(2021-05-12) Alexander Welcome To The Terrible World Of Prescription-only Apps

Scott Alexander: Welcome To The Terrible World Of Prescription-Only Apps. Trouble falling asleep? Guidelines recommend you try Cognitive Behavioral Therapy For Insomnia (CBT-i). The journals are full of articles begging doctors to use CBT-i instead of potentially-dangerous sleeping pills. Doctors rarely comply: getting patients CBT-i is hard. The usual sound bite is that “there are 60 million people with insomnia in the US but only 75 licensed CBT-i therapists.” What can you do? Not much. Late last year, Pear Therapeutics released a CBT-i app (formerly “SHUT-i”, now “Somryst”) which holds the patient’s hand through the complicated CBT-i process. Studies show it works as well as a real therapist, which is very well indeed. There’s only one catch: you need a doctor’s prescription.

In theory, an app is a great solution to accessibility issues

Fredrik de Boer, who has more resources and know-how than most people, describes his experience trying to get a therapist... And when you do get a professional, half the time they tell you that you just need to lose weight / quit marijuana / find Jesus / find wokeness, and refuse to treat you until you qualify as virtuous enough to deserve their help.

Therapy apps are a perfect solution to this problem. Except that if you make people go to a professional to get a prescription to use the app, you’re kind of clutching defeat from the jaws of victory.

It’s hard and expensive to get a product into the official medical system.

By the time you’ve done all those things, you’ve spent a lot of money. And also you have a sort of monopoly, in that you’re the only company whose fish oil is FDA approved and able to interface with organizations who will only work within the regular medical system (eg insurance). So you increase the price by 30x.

Pear Therapeutics created a CBT-i app, put in the work to make it official, and now they’re selling it for $899.

My guess is that prescription-gating is necessary because it’s the last step in the process of transforming it from an app ($10 price tag) to “digital therapeutics” ($899 price tag)

The good news is, Somryst has partnered with telemedicine provider UpScript. I know nothing about UpScript, but I suspect they are a rubber-stamping service.

Who killed the democratization of mental health?

A few years ago, I was so optimistic about therapy apps

But CBT-i is the killer app here, and people have spent the last few years bungling it. And now when something finally comes out that I can have confidence in, it’s designed to replicate all the worst features of the old system. Why?

I can’t really blame the FDA here. Their regulatory guidelines for medical apps are clear as mud, but I think they would let people make non-prescription CBT-i courses. You would have to replace claims about “treating insomnia” with weasel language like “supports healthy sleep”, but you could do it.

And I’m philosophically opposed to blaming Pear Therapeutics, the company behind Somryst. If you let a for-profit company charge $899 for an app, of course they’ll be all over that.

I think I mostly blame the US health care system. Patients don’t pay for any of their own care, the government regulates health insurance companies to the point of effectively deciding what they have to cover, and nobody is allowed to exercise common sense at any point.

This is part of why I am dedicating my life to building an alternative, non-insurance-based system of mental health care.

I secondarily blame all the people who should have made the $10 app but didn’t. There is just an appalling shortage of freely available CBT-i material right now. This person sells a $50 CBT-i course/workbook, and I hear it’s pretty good.

Right now, in the heady youth of the industry, I feel angry about prescription-gated apps that cost $899. CBT-i is so good, and so important, and we were so close to being able to make it accessible to everyone. Then we snatched defeat from the jaws of victory. Getting your CBT-i will remain as financially and logistically inaccessible as everything else in medicine. Diphenhydramine, one of those risky, tolerance-building sleeping pills we want patients to avoid, is sold over-the-counter at every drugstore for a few cents a pill.

So do something with your anger while it’s hot. In a few years, $899 prescription-gated apps will seem good and normal.

Highlights From The Comments On CBT-i Apps

Several people in the comments pointed out existing lower-cost CBT-i apps!...

Someone mentioned the creator of Dozy (Sam Stowers) was an effective altruist and connected to me through the social graph, so I reached out. He says he's a CS student who dropped out to work on "creat[ing] more accessible & impactful mental health treatments, with insomnia as a starting point".

• see this: I think insomnia has a burden of ~130 million QALYs (Quality-Adjusted Life Years) annually (compare to malaria's 55 million for scale). Furthermore, I think a (technically simple) implementation of a proven therapy intervention can drastically reduce the above number.

Honorary mention to Say Good Night To Insomnia, which is a CBT-i book rather than an app; it got rave reviews from several commenters. It's written by a world expert and probably the most trustworthy source here. (Choose your Medium)

According to UpToDate ($) "CBT for insomnia (CBT-I) is preferred as first-line therapy for chronic insomnia in most patients

Argos writes: 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.

See also comments from the clinical director of a digital therapeutics company, the libertarian Cato Institute’s Director of Health Policy Studies, and a former employee of Pear Therapeutics.