to do any of the programming work myself as I have other responsibilites.

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Would you be taking investment at some point? I’m interested

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Buy the 899$ app and rip it off. You only have to sell a 900 1$ copies of your knock-off to make a profit.

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The real question is why hasn't anyone done this? I'm not saying that they should do it, I'm saying that when I see a too-obvious-to-be-true way to make profits (it's illegal but so is piracy of any other kind and people rip movies and seed torrents for peanuts) I suspect there is a barrier of some sort. So I'd be curious to understand which one. Maybe it's an artificial obstacle put there to discourage rip-offs, or maybe it isn't (for instance: does this app need cloud servers to compute stuff?) , in which case this could go into the determination of the $899 price tag.

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I strongly doubt the price tag is for anything other than trust & recouping testing costs. The issue any copy would have is discoverablility: have a quick look on your app store of choice for "PDF readers". Given the hundreds of options, how likely are you to find & select on a specific third-party app? Do you have any trust in any of those non-adobe apps? One of the few ways to inspire a hint of trust is to charge more: either you are legitimate, at which point people are willing to pay, or you're a really confident bluff, at which point the reviews will hopefully catch you.

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If you want normal people to be able to access the app, you need it in the Apple and Google app stores.

To distribute in Apple's store, you need a yearly developer license ($100 per year). The application requires a Dunn and Bradstreet number (essentially a unique identifier for your business). At any time, Apple can deem your app or business to be in violation of their policies, and your app will be removed.

If you start distributing an app that is a copy of the $899 app, there are a few obvious reasons Apple can remove you:

1) Your app is a medical device. It is a copy of an app that is in this category. Why would a copy not be in the same category? If it is in that category, then you are in violation of laws against unlicensed medical devices.

2) Your app infringes on a patent held by the $899 app creator. I would be shocked if some aspect of their work is not patented.

I don't know the Android ecosystems rules, but Google has the same power in the Play Store.

This is not a problem on platforms where anyone can run arbitrary software. Can it be built as a web page?

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Yes absolutely it would make more sense to develop it as an web app, but if patent infringement is something they were willing to pursue you'll run into the legal issues either way.

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Is it really possible to regulate an app as a "medical device"? It seems to me that there are First Amendment issues with that.

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I'm an altruistic programmer attempting this (www.dozy.health), but haven't been successful in finding cofounders with the same vision so far. Looks like the problem is getting more attention though, especially with Somryst's launch + this post.

(the site's pretty bare right now, will be fleshing it out ahead of a public launch next month)

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May 16, 2021
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Hey! You can reach me at sam@dozy.health. :)

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Why do you think he wrote this post? ;)

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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

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Piracy isn't accessible to most people. It's easy to forget, but a set of instructions that starts with "1) download and install bittorrent" is beyond the computer skills of millions of people, and even if you somehow managed to host a dedicated site with a dead simple install wizard, if it became visible enough to make a difference it wouldn't stay up for long.

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fair enough, I’m willing to accept that I might be overestimating how accessible it would be

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+1. Most people don’t know what a bittorrent is and would probably be afraid of trying it.

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In poorer countries that couldn't afford to buy DVDs and CDs, piracy is or used to be very widespread. Almost every computer user in Eastern Europe knows bittorrent. Why? Because if some barrier stand between you and your favorite TV show or movie or music band then you will put in the cognitive effort to figure it out. People suddenly get quite smart under these conditions and drop their usual learned helplessness.

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I mean, this is also because almost every computer user knows bittorrent. That means that Average Joe who wouldn't figure it out himself can copy off of Already-Torrenting Albert who lives next door.

There's a network effect to these sorts of things.

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Yes. Even if you don't know how to pirate, you can ask somebody to do it for you or to teach you. It's not like nobody would explain it.

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I highly doubt this! In Eastern Europe most people got all their digital entertainment by torrenting until very recently, and many still do it that way. Not just geeks. It's not much more complicated than using Facebook. And for the computer illiterate, there's alway someone in the family who can help out. Don't tell me people help with movies but wouldn't help with improving their relative's insomnia.

Sure there are some computer illiterate old people without a family. There are also homeless people etc. But don't underestimate what people can accomplish if they want to.

The truth is rather that we probably value our entertainment and weekly dose of TV series more than health. Thinking about medicine is an unpleasant thing that most people like to avoid and put off.

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You are underestimating the number of people who don't use bittorrent. I don't, and I'm not particularly computer illiterate, or old, or homeless. There are a lot of people like me—it is after all in the US quite easy to get TV, music, etc. legally, so there's no real need. I wouldn't ask for help with something illegal, either.

