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).
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.
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.
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?)
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.
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)
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.
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.
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.
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?
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.
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)
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
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.
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.
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.
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.
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.
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.
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.
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.
I have yet to have any patient have a long-lasting result from any app. Except the Healthy Minds app released by the Center for Healthy Minds at the University of Wisconsin. It is a comprehensive engaging program for mental and emotional well-being. And it is free. https://hminnovations.org/meditation-app
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)
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."
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...
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.
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.
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.
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).
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.
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.
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).
> 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.
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)
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.)
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.
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.
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.
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'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.
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?
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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).
"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.
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.
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.
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).
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.
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.
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.
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.
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.
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).
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.
>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.
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.
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).
I take Xyrem. Yes, it is patented. It's not especially expensive to manufacture. When I had no health insurance the manufacturer was happy to put me in a "coupon program" that allowed me to buy it for. . . I think it was about $35/month? Maybe as much as $50? The thousands of $ of sticker price is strictly for soaking Medicaid/care and negotiating with insurers.
I think it's worth looking into, but personally I've developed a lot of tolerance to Xyrem's hypnotic effects. It still helps my sleep quality a ton, but it used to knock me out swiftly and now it really doesn't.
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 ?
Here's a good sample study - https://pubmed.ncbi.nlm.nih.gov/28472528/ - where in-person has effect size of 0.89 and online has effect size of 0.53 (other studies are more optimistic about online being equally good).
While there's not much motive for exclusively harmful apps, there's plenty that could be argued to cause harm in search of profit; timed events on "gatcha" games are often such that you can either spend excessive amounts of time, including during specific periods (aka set an alarm to wake up at midnight to grab those rewards) or you can spend increasingly worrying amounts of money.
"Or is there some process that prevents malicious apps from working too well ?"
All an app can do is recommend a course of action to its user. The user has to decide to follow the advice, and continue to do so even as their insomnia worsens. There's nothing to stop someone from creating an app that tells the user to drink a lot of coffee before bedtime, set their alarm to wake them up every hour to do twenty minutes of exercise, and sleep in to noon, but its advice would be unlikely to be adopted.
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.
You could do it. I don't even think you have to pretend it's a meditation app. Just say it's a CBT-i app that "supports healthy sleep". I agree this is the right call, commenters have pointed me to ones that are trying to do this, and I support them.
There's a reason why a lot of things have the phrase "Not intended to Diagnose, Treat, Prevent or Cure any disease". It's (mostly) a waiver of FDA regulation.
"Insomnia" is a medical condition. Can't mention it.
"Healthy sleep" or "restful night" are vague enough that they avoid regulation.
The point is that no exemption from regulation is needed. Anyone can create an app without FDA regulation, as long as they don't make a certain class of medical claims.
I tried an SSRI and it activated some latent bipolar, cause a sever manic episode that lasted for months bc I didn't realize that's what it was at the time. So there's your downside risk.
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?
I'm not going to say it's impossible in the US, but getting from here to there in the US is at least very difficult.
So now I notice yet another problem with English. "Impossible" can mean completely impossible, or it can mean that there's no clear path from here to the goal.
What is effective access to mental health like in other countries? A friend in Canada has a child with Autism. Officially, therapy for the child is provided by the government. In-practice, the waiting list is so long that they would miss out on most of the developmental benefits by the time they could get an appointment. And the amount of services would be far less than the child needs. So they have to pay cash to see a private provider.
In Slovakia, the waiting list to get a child diagnosed with autism is a few months; less if you are willing to pay, more if you want it paid by insurance. I have no idea what services are provided and under what circumstances.
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.
Counterpoint: I discovered SSC via "Untitled", and am very glad that Scott at long last seems to feel free to write about online culture again. I'm sure these rants about the US medical system are useful in the local context, but to an outsider such discussions are like listening to an argument about how the Titanic's deck chairs ought to be arranged; i.e., only interesting because Scott is such an engaging writer. If he never blogged about psychiatry again that would be just fine with me.
Echoing what others have said, the number of comments is a poor metric as to how useful a post is. Likes is at least somewhat useful; although one can argue that it isn't a perfect metric, it's at least reasonably related to expressing sentiment.
Nothing wrong with stating your opinion, but look at the number of likes and comments on this vs the culture war. You're in a solid minority.
Also, the latest culture war post wasn't Scott's best, but "I can tolerate everyone except the outgroup" is an all time great piece of writing and insight.
I agree partly with both you and the OP. I found this post a delight to read and less muddy than the last couple of online culture ones. But at least as far as likes and comments are concerned, you're right - very much a minority.
One thing about the "I can tolerate everyone.." essay is that it wasn't tied down to the object level stuff. It was a post for the ages, and for me, vastly better and more interesting as a result.
This is the entire problem with social media. Optimization of engagement-based metrics incentivizes material that provokes outrage and/or applause choruses, rather than being informative. That is fine if you explicitly want to be a Culture Warrior, but Scott has never wanted to be that and avoided these topics on purpose to avoid giving himself bad incentives. It would be unfortunate, to me at least, if the fact that his reach has expanded and the newer generation of commenters who are coming here mostly because they ran out of other places where they could freely say verboten things turns him into a Culture Warrior to please those commenters.
Remember your goals, Scott. Maybe they've changed over the years, but your purpose for writing and sharing that writing didn't use to be "maximally please whatever audience I end up with."
Acknowledging that you have goals not explicitly related to writing that can be helped by a revenue stream possibly generated by writing that does nothing more than maximally please some plurality of your audience.
Scott has an old essay where he says that he gets the most engagement (and if he sold ads, the most money -- this is largely irrelevant as he sells a giant bundle of everything now) on his CW posts and the least on his "here is how to save your mental health" posts, even though he would prefer it the other way in terms of saving mankind.
Scott is an expert in mental health and a clear and comprehensive writer. If he says something about mental health, it's either irrelevant to me or useful to me, but in either way there's not likely to be much for me to comment about except some variation on "+1". Which isn't the culture here, or at least wasn't on SSC and we mostly liked it that way.
Culture War stuff, may not be helpful but it's probably not irrelevant and there's much more scope for commentary by amateurs like myself.
I can see the time-management point which I think you're trying to make behind that sentence, but I think that's a very dangerous framing and actively recommend against anyone internalizing it.
As a longtime reader and recent subscriber, I really liked both posts. Scott, please keep writing about psychiatry and the culture war!
Scott's interests overlap with my own quite a bit, but he's a good enough writer that I enjoy getting a new post in my inbox even when the topic isn't something I would otherwise choose to read about.
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.
There are (or were) several bills moving around the Senate to make "surprise billing" illegal in the US, but I don't know what their status is. I know insurance companies themselves are also working to make surprise billing not happen, because usually it makes them look like assholes (The stereotypical surprise billing scenario is: you go to a hospital that's in-network to have surgery performed by an in-network surgeon, but unbeknownst to you--because how would you ever find out?--the anesthesiologist on the surgery team is *not* in-network, and you suddenly have thousands of dollars of expenses not covered by your insurance).
I would assume they would apply to the scenario where you're unknowingly assigned to a therapist who is not in-network.
You *can't* find out. I *specifically asked* if the anesthesiologist would be "in network" for me when I had some elbow surgery done, and NOBODY WOULD COMMIT TO TELLING ME THAT THEY WOULD BE.
(The most anyone would say was that the facility I was having it done in and the doctor who was doing it would be)
(And as it turned out, they were. But I have excellent and wide-network insurance)
Interesting. Never realised (I'm looking at this from outside) that the US healthcare system was that atomised. I assumed your contract for an operation would be with a single provider who dealt eith sub-contracting required personnel. I'd suggest that there's a lot of convenience and possibly savings to be had by reducing the number of billing points.
This also has an interesting implication in the UK: debates about the future of our health system are bedevilled by a tendency to assume bad faith in the other side and to portray any proposal for change is a move towards a dysfunctional caricature of the US system (or from my own side of the debate, a move towards some fantasy of socialism that will damage people - it's a frustrating experience finding sensible opinions). Yet the debate still sees the hospital as the billing unit, not the doctor. It may be that those portraying a cartoon scenario of 'US'-style private healthcare providers have less knowledge of that system than they like to portray (it wouldn't be a shock: they generally seem ignorant of the other 200-odd healthcare systems in the world, so why expect knowledge about the one they focus on?).
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.
This is definitely a challenge that I'm facing trying to make a primarily automated program. The steps are pretty straightforward, but many people have unique obstacles that arise. Currently using a human-supported system to address this, with the goal of building in more support and edge cases as I discover overlaps.
If you want me to stress test your app, let me know. I'm a former software developer, and I'm good at generating complaints about UI and general usability.
Hey Kat! There's a lot of low-hanging fruit I'm currently working through re: usability, but if you shoot me an email at sam@dozy.health I'd love to circle back in a few months once that feedback would be more useful. :)
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).
> 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.
Is it still true? AFAIK nowadays they typically sell ones where some cores are with defects (and some defects are expected).
So they try to produce 8 core processor, ones where 2 cores failed get them disabled and are sold as 6 core processor.
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?
Well, I don't know if you should be worried, I am not a doctor, but it may depend on what your two-year-old son's doctor is prescribing the Benadryl for and how long that is forecast to go on. There may be other ways to manage whatever condition it is, or there might not be. One of my takes on parenting is that it is a medical research project. It is ok to look around at other sources and other treatments.
The main risks are tolerance developing eventually, dementia in older people, and some questionable studies saying they raise all-cause mortality which I don't really believe but can't 100% dismiss.
There are studies showing increased dementia use for long-term heavy use of anticholinergics like diphenhydramine. This is enough to make me keep my use to “very occasional.” But, like everything, it’s a cost-benefit calculation. Why does a 2-year-old need it every day?
For allergies, shouldn't you use a 2nd or 3rg gen antihistamine such as loratadine (claritin) or cetirizine? They cross the blood-brain barrier much less readily than diphenhydramine so they are able to reduce the effect of allergies on the eyes and respiratory tract without being a sedative.
My son has occasionally has a stuffy nose and puffy eyes. The doctor took a look, said that it was probably mild seasonal allergies, and told us to give him 6.25mg of diphenhydramine every night, and 1.25 mg of desloratadine every morning indefinitely. It sounds as though I should switch to a different antihistamine.
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.
Never tried any of these so idk whether they're any good but public funding strikes me as a way to avoid the economic perversities that result in $998 apps.
Disclaimer: I haven't tried any of these, so I can't really comment on effectiveness. Some of the options CVS (and others) are working with =
-Daylight (based on CBT to reduce anxiety/worry)
-Sleepio (CBT to help with poor sleep) [this is one of the OG's, so it would likely be more ubiquitous than the others]
-Torchlight (guidance for the different demands (including health) specific to caretakers)
-Naturally Slim, Vida, or WW (focused on weight loss and developing healthy eating habits)
-Whil (mindfulness, stress relief)
Like I said, can't comment much on efficacy. Just know that these tools will become more and more integrated over time.
There's also a company called Kick, which sends out propranolol to people who suffer from performance anxiety. I'm highly dubious that they ensure quality continuity of care before prescribing (as I would be for any service acting as a stopgap solution for psychiatric conditions), but it's been around for a few years and hasn't appeared to run into much trouble.
I used Sleepio free as part of a trial in the UK. It seemed to help somewhat with the quality of my sleep, although I only had minor sleep problems. The website is secretive about how much it costs. NICE (which evaluates treatments for use by the National Health Service) said it was 200 GBP for a 1-year subscription a few years back. The Apple Store says it costs 450 GBP now.
However, the yearly cost might not be the important figure. The core programme is only 6 weeks long and there seems to be a weekly/monthly subscription option, so you could work through that for a much lower fee, then cancel the subscription if it didn't help, or if it had fixed your problems and you didn't need it any more.
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
That would be one of those trade-offs. One the one hand, it works better if it's expensive. On the other hand, a lot of people won't be able to get it at all.
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.
To clarify: I have experience with Android, but not with Apple devices (I never owned one), to develop on them I would need more funds as I would need to buy iPhone and Mac.