No doubt I could figure it out if sufficiently motivated, but Scott's whole point here is that we should be looking to take down the barriers between people and healthcare, not create a system where you *can* get the thing, but only if you're exceptionally savvy and determined.

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This. America is not Eastern Europe. I know that bittorrent exists, and I am fairly confident that if I find a need for an illegal download I can figure out how to use it. But I'm not entirely confident that I can screen out malware from a source hiding behind bittorrent, and I don't need to use it at all because I can get pretty much everything I want through legal channels at a price I can easily afford.

And I'm at least 90th percentile in both general technological literacy and willingness to break stupid rules. For the median American who self-identifies as "not a thief", telling them to just use bittorrent is not a realistic option.

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In some countries, copyright laws are routinely enforced against individuals via so called copyright trolls. They log your IP address from a torrent swarm, get your address from the court and ask for a ridiculous amounts of money to settle the issue without suing you. A scumbag company charging 900 dollars from an app is exactly the kind of company I would expect to use the services of the trolls to extort money.

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I can only think of Germany like that. They are an outlier in this.

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that happened to me and I live in the us

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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.

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I'm suspicious that the sleep restriction is the part that helps. As I understand it, real hard-core CBTi can sometimes look like you only getting 3 hours of sleep for a while, because you're staying out of bed until (eg) 4 AM because you're not tired until 4 AM (and then waking up at 7 as usual). Then once you've REALLY associated your bed with tiredness, hard-core, you can push your bedtime earlier to 3AM, 2AM, and so on. This is the only part that doesn't seem like bog-standard sleep hygiene, which for most people isn't enough.

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I'd say the part of the regime you describe that "works" is that going so short on sleep (three hours from 4 to 7 am) makes you tired enough to go to sleep earlier the following day. Going to sleep when you're falling over from lack of sleep isn't very hard.

I have always had great difficulty falling asleep, but I've seen some success by playing music. I'm almost always asleep before the end of the CD. Funny story there, actually -- I first did this while I was in high school, and it worked. (We're considering taking less than an hour to fall asleep as "working".) I stopped doing it for years mainly out of not having a music player. Recently, my sister reminded me of the possibility, and I started doing it again. It still works. Phones are now music players, so I could have been doing this for quite a while, but I just didn't, even though I had every reason to think it would work.

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I've found interesting but non-stimulating podcasts work quite well. I was once plagued by sleeplessness, night terrors, and sleep paralysis in the hours after I went to bed. A calming podcast gives me something to focus on so my mind doesn't race, but not so much that it keeps me awake. My favorite at the moment is "The History of the English Language". (Sam Harris's voice is another excellent soporific).

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Lullabies and bed time stories are a thing for a reason.

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The boomer way to do this is a clock radio. Most of them can be set to turn off at a certain time so they're not going all night after you fall asleep.

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This is what I've been told by practicing sleep therapists - the combo between Sleep Restriction Therapy and Stimulus Control Therapy are the heavy hitters, and have been shown to work pretty well even on their own.

Paradoxical Intention Therapy and relaxation training have also been shown to work decently well on their own. Sleep hygiene is kinda the weak link in the literature, but it's still recommended in CBT-i practitioner guides, with the idea that it helps maintain sleep improvements / prevents some future episodes of insomnia.

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You've just solved a mystery for me - I used to have insomnia, but haven't for a few years now. The pattern you describe above is more or less exactly what happened when I started working in finance, except that the horrible bedtimes were not by choice and I then only went to bed when absolutely exhausted (but did gradually get better over time, mimicking the gradual earlier bedtimes above).

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> I think any sort of therapy app would do, here, as long as it had a sleep diary component.

From the sounds of things the app isn't necessary either, I reckon I've got 80% of the value of the therapy from reading your four-sentence description.

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I knew about CBT-i Coach (it's the VA app mentioned in the post) but Night Owl seems like maybe what I want, and I'll look into it more. Thanks! (and too bad it's not on Android)

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And this one is on its way, and developed by an EA: https://www.dozy.health/

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I should have known someone would have figured out this was important before me! I'll get in contact.

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Thanks for the mention!

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Perhaps this is the crux of the matter. Scott, a doctor, who just researched for an article on the matter, hadn't heard of Night Owl or Dozy (mentioned below). But he had heard of Somryst. Either the price pays for marketing, or being in the system is the marketing.

I'm not going to waste time making an app that only 10k people buy, or waste time doing it for free if only 1k people take it seriously and are helped. (And I think the question of why a good citizen hasn't done it for free is the deeper question. Software devs have plenty of other options when money is the goal.)

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You already give the answer to your deeper question yourself: why waste time doing something that only helps 1K people, if you feel you can spend your time on something more effective?