But for standard apps (forms rather than cinematic quality MMORPG with micropayments, deep integration with random stuff) skills should be transferable.
For what I consider interesting: maps, especially OpenStreetMap based, cycling, making world better in general.
Definitely no: blockchain, deep learning and other buzzwords. I would be willing to work on that, but on commercial rates with premium for buzzwordness.
To clarify business model: maybe getting grant/funding would be a good alternative to commercial app?
Maybe I am overly pessimistic but I see no point in making paid app.
You can earn money, but you need to be lucky, have great way to promote app, have app to be gate to real content (Netflix) or make something malicious (see term "whale")
In considering it, the big costs are likely to be liability insurance, and "promotion". While it's unlikely such an app could cause problems, you'll still need some sort of legal protection. As for the promotion angle: either you get it through FDA (costly) at which point it can be prescribed, thus promoting to the target market, but leaving you with a big bill; you find a known IP willing to promote the app (Pokemon was planning some sort of sleep health app, no news recently though), but anything big enough to promote is going to want to avoid Liability, so you're back to FDA: perhaps company will eat the cost as part of a charity push? Finally, you could make your own, viral IP that incorporates the health into something people will seek out, the "edutainment" model. Very hard to pull off.
(This is my attempt to steelman expensive prescription apps.)
People demand free, and then value it at what they paid for it.
Give me a free app to treat insomnia, and I'll use it between and slap at the screen to get through it as fast as possible.
If I spend hundreds of dollars on it, or at least invest several hours into getting it, I will value it a lot more. I will pay attention to the application and listen to it carefully.
Also, being "the $900 app that we know works" may be the gateway to becoming "the $10 app that we know works."
Using grants from a socialised healthcare system is probably the best way to do it. You pay to develop the app once and then it's available to all of your citizens.
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...
One difference between CBT-i and fish oil is that you can just check if CBT-i works - are you sleeping better after using the $10 app than you were before? Sleep is noisy, and it's not trivial to check, but it's not impossible. I don't see how this is different from eg a self-help book, or a recommendation to use more salt when cooking a certain dish, or buying a car that promises to be a "smoother ride" than your last car.
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!
1. The person reaches a crisis point and emergency medical services become involved, which often involves the hospital making an appointment for you and/or helping you make one
1a. Depending on the mental illness in question, the criminal justice system might get involved and demand therapy
2. The mental illness goes into remission, and the person feels well enough to make an appointment. It doesn't help for the previous bout of the illness, but might help ameliorate the next one
3. Family/friends become concerned enough to make appointments for the person and force them to go
It is definitely more difficult than it ought to be, although I don't think there's many easy answers (one of the things I keep running into is a lack of providers in my area--there just aren't enough therapists, apparently). From personal experience, without a supportive family or friend network, the severely sick just...don't get help. The process is too onerous for them to manage.
Jebus. It is really pretty bad isn’t it. It is so complicated. I have a brother with a bipolar disorder. When he’s manic he feels he doesn’t need his meds. There is no way to force him to take them and there probably shouldn’t be.
Them there are all local no news stories of police taking some sort of drastic action against someone “who has been known to them for years”. If that person is lucky the drastic action is something short of having a lot of bullets put in them.
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.
I mean...yes, but as mentioned in this very article. _Scott's own practice is also doing this_. It's not a new or unique concept. It's just not very widespread.
Indeed, my noticing Scott saying he was doing something very similar was the reason I posted this - I figured that it might be beneficial to make sure different folks trying to concretely move forward a good, but not very widespread, idea knew about each other's efforts. Especially considering both are internet celebrities with large, partially overlapping audiences.
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
>Diphenhydramine, one of those risky, tolerance-building sleeping pills we want patients to avoid
>The main risks are tolerance developing eventually, dementia in older people, and some questionable studies saying they raise all-cause mortality which I don't really believe but can't 100% dismiss.
Oh yeah, dementia in older people. That's what it was. Is 68 considered older? I know it sure was when I was 18. Not so much now. Funny how that works.
Is not recognizing the generic equivalent of Benadryl a sign of dementia? How about not remembering the particulars of a NYT “Latest Thing Bad For You” article a couple of months after half reading.
I read somewhere that you are likely to develop tolerance to Benadryl after some ridiculously short period of time - I think there was a study that claimed it was 4 days - and then it's like taking a placebo. That is, it's likely to become useless as a sleep aid really fast (and long before it becomes harmful).
(I've had sleep issues, and I found some other antihistamines helpful with those long-term. However, the ones that were most helpful to me were prescription-only. Hydroxyzine and cyproheptadine have been awesome. Hydroxyzine is supposed to be very safe, and a lot of people take it long-term. Cyproheptadine's formula is close to tricyclic antidepressants, which are prescribed off-label as sleep aids - I've had a good experience with nortriptyline for this purpose, too. If you're not looking to get a prescription, you might find cetirizine helpful, but it looks like by far not everyone is lucky like that.)
Thanks for the information. I haven’t had any issue with developing a tolerance. I take one at bedtime and I’m out like a light. I am concerned with the studies showing a risk of dementia though. I’m 68 but I am not aware of any cognitive issues. Of course I see the problem with self diagnosing such a thing.
Welcome. If I was you, I'd check if Benadryl is doing more for you than a placebo would right now - who knows, maybe your sleep normalized a long time ago.
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.
I don't mean to shirk responsibility for the "$899" price tag phenomenon, but it really wasn't my choice, as a clinician who just wants to develop digital therapeutics. As you noted, innovation prior to wide-scale adoption is expensive, and it’s even more expensive in healthcare. The way grants work, and the way government budgets work, you can build an app but you can't sustain it. Tech moves too quickly, both with regards to how people use things as well as the constant upgrades and updates of the software your program is built on. Also, I think if we had more hard science on the moderators and mediators of their effectiveness, digital therapeutics would be less expensive to design and test. Anyway, eventually, my mentor and I agreed to talk to some venture capitalists. Then we began operating according to their paradigm.
There were also institutional pressures. Submitting a phase I SBIR proposal for a cannabis intervention app in 2017, my science officer at NIDA advised that the reviewers would be considering the worth of our proposal in light of the FDA's budding intentions to regulate the field. Not that anyone could say, at the time, what those intentions were, but we were on notice that it was officially a priority. Today I review tech-based grants at NIDA and reviewers routinely bring up FDA considerations; we're all fairly knowledgable about it now and if investigators haven't accounted for it, it's considered a serious shortcoming in their proposal.
Once the FDA stepped into the sandbox, investors seem to feel more sanguine about the significant risk that comes with playing in it. And yes, they've got to spend a ton up front for development and the clinical trials, all in a terrain that is much more wild-westy than the well-groomed burbs of big Pharma.
I think there's something else that "justifies" the price tag: engagement. We've implemented our pre-therapeutic device version of the program in a variety of contexts: direct-to-consumer, university, correction, DoD, healthcare, both as secondary prevention and as an intervention. Left to their own devices, people don't tend to use these (or any?) interventions the way their designed, but given the right support/supervision, they are much more likely to. No surprise there I suppose. I am hopeful that if a doctor specifically prescribes an app, patients will be more likely to engage with it, and that should increase its effectiveness. But then that is the $899 question, I suppose.
But again, this is all preliminary skirmishing to the big Waterloo that's coming. I wonder if we'll remember these conversations when people are routinely dialing up clinically validated exposure exercises on their VR headsets.
There’s a crossroads in the development of any non-drug therapeutic product: one road takes you down the non-RX path; the other means becoming involved with the FDA and their outdated and inflexible rules about what is a drug and what is a device, with the former designation costing multiples of the latter to get approved.
The way the VCs look at it, they’d always rather go down the FDA path if the likely costs of approval make sense in relation to the potential market as an RX product, especially if patent protection enables them to make sales at the highest price they can get during a multi-year protected period.
Faced with an app-based product with a large, international, insurance-funded market, they’d have been licking their lips at the prospect of getting $899 each for a product with a marginal cost of supply of around zero. It doesn’t require a blockbuster to quickly generate a billion dollar valuation at those kind of markups and I understand the temptation of finding yourself and your founding colleagues holding stock you’re told could be worth hundreds of millions that can be turned into cash at some time in the future.
Good luck to you - I hope your big payday arrives.
Hi Max. I'd say your assessment was pretty accurate, right up to the point when you wished me a big payday! If you're familiar with this world, it might not surprise you that only one person in our original company is getting that, and that's the guy who founded it. I'm hoping my "share" is large enough to pay off my student loans. And honestly, I'm not sure the tech that's needed to really make "digital therapeutics" truly effective will appear for another five years or so, by which time our company may well have expired. The real pay-off for me is that this is a mini-Kuhnian, dynamic space in which to develop interventions. Cheers.
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.
Insurance companies and ever declining reimbursements are a much bigger obstacle to people getting a properly scored PSG, at least in my neck of the woods. Good luck finding a sleep center that can still make a sleep study appointment before fall at this point.
Are you in the US? From my experience, many insurance plans will help cover a PSG (they'll often ask you get an HSAT first, of course) and the few clinics that I've dealt with don't have Covid backlog any more.
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).
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.
They even have CBT-i Coach!
And they have insomnia coach! for free! not only a treatment companion app!
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.
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 (~$600 month?)
I was hoping someone would say that! I think what you want is the aforementioned "Say Goodnight To Insomnia" book, but the really high-value thing would be for you to get in touch with Gregg Jacobs (the guy who wrote it) and see if he is on board with helping. Needless to say I would give so much free advertising to anyone who did this.
Right but how do I know you work? Got any independent studies to verify it works? What about my data and how qualified are your “coaches”?
I’ll take a hard pass…
Monthly fees boo. More monthly fees than netflix also boo.
I think their model included human coaching - not sure how you expect that to cost less than Netflix
By having an option to not have human coaching.
This is actually what I'm experimenting with in Dozy! Going fully automated is tricky though, lots of edge cases & unique obstacles (some discussed elsewhere in these comments)
Alternatively, you could just have a whole bunch of people randomly working on different parts in the "bazaar" sense of "the cathedral and the bazaar".
I was going to suggest you make a github repository and see if anyone shows up, but then I decided to make one myself here: https://github.com/mwacksen/iCBTi . So there's your Schelling point, knock yourselves out.
I'm happy to give control of it away as soon as possible and don't really intend to do any of the programming work myself as I have other responsibilites.
Would you be taking investment at some point? I’m interested
Buy the 899$ app and rip it off. You only have to sell a 900 1$ copies of your knock-off to make a profit.
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.
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.
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?
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.
Is it really possible to regulate an app as a "medical device"? It seems to me that there are First Amendment issues with that.
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)
Hey! You can reach me at sam@dozy.health. :)
Why do you think he wrote this post? ;)
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
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.
fair enough, I’m willing to accept that I might be overestimating how accessible it would be
+1. Most people don’t know what a bittorrent is and would probably be afraid of trying it.
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.
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.
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.
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.
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.
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.
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.
I can only think of Germany like that. They are an outlier in this.
that happened to me and I live in the us
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.
Thanks, this is helpful!
I have yet to have any patient have a long-lasting result from any app. Except the Healthy Minds app released by the Center for Healthy Minds at the University of Wisconsin. It is a comprehensive engaging program for mental and emotional well-being. And it is free. https://hminnovations.org/meditation-app
I loaded this onto my iPhone and have poked around a bit it looks promising. Good for UW!
omg - thanks so much
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.
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)
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."
...You thought "someone should make an app for this" in 1998?
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...
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.
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.
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.
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).
Lullabies and bed time stories are a thing for a reason.
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.
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.
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).
> 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.
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
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)
And this one is on its way, and developed by an EA: https://www.dozy.health/
I should have known someone would have figured out this was important before me! I'll get in contact.
Thanks for the mention!
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.)
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.
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.
No, they don’t.
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.
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.
Are EEG headbands useful? I hadn't heard of them
Dreem recently stopped selling their headsets to consumers :'(
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'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.
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?
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.
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.
Thanks for the tip on All Day Chemist.
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.
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.
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.
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.
Do you live in the States?
Yes, hence my confusion.
If it requires a prescription, isn't it by definition a controlled substance?
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.