Or: you intend to spend the time, do your research and discover Night Owl and Dozy already exist.

The crux is not only that doctors haven’t hears of these apps: it’s also that regular folks don’t realize they could exist or, in my opinion much underestimated, don’t manage to find them. The number of times I manage to find something on the internet that my colleagues, my wife or my parents (in decreasing order of skill at such things) didn’t manage to find is much larger than I ever thought it would be. Search skills are a large component of digital literacy.

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No, they just don't care and give up or have learned helplessness. People suddenly become great at finding stuff if it's their favorite TV show for example.

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No, they don’t.

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I actually searched this space pretty hard for writing my earlier Lorien page and this post. I wasn't able to find them, no good excuse for why. Trying again, Night Owl is on the second page of a Google search for "CBT-i app" (though Dozy isn't); maybe I just missed it.

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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.

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Are EEG headbands useful? I hadn't heard of them

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Dreem recently stopped selling their headsets to consumers :'(

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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.

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You're luckier than you think. Most psychiatrists (including me) will only write 3 month prescriptions (I have no real justification for this other than that that's the culture, and doing things that aren't the culture is legally risky). Asthma doctoring must have a less restrictive culture.

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Interesting. Come to think of it, once upon a time I was insured with Kaiser and they gave me a 3 year prescription (!). I guess their vertical integration aligns their interests with health care minimalists like myself.

If prescription duration is limited by culture rather than regulation, I wonder if I could bribe someone to give me a lengthy 'script.

Weirdly, I never hear anyone else complaining about this. Surely I can't be alone on this soapbox?

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You’re not alone on the soapbox. I used to see a clinic that had providers that would leave every year or so. In order to keep getting my bog-standard thyroid prescription I would have to do a new intake with the new provider. If I tried to dodge that they would stop filling it. I finally spent enough time in the local health food stores to find out which “vitamins” were more or less equivalent, so I can get those in a pinch. Before that there were bodybuilding websites that looked promising. But that doesn’t work for asthma medicine. I knew someone who was self-managing unspecified mental health problems with lithium in vitamin form, right out of the grocery store. Less degrading and more predictable than much of mental health care. I’m so scared of children’s psychiatry at this point that I’ve been self-prescribing various vitamins for my family for years, thyroid, methyl B-12, St. John’s wort, GABA, reseveratrol. The strange part is if the doc doesn’t see the symptom, it doesn’t count, so savvy vitamin use makes it harder to “diagnose” certain things, but maybe that’s for the best in the long run. I get decent results and I just hope it carries on like that. One of my kids has asthma and we had moved and I called up the pediatrician because he was needing an inhaler again. A nurse called back and got quite aggressive and needed to talk with the patient, who was 9, to verify that mommy wasn’t lying and he actually had asthma. Then they wrote the script for the wrong kid. Maybe some people abuse Qvar? Makes me wonder. I’m in a sweet spot now with my own providers, miraculously. But yes, maintenance medication should be written in at least a year duration. If they need to check your blood pressure once a year you should be able to do a walk in at urgent care and fax them the numbers.

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You can get them online from All Day Chemist. They ask for a script but you can just click through. N.b.: lately they've been taking *forever* to deliver (I think it was three months last time) and given the current COVID situation in India, I expect that it's getting even worse.

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Thanks for the tip on All Day Chemist.

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The usual reason for psychiatrists not to prescribe a lot of pills at a time is concern that the patient will overdose (or more cynically, that the psychiatrist will get sued if the patient overdoses.) But it's fairly common for them to check a box allowing several refills so that the prescription will last longer, at least for non-controlled meds.

Lorien's (financial) interests would also align with infrequent appointments, probably even moreso than Kaiser's because Lorien has no copays or drug costs.

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This is a good argument for not giving someone a year's worth of pills at once, but not a good argument for giving them one prescription with eleven refills, or just agreeing to send them a new refill without seeing them.

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Kaiser will also let you do most or all of the transaction online. When I've run out of refills on a med, they send the request to the doc, who approves it. Delays it by a day or two compared to prescriptions where I still have refills.

Kaiser will only send me a three-month *supply* at a time, but some things they just keep refilling for years.

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Does that matter if it's a controlled substance or not? I know around me that controlled substances are limited to 90-day supplies, but maintenance non-controlled substances (Eg. SSRIs) will routinely be given a 1-year supply once the patient is established and stable.

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Do you live in the States?

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Yes, hence my confusion.

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If it requires a prescription, isn't it by definition a controlled substance?

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Err, yes in the sense that someone is controlling something, but not as commonly-used.