I assume you're aware that Fluticasone is available OTC now and dirt cheap, right? No Salmeterol, but it may be better than nothing.
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).
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.
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.
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.
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).
"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.
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.
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.
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).
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.
ok I'll ask does a torrent tracker exist for prescription apps. if not it should.
Can you torrent apps? Serious question, I know zero about mobile as a platform.
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.
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.
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.
Well if your torrenting an app and side loading your definitely not getting it from a legitimate source.
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.
If you want to know whether your copy is authentic, you hash the .apk and compare it against a legitimate copy.
How do you go about getting the hash of the legitimate copy?
my private tracker has loads of mobile apps. its just usually for specialized stuff people set up more super secrect trackers.
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).
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.
Be aware that answering this question by posting a link to such a torrent tracker (assuming one exists) might be ill-advised.
Why is that? Last I checked, only the act of torrenting itself is legally regulated, at least in the US.
It's entirely possible that it's against Substack's ToS.
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.
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.
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.
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).
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.
I take Xyrem. Yes, it is patented. It's not especially expensive to manufacture. When I had no health insurance the manufacturer was happy to put me in a "coupon program" that allowed me to buy it for. . . I think it was about $35/month? Maybe as much as $50? The thousands of $ of sticker price is strictly for soaking Medicaid/care and negotiating with insurers.
I think it's worth looking into, but personally I've developed a lot of tolerance to Xyrem's hypnotic effects. It still helps my sleep quality a ton, but it used to knock me out swiftly and now it really doesn't.
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 ?
Here's a good sample study - https://pubmed.ncbi.nlm.nih.gov/28472528/ - where in-person has effect size of 0.89 and online has effect size of 0.53 (other studies are more optimistic about online being equally good).
And here's an example study - https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/217394/ioi30727.pdf of CBTi beating medication, although it's by some CBTi fans and potentially biased.
Thanks, much appreciated.
While there's not much motive for exclusively harmful apps, there's plenty that could be argued to cause harm in search of profit; timed events on "gatcha" games are often such that you can either spend excessive amounts of time, including during specific periods (aka set an alarm to wake up at midnight to grab those rewards) or you can spend increasingly worrying amounts of money.
"Or is there some process that prevents malicious apps from working too well ?"
All an app can do is recommend a course of action to its user. The user has to decide to follow the advice, and continue to do so even as their insomnia worsens. There's nothing to stop someone from creating an app that tells the user to drink a lot of coffee before bedtime, set their alarm to wake them up every hour to do twenty minutes of exercise, and sleep in to noon, but its advice would be unlikely to be adopted.
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.
Are there studies showing that more expensive placebos have stronger effect?
https://n.neurology.org/content/84/8/794.short?rss=1
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.
You could do it. I don't even think you have to pretend it's a meditation app. Just say it's a CBT-i app that "supports healthy sleep". I agree this is the right call, commenters have pointed me to ones that are trying to do this, and I support them.
There's a reason why a lot of things have the phrase "Not intended to Diagnose, Treat, Prevent or Cure any disease". It's (mostly) a waiver of FDA regulation.
"Insomnia" is a medical condition. Can't mention it.
"Healthy sleep" or "restful night" are vague enough that they avoid regulation.
Right, I totally get that. That's why you need a lawyer to take a look and make sure you haven't said any taboo words.
My larger point is, so what? This seems like nothing more than a small tax that you can pay and move forward.
Or how about selling it as a worship of Hypnos, the Greek god of sleep, and claim religious exemption from regulation?
The point is that no exemption from regulation is needed. Anyone can create an app without FDA regulation, as long as they don't make a certain class of medical claims.
Try SSRI. I had severe insomnia and it has worked for 3 decades. Risk reward so good that it should be first line
This works well if your insomnia is due to anxiety or depression, not as good otherwise.
I tried an SSRI and it activated some latent bipolar, cause a sever manic episode that lasted for months bc I didn't realize that's what it was at the time. So there's your downside risk.
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?
I'm not going to say it's impossible in the US, but getting from here to there in the US is at least very difficult.
So now I notice yet another problem with English. "Impossible" can mean completely impossible, or it can mean that there's no clear path from here to the goal.
People don't exaggerate in other languages?
I'm comparing English to a hypothetical language in which it would be easier to make things clear.
"Intractable" seems close to what you want.
What is effective access to mental health like in other countries? A friend in Canada has a child with Autism. Officially, therapy for the child is provided by the government. In-practice, the waiting list is so long that they would miss out on most of the developmental benefits by the time they could get an appointment. And the amount of services would be far less than the child needs. So they have to pay cash to see a private provider.
In Slovakia, the waiting list to get a child diagnosed with autism is a few months; less if you are willing to pay, more if you want it paid by insurance. I have no idea what services are provided and under what circumstances.
"Like it is very soon and gloom"
The usual expression is "doom and gloom".
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.
+1
Counterpoint: I discovered SSC via "Untitled", and am very glad that Scott at long last seems to feel free to write about online culture again. I'm sure these rants about the US medical system are useful in the local context, but to an outsider such discussions are like listening to an argument about how the Titanic's deck chairs ought to be arranged; i.e., only interesting because Scott is such an engaging writer. If he never blogged about psychiatry again that would be just fine with me.
Echoing what others have said, the number of comments is a poor metric as to how useful a post is. Likes is at least somewhat useful; although one can argue that it isn't a perfect metric, it's at least reasonably related to expressing sentiment.
Nothing wrong with stating your opinion, but look at the number of likes and comments on this vs the culture war. You're in a solid minority.
Also, the latest culture war post wasn't Scott's best, but "I can tolerate everyone except the outgroup" is an all time great piece of writing and insight.
I agree partly with both you and the OP. I found this post a delight to read and less muddy than the last couple of online culture ones. But at least as far as likes and comments are concerned, you're right - very much a minority.
One thing about the "I can tolerate everyone.." essay is that it wasn't tied down to the object level stuff. It was a post for the ages, and for me, vastly better and more interesting as a result.
This is the entire problem with social media. Optimization of engagement-based metrics incentivizes material that provokes outrage and/or applause choruses, rather than being informative. That is fine if you explicitly want to be a Culture Warrior, but Scott has never wanted to be that and avoided these topics on purpose to avoid giving himself bad incentives. It would be unfortunate, to me at least, if the fact that his reach has expanded and the newer generation of commenters who are coming here mostly because they ran out of other places where they could freely say verboten things turns him into a Culture Warrior to please those commenters.
Remember your goals, Scott. Maybe they've changed over the years, but your purpose for writing and sharing that writing didn't use to be "maximally please whatever audience I end up with."
Acknowledging that you have goals not explicitly related to writing that can be helped by a revenue stream possibly generated by writing that does nothing more than maximally please some plurality of your audience.
Scott has an old essay where he says that he gets the most engagement (and if he sold ads, the most money -- this is largely irrelevant as he sells a giant bundle of everything now) on his CW posts and the least on his "here is how to save your mental health" posts, even though he would prefer it the other way in terms of saving mankind.
Scott is an expert in mental health and a clear and comprehensive writer. If he says something about mental health, it's either irrelevant to me or useful to me, but in either way there's not likely to be much for me to comment about except some variation on "+1". Which isn't the culture here, or at least wasn't on SSC and we mostly liked it that way.
Culture War stuff, may not be helpful but it's probably not irrelevant and there's much more scope for commentary by amateurs like myself.
Scott can have a little culture war as a treat. (imo)
I can see the time-management point which I think you're trying to make behind that sentence, but I think that's a very dangerous framing and actively recommend against anyone internalizing it.
As a longtime reader and recent subscriber, I really liked both posts. Scott, please keep writing about psychiatry and the culture war!
Scott's interests overlap with my own quite a bit, but he's a good enough writer that I enjoy getting a new post in my inbox even when the topic isn't something I would otherwise choose to read about.
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.
Is there not consumer protection legislation in the US to make this sort of bait and switch (even if inadvertent) illegal?
There are (or were) several bills moving around the Senate to make "surprise billing" illegal in the US, but I don't know what their status is. I know insurance companies themselves are also working to make surprise billing not happen, because usually it makes them look like assholes (The stereotypical surprise billing scenario is: you go to a hospital that's in-network to have surgery performed by an in-network surgeon, but unbeknownst to you--because how would you ever find out?--the anesthesiologist on the surgery team is *not* in-network, and you suddenly have thousands of dollars of expenses not covered by your insurance).
I would assume they would apply to the scenario where you're unknowingly assigned to a therapist who is not in-network.
It's not just "how would you find out"
You *can't* find out. I *specifically asked* if the anesthesiologist would be "in network" for me when I had some elbow surgery done, and NOBODY WOULD COMMIT TO TELLING ME THAT THEY WOULD BE.
(The most anyone would say was that the facility I was having it done in and the doctor who was doing it would be)
(And as it turned out, they were. But I have excellent and wide-network insurance)
Interesting. Never realised (I'm looking at this from outside) that the US healthcare system was that atomised. I assumed your contract for an operation would be with a single provider who dealt eith sub-contracting required personnel. I'd suggest that there's a lot of convenience and possibly savings to be had by reducing the number of billing points.
This also has an interesting implication in the UK: debates about the future of our health system are bedevilled by a tendency to assume bad faith in the other side and to portray any proposal for change is a move towards a dysfunctional caricature of the US system (or from my own side of the debate, a move towards some fantasy of socialism that will damage people - it's a frustrating experience finding sensible opinions). Yet the debate still sees the hospital as the billing unit, not the doctor. It may be that those portraying a cartoon scenario of 'US'-style private healthcare providers have less knowledge of that system than they like to portray (it wouldn't be a shock: they generally seem ignorant of the other 200-odd healthcare systems in the world, so why expect knowledge about the one they focus on?).
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.
This is definitely a challenge that I'm facing trying to make a primarily automated program. The steps are pretty straightforward, but many people have unique obstacles that arise. Currently using a human-supported system to address this, with the goal of building in more support and edge cases as I discover overlaps.
(I'm building www.dozy.health)
If you want me to stress test your app, let me know. I'm a former software developer, and I'm good at generating complaints about UI and general usability.
Hey Kat! There's a lot of low-hanging fruit I'm currently working through re: usability, but if you shoot me an email at sam@dozy.health I'd love to circle back in a few months once that feedback would be more useful. :)
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).
> 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.
Is it still true? AFAIK nowadays they typically sell ones where some cores are with defects (and some defects are expected).
So they try to produce 8 core processor, ones where 2 cores failed get them disabled and are sold as 6 core processor.
I think some storage is deliberately kneecapped to however many TB. As are tesla batteries.
And the BMW 330i is just a BMW 320i with the cripple switch turned off and a $10K higher price tag.
Still true, though what you described a minor factor. A lot of hardware also detects how premium its variant is and disables features in the driver.
Ah, yes. The 486 with the disabled math coprocessor.
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?
Well, I don't know if you should be worried, I am not a doctor, but it may depend on what your two-year-old son's doctor is prescribing the Benadryl for and how long that is forecast to go on. There may be other ways to manage whatever condition it is, or there might not be. One of my takes on parenting is that it is a medical research project. It is ok to look around at other sources and other treatments.
The main risks are tolerance developing eventually, dementia in older people, and some questionable studies saying they raise all-cause mortality which I don't really believe but can't 100% dismiss.
There are studies showing increased dementia use for long-term heavy use of anticholinergics like diphenhydramine. This is enough to make me keep my use to “very occasional.” But, like everything, it’s a cost-benefit calculation. Why does a 2-year-old need it every day?
For allergies, shouldn't you use a 2nd or 3rg gen antihistamine such as loratadine (claritin) or cetirizine? They cross the blood-brain barrier much less readily than diphenhydramine so they are able to reduce the effect of allergies on the eyes and respiratory tract without being a sedative.
Thank you for your replies, everyone!
My son has occasionally has a stuffy nose and puffy eyes. The doctor took a look, said that it was probably mild seasonal allergies, and told us to give him 6.25mg of diphenhydramine every night, and 1.25 mg of desloratadine every morning indefinitely. It sounds as though I should switch to a different antihistamine.
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.