Something referred to as a controlled substance in the US is regulated under the Controlled Substances Act (https://en.wikipedia.org/wiki/Controlled_Substances_Act). I probably should have capitalized it. In any case, the drugs which are on that list are the fun/addictive ones which you might expect criminal prosecution for distributing.

Most drugs and medical devices are referred to as "legend drugs" or "legend devices" which means that they are required to carry a label which states something like "Rx Only" or "Only for sale or use to or on the order of a physician". Think things like antibiotics, blood pressure medication, and cardiac monitors. These still in-practice require a prescription from a physician to buy, but don't really cause much of a problem for anybody.

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I assume you're aware that Fluticasone is available OTC now and dirt cheap, right? No Salmeterol, but it may be better than nothing.

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I didn't know that inhaled fluticasone was OTC! That's great! Unfortunately, salmeterol makes all the difference for me (because my asthma appears to be steroid resistant, though some docs deny that is possible). But I'm happy for other asthmatics. I mean, damn, if you don't want bottom quintile kids relying upon awful Primatene Mist, make better options available OTC (which IMO should also include albuterol, because Primatene works *well enough* to keep low-income asthmatics, as I used to be, away from the doctor).

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I was thinking of intranasal-insufflated fluticasone (the preparation of it I use for bad seasonal allergies); it looks like the inhalers are still prescription-only, unfortunately. You could probably diy something with the fluticasone preparation in the intranasal sprayers, though.

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I've had roughly the same experience, except with allergy meds.

I've had a lot of trouble finding an allergy medication that worked for me. One that is actually working well for me is Xhance. Now, Xhance is just slightly-more-concentrated Flonase with a fancy dispenser top that's supposed to drive the drug deeper into your nasal passages, which in fairness it seems to do very well.

I don't mind paying a premium for it, because it does work and I can afford it and it's a clever design. It is kind of grating to need a doctor's visit and a new prescription every six months for it, given that it's literally a drug already available over-the-counter, dispensed is basically the same way, just slightly more effectively.

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There's liability involved. If a doctor writes you the prescription, it says several things bundled together:

1. The medication is safe for you to use. But we already knew that.

2. The medication will treat your condition appropriately. But we already knew that.

3. Your condition isn't likely to deteriorate in such a way that the medication is insufficient.

I think #3 is what freaks the doctors out. The main problem (especially with asthma) is that it can get worse over time. But people ignore that and eg. start using their rescue inhaler more and more. And then it gets bad enough that their rescue inhaler doesn't work any more/sufficiently and the patient dies. (I once dealt with a patient who was living on continual rescue inhalers, and then the smog started up - scary and nearly fatal).

Instead, the "right" thing is for doctors to be reassessing patients to determine how well their asthma is managed and to change their long-term medication so that the rescue inhaler isn't needed. But that can only happen if the doctor sees the patient.

So the doctor gets to avoid liability by only "covering" the medication for a year at a time.

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Right, this is the answer: it's about liability, whether that liability be legal or moral.

But #3 has a strong component of paternalistic bullshit (well-intended as it may be). My lung function is slowly declining as I get older (in particular, my FEF25-75 is low, though my FEV1 is typical for my age/gender), which is a situation worth addressing if only they had something to try besides "go up to Advair 500/50 and see if that helps" and when that doesn't change a damn thing, they say "*shrug* let's take you back down to 250/50."

Meanwhile, the combination of my neurotic stubbornness AND #3 results in my surviving on a rescue inhaler until I finally drag myself back to the doc (whereas on Advair, I never need my rescue inhaler- yay for LABAs!). While I understand that this is my fault/responsibility, it is also an instance of an indifferent Molloch: a patient unseen is a patient who is not of moral or legal concern. The damn doctors can't do anything for me (perhaps, until, the IgE monoclonal antibody is affordable; I should note that prednisone bursts weirdly don't improve my symptoms), yet act like it is essential for me to be under their care.

But I get it. It is an instance of both 1) Molloch and 2) my own set of oddities (some steroid-resistant phenotype of asthma and my intense dislike of doctors). The docs are doing what they know to do. I just wish they'd do a better job of meeting the patient where they are, especially given the widespread problem of 1) poor medication adherence and 2) unaffordability of healthcare (which truthfully isn't my problem, yet *must* be a factor in for those with low incomes).

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"1. The medication is safe for you to use. But we already knew that."

No, we don't. Unsafe medication gets prescribed all the time (the philosophy behind chemotherapy is "this kills cancer cells slightly faster than it kills non-cancer cells"). The question is whether the danger of one not being on the medication outweighs the danger of being on the medication.

"2. The medication will treat your condition appropriately. But we already knew that."