Please recommend the good psychiatry-related ones to me. I don't know enough about them and I'm trying to get a list.
https://www.nhs.uk/apps-library/filter/?categories=Mental%20health,Sleep
Never tried any of these so idk whether they're any good but public funding strikes me as a way to avoid the economic perversities that result in $998 apps.
Yes except I can't figure out how to get any of them. I think they might have somehow made it only available by UK prescription.
Disclaimer: I haven't tried any of these, so I can't really comment on effectiveness. Some of the options CVS (and others) are working with =
-Daylight (based on CBT to reduce anxiety/worry)
-Sleepio (CBT to help with poor sleep) [this is one of the OG's, so it would likely be more ubiquitous than the others]
-Torchlight (guidance for the different demands (including health) specific to caretakers)
-Naturally Slim, Vida, or WW (focused on weight loss and developing healthy eating habits)
-Whil (mindfulness, stress relief)
Like I said, can't comment much on efficacy. Just know that these tools will become more and more integrated over time.
There's also a company called Kick, which sends out propranolol to people who suffer from performance anxiety. I'm highly dubious that they ensure quality continuity of care before prescribing (as I would be for any service acting as a stopgap solution for psychiatric conditions), but it's been around for a few years and hasn't appeared to run into much trouble.
I used Sleepio free as part of a trial in the UK. It seemed to help somewhat with the quality of my sleep, although I only had minor sleep problems. The website is secretive about how much it costs. NICE (which evaluates treatments for use by the National Health Service) said it was 200 GBP for a 1-year subscription a few years back. The Apple Store says it costs 450 GBP now.
However, the yearly cost might not be the important figure. The core programme is only 6 weeks long and there seems to be a weekly/monthly subscription option, so you could work through that for a much lower fee, then cancel the subscription if it didn't help, or if it had fixed your problems and you didn't need it any more.
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
That would be one of those trade-offs. One the one hand, it works better if it's expensive. On the other hand, a lot of people won't be able to get it at all.
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.
You're likely aware, but Scott did a great write-up on melatonin a few years ago. Most people take way too high a dose: https://www.lesswrong.com/posts/E4cKD9iTWHaE7f3AJ/melatonin-much-more-than-you-wanted-to-know
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.
To clarify: I have experience with Android, but not with Apple devices (I never owned one), to develop on them I would need more funds as I would need to buy iPhone and Mac.
But for standard apps (forms rather than cinematic quality MMORPG with micropayments, deep integration with random stuff) skills should be transferable.
For what I consider interesting: maps, especially OpenStreetMap based, cycling, making world better in general.
Definitely no: blockchain, deep learning and other buzzwords. I would be willing to work on that, but on commercial rates with premium for buzzwordness.
To clarify business model: maybe getting grant/funding would be a good alternative to commercial app?
Maybe I am overly pessimistic but I see no point in making paid app.
You can earn money, but you need to be lucky, have great way to promote app, have app to be gate to real content (Netflix) or make something malicious (see term "whale")
In considering it, the big costs are likely to be liability insurance, and "promotion". While it's unlikely such an app could cause problems, you'll still need some sort of legal protection. As for the promotion angle: either you get it through FDA (costly) at which point it can be prescribed, thus promoting to the target market, but leaving you with a big bill; you find a known IP willing to promote the app (Pokemon was planning some sort of sleep health app, no news recently though), but anything big enough to promote is going to want to avoid Liability, so you're back to FDA: perhaps company will eat the cost as part of a charity push? Finally, you could make your own, viral IP that incorporates the health into something people will seek out, the "edutainment" model. Very hard to pull off.
(This is my attempt to steelman expensive prescription apps.)
People demand free, and then value it at what they paid for it.
Give me a free app to treat insomnia, and I'll use it between and slap at the screen to get through it as fast as possible.
If I spend hundreds of dollars on it, or at least invest several hours into getting it, I will value it a lot more. I will pay attention to the application and listen to it carefully.
Also, being "the $900 app that we know works" may be the gateway to becoming "the $10 app that we know works."
Using grants from a socialised healthcare system is probably the best way to do it. You pay to develop the app once and then it's available to all of your citizens.
Maybe it would be even cost-effective for insurance company to create a replacement?
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.
Pro: plenty of time to develop it at 3AM when you can't sleep
Con: coders are just about the last people i'd trust to look after my circadian cycle
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...
One difference between CBT-i and fish oil is that you can just check if CBT-i works - are you sleeping better after using the $10 app than you were before? Sleep is noisy, and it's not trivial to check, but it's not impossible. I don't see how this is different from eg a self-help book, or a recommendation to use more salt when cooking a certain dish, or buying a car that promises to be a "smoother ride" than your last car.
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.
Congrats on your work on Reset and Reset-O - I've heard some exciting things about them.
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!
From personal experience, one of several paths:
1. The person reaches a crisis point and emergency medical services become involved, which often involves the hospital making an appointment for you and/or helping you make one
1a. Depending on the mental illness in question, the criminal justice system might get involved and demand therapy
2. The mental illness goes into remission, and the person feels well enough to make an appointment. It doesn't help for the previous bout of the illness, but might help ameliorate the next one
3. Family/friends become concerned enough to make appointments for the person and force them to go
It is definitely more difficult than it ought to be, although I don't think there's many easy answers (one of the things I keep running into is a lack of providers in my area--there just aren't enough therapists, apparently). From personal experience, without a supportive family or friend network, the severely sick just...don't get help. The process is too onerous for them to manage.
Jebus. It is really pretty bad isn’t it. It is so complicated. I have a brother with a bipolar disorder. When he’s manic he feels he doesn’t need his meds. There is no way to force him to take them and there probably shouldn’t be.
Them there are all local no news stories of police taking some sort of drastic action against someone “who has been known to them for years”. If that person is lucky the drastic action is something short of having a lot of bullets put in them.
At times it seems like an unsolvable problem.
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.
I mean...yes, but as mentioned in this very article. _Scott's own practice is also doing this_. It's not a new or unique concept. It's just not very widespread.
Indeed, my noticing Scott saying he was doing something very similar was the reason I posted this - I figured that it might be beneficial to make sure different folks trying to concretely move forward a good, but not very widespread, idea knew about each other's efforts. Especially considering both are internet celebrities with large, partially overlapping audiences.
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
>Diphenhydramine, one of those risky, tolerance-building sleeping pills we want patients to avoid
>The main risks are tolerance developing eventually, dementia in older people, and some questionable studies saying they raise all-cause mortality which I don't really believe but can't 100% dismiss.
Oh yeah, dementia in older people. That's what it was. Is 68 considered older? I know it sure was when I was 18. Not so much now. Funny how that works.
Is not recognizing the generic equivalent of Benadryl a sign of dementia? How about not remembering the particulars of a NYT “Latest Thing Bad For You” article a couple of months after half reading.
Hmmm….
I read somewhere that you are likely to develop tolerance to Benadryl after some ridiculously short period of time - I think there was a study that claimed it was 4 days - and then it's like taking a placebo. That is, it's likely to become useless as a sleep aid really fast (and long before it becomes harmful).
(I've had sleep issues, and I found some other antihistamines helpful with those long-term. However, the ones that were most helpful to me were prescription-only. Hydroxyzine and cyproheptadine have been awesome. Hydroxyzine is supposed to be very safe, and a lot of people take it long-term. Cyproheptadine's formula is close to tricyclic antidepressants, which are prescribed off-label as sleep aids - I've had a good experience with nortriptyline for this purpose, too. If you're not looking to get a prescription, you might find cetirizine helpful, but it looks like by far not everyone is lucky like that.)
Thanks for the information. I haven’t had any issue with developing a tolerance. I take one at bedtime and I’m out like a light. I am concerned with the studies showing a risk of dementia though. I’m 68 but I am not aware of any cognitive issues. Of course I see the problem with self diagnosing such a thing.
Welcome. If I was you, I'd check if Benadryl is doing more for you than a placebo would right now - who knows, maybe your sleep normalized a long time ago.
Good idea. I’ll give it a try. Thanks again
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.
Can I ask what drove you to stop offering the programs for free and start redesigning them as digital therapeutics?
I don't mean to shirk responsibility for the "$899" price tag phenomenon, but it really wasn't my choice, as a clinician who just wants to develop digital therapeutics. As you noted, innovation prior to wide-scale adoption is expensive, and it’s even more expensive in healthcare. The way grants work, and the way government budgets work, you can build an app but you can't sustain it. Tech moves too quickly, both with regards to how people use things as well as the constant upgrades and updates of the software your program is built on. Also, I think if we had more hard science on the moderators and mediators of their effectiveness, digital therapeutics would be less expensive to design and test. Anyway, eventually, my mentor and I agreed to talk to some venture capitalists. Then we began operating according to their paradigm.
There were also institutional pressures. Submitting a phase I SBIR proposal for a cannabis intervention app in 2017, my science officer at NIDA advised that the reviewers would be considering the worth of our proposal in light of the FDA's budding intentions to regulate the field. Not that anyone could say, at the time, what those intentions were, but we were on notice that it was officially a priority. Today I review tech-based grants at NIDA and reviewers routinely bring up FDA considerations; we're all fairly knowledgable about it now and if investigators haven't accounted for it, it's considered a serious shortcoming in their proposal.
Once the FDA stepped into the sandbox, investors seem to feel more sanguine about the significant risk that comes with playing in it. And yes, they've got to spend a ton up front for development and the clinical trials, all in a terrain that is much more wild-westy than the well-groomed burbs of big Pharma.
I think there's something else that "justifies" the price tag: engagement. We've implemented our pre-therapeutic device version of the program in a variety of contexts: direct-to-consumer, university, correction, DoD, healthcare, both as secondary prevention and as an intervention. Left to their own devices, people don't tend to use these (or any?) interventions the way their designed, but given the right support/supervision, they are much more likely to. No surprise there I suppose. I am hopeful that if a doctor specifically prescribes an app, patients will be more likely to engage with it, and that should increase its effectiveness. But then that is the $899 question, I suppose.
But again, this is all preliminary skirmishing to the big Waterloo that's coming. I wonder if we'll remember these conversations when people are routinely dialing up clinically validated exposure exercises on their VR headsets.
I have some knowledge of this issue.
There’s a crossroads in the development of any non-drug therapeutic product: one road takes you down the non-RX path; the other means becoming involved with the FDA and their outdated and inflexible rules about what is a drug and what is a device, with the former designation costing multiples of the latter to get approved.
The way the VCs look at it, they’d always rather go down the FDA path if the likely costs of approval make sense in relation to the potential market as an RX product, especially if patent protection enables them to make sales at the highest price they can get during a multi-year protected period.
Faced with an app-based product with a large, international, insurance-funded market, they’d have been licking their lips at the prospect of getting $899 each for a product with a marginal cost of supply of around zero. It doesn’t require a blockbuster to quickly generate a billion dollar valuation at those kind of markups and I understand the temptation of finding yourself and your founding colleagues holding stock you’re told could be worth hundreds of millions that can be turned into cash at some time in the future.
Good luck to you - I hope your big payday arrives.
Hi Max. I'd say your assessment was pretty accurate, right up to the point when you wished me a big payday! If you're familiar with this world, it might not surprise you that only one person in our original company is getting that, and that's the guy who founded it. I'm hoping my "share" is large enough to pay off my student loans. And honestly, I'm not sure the tech that's needed to really make "digital therapeutics" truly effective will appear for another five years or so, by which time our company may well have expired. The real pay-off for me is that this is a mini-Kuhnian, dynamic space in which to develop interventions. Cheers.
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.
What condition does it treat?
Happiness ?
LOL
That _did_ occur to me too when first reading this post!
Some games seem pretty addictive too – it's kind of an interesting (if, ultimately, horrifying) alternate universe to imagine!
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.
Insurance companies and ever declining reimbursements are a much bigger obstacle to people getting a properly scored PSG, at least in my neck of the woods. Good luck finding a sleep center that can still make a sleep study appointment before fall at this point.
Source: orders a PSG most days
Are you in the US? From my experience, many insurance plans will help cover a PSG (they'll often ask you get an HSAT first, of course) and the few clinics that I've dealt with don't have Covid backlog any more.
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.