What do you mean? How do we "already know that"? The terms of your hypothetical are unclear.

"3. Your condition isn't likely to deteriorate in such a way that the medication is insufficient."

No, that is not at all a warranty that a prescription implies.

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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.

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Yes, the app economy writ large has struggled with any price point bigger than $5. It's a culture thing I guess: once we created the expectation that you pay that or less for an app, people just balk at a higher price even if the app is deserving.

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Straying far from the topic of the post, but... I'd really like to see pay-what-you-want more often. There are apps I refuse to try because they are $5. I've also had apps that let me donate $2 but I'd give $20. And far too many apps that are free with no way at all to donate.

Same goes for other media. I'll pay a ton for NPR but won't subscribe to WSJ because I can't try it for free first. Bandcamp is great for pay-what-you-want, but it's unfortunately hard to find quality material (there is some).

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I think this is a great point. I remember reading an article about a guy who created a prescription app that linked directly to the research. Everyone thought it was amazing, but no one would buy it.

He went into detail about why he failed and how he didn't create value for everyone in the chain.

But it was clear that his app was great and worth at less a few hundred for everyone involved. People were just used to this kind of thing being free.

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ok I'll ask does a torrent tracker exist for prescription apps. if not it should.

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Can you torrent apps? Serious question, I know zero about mobile as a platform.

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For Android, generally yes, though you'll need to bypass some warning messages designed to make what you're doing sound dangerous, and maybe enable developer mode. On iOS, I think you would need to jailbreak the phone, which is against terms of service, but I *think* either legally protected or tolerated in most jurisdictions.

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The one time I tried to install an app from a .apk instead of the app store, it was fairly painless - I had to change one thing in settings to allow "unofficial" apps, but I didn't have to root the phone or anything. But of course, that setting exists *because* most users aren't savvy enough to know if they can trust a random download, so this may not be good enough for the general market.

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Torrent is for copying files and on Android you can “side-load” apps, which are files in apk format. I would guess the difficulty is knowing whether you got the file from a legitimate source.

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Well if your torrenting an app and side loading your definitely not getting it from a legitimate source.

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Is there not potentially a useful function to be performed here: identifying and maybe verifying legitimate sources for useful .apks? Probably legally dubious mind you.

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If you want to know whether your copy is authentic, you hash the .apk and compare it against a legitimate copy.

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How do you go about getting the hash of the legitimate copy?

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my private tracker has loads of mobile apps. its just usually for specialized stuff people set up more super secrect trackers.

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Everyone is talking about torrenting the app itself, but the real gate is the in-app prescription wall. You would need a, let's say 3rd-party-modified version of the app to bypass that gate, assuming that the content exists locally in the app (which is likely).

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Since they're often not too large, it's often possible to download the entire thing as a normal file. The hardest part is discovering the app followed by finding it and keeping it updated.

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Be aware that answering this question by posting a link to such a torrent tracker (assuming one exists) might be ill-advised.

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Why is that? Last I checked, only the act of torrenting itself is legally regulated, at least in the US.

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It's entirely possible that it's against Substack's ToS.

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It is. From https://substack.com/tos :

>Don’t … broadcast, transmit, distribute, … or otherwise exploit for any purpose any content not owned by you unless you have prior consent from the owner of that content.

I don't know how strict they are about this, especially in the case of a link rather than posting copyrighted text yourself.

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On the other hand, Scott linked to an article on Sci-hub in a post (for Rindermann & al.'s survey of scientists in https://astralcodexten.substack.com/p/book-review-the-cult-of-smart ), so Substack clearly isn't very strict about this.

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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

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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.

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Also, fun fact: Xyrem apparently costs $5800 (!) per month -- $193/night. And this is for a small dose of ~2grams/day! Now, the source for this, https://www.drugs.com/price-guide/xyrem, says "prices are for cash paying customers only". I'm not sure what to make of this. Can GHB be patented? Or does Xyrem have a patent on its particular formulation of GHB (NaGHB, the sodium salt of GHB).

Another musing: One reason the medical community is careful with GHB is because it's addictive and quite euphoric. Of course, this is also true for opiates and amphetamine. In contrast with these, GHB was used as a recreational drug before it was thought to be useful medically (I think). Maybe its reputation as a recreational drug is holding it back.

(Or maybe I'm just overrating the drug. I might be underestimating its risks and overestimating its benefits. Still, I'm surprised I never see it being mentioned on, say, r/slatestarcodex).

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GHB has a reputation as a date-rape drug, which could explain the hesitancy. On the other hand, so do sleeping pills.

Wikipedia says GHB has exhibited neurotoxicity with chronic use. In rats, and I don't know what dosage.

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