Insomnia with an EA lens: Bigger than malaria?

by samstowers 3 min read3rd Mar 202014 comments


Introduction & overview

Hi all! I'm Sam, a US-based web developer & designer. My apologies for the clickbait title, but some basic research has led me to think that insomnia is a neglected, burdensome problem on a global scale with a tractable solution. Specifically, based on assumptions laid out below, I think insomnia has a burden of ~130 million QALYs lost 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. I'm building a project to attempt the very thing ( and am looking for some EA aligned team members.

Insomnia annual QALY loss estimation

Estimates on the prevalence of insomnia vary widely, according to definition and methodology. According to one 2008 paper, numbers range from 10% to 40%, and "Given all the information available, the prevalence of insomnia symptoms may be estimated at 30% and specific insomnia disorders at 5–10%".

A 2018 paper estimated the QALY burden of insomnia at 5.6 million QALYs per year. This estimate only counts quality of life effects, not length of life, so the real number may well be larger than this. Its methods are not extremely robust but they end up with an insomnia prevalence of 28%, which is close to the number from the previous paper.

If we assume the QALY burden of insomnia is similar among global populations (may or may not be true), then we can expand the US number to ballpark the global annual burden of insomnia at 130,000,000 QALYs lost per year.

QALY burden in perspective

A Gates Foundation-funded report in 2015 estimated the global DALY burden of malaria at 55M QALYs per year. All cardiovascular diseases together were estimated at 347M/year, depressive disorders at 54M/year, drowning at 17M/year, and interpersonal violence at 21M/year. By these estimates, insomnia has a comparably serious burden to some major issues facing humanity.

The report doesn't have insomnia as one of their 315 evaluated conditions, so I can't get a direct number for accuracy, but I can provide some estimates. For example, the report says that depressive disorders have a burden of 55M QALYs/year. If we divide that down to the US population, that's 2.3M QALYs/year. This is more conservative than the 2018 insomnia paper, which estimates depression's impact at 4M/year in the US. Same order of magnitude, but a bit less than twice what the Gates report estimated. Their anxiety burden estimate differs by a similar amount.

If we construct an (informal, statistically invalid) confidence interval for this, it might range from 30M QALYs/year to 200M QALYs/year, again depending on definitions and methods.

Tractability of insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-i) is a therapy treatment that takes 4-10 weeks, has 2-3x the impact of sleeping pills, and whose benefits are essentially permanent. We have a handful of meta-analyses to show that Cognitive Behavioral Therapy for Insomnia (CBT-i) is effective for nearly all sleep indicators - it speeds sleep onset, reduces nightly wakefulness, improves quality, reduces daytime symptoms. It works even in cases where the insomnia is comorbid with other medical or psychiatric issues.

The problem with CBT-i is it's currently inaccessible. In the entire United States, where ~60M people deal with insomnia annually, there's a total of ~250 certified providers of CBT-i. To make matters worse, many of them are researchers, or not accepting new patients, and neither patients nor doctors are aware of the treatment in the first place. This is especially shocking considering it's usually the first-line treatment recommended by relevant governing bodies. The problem is similar in other developed countries, and like other mental health treatments, completely lacking in developing countries.

Researchers who've studied the issue are excited by the potential of digital CBT-i (dCBT-i), but the issue encountered with existing solutions is a lack of personalization. It's like trying to get surgery done on yourself by taking a class on how to do surgery. Researchers suggest that further personalization options and custom treatment could result in much better retention and outcomes.

Such a digital solution would be extremely scalable, with a primarily automated treatment system supported by human attention to answer questions and reduce churn. In principle, the treatment could even be delivered over SMS.

Long story short, despite its non-communicable nature, I (and researchers in the field, plus my sleep therapist advisors) believe it's possible to dramatically reduce the DALY burden of insomnia by creating effective tools and rapidly improving them with RCT-type experiments.

Introduction to Slumber (an attempted solution)

Hence, why I'm working on my current project, Using my existing design & development expertise, I'm creating an app that does exactly what I talked about above - automated, personalized treatment, ideally like a sleep therapist in your pocket (with human support).

Have only run a few people through my prototype so far but initial results are mostly on par with the meta-analysis on human therapists. One user went from moderate severity insomnia to no clinically significant insomnia within 6 weeks (sleep efficiency 60% > 94%, sleep duration 5.6 hours > 6.6 hours).

I'm not profit driven on this, so am looking for alternative legal structures for maximum positive impact (such as a steward ownership structure). Have been working on it unpaid full-time since May/June 2019, living extremely cheaply.

Some asks

First, is this estimate / are these assumptions reasonable to you? I don't have much formal EA research experience, so would love to know if I'm missing anything obvious.

Second, I'm actively looking for cofounders on this project to help me speed up development & iteration. If you're a mobile developer who's impact-motivated (and possibly interested in sleep science), or know anyone who fits that description, please reach out - am ready to offer an equal equity split (with cliff etc) to the right person(s).

Finally, legal structures - is a startup the best structure to scale quickly & thoroughly address the problem? Are there charity or non-profit structures that would work? I'd like to be paid eventually but will donate most of what I make anyway (already took the Founders Pledge, will likely raise my pledge later), so personal financial return is not a primary concern.


Prevalence of insomnia and insomnia burden:

2008, Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation.

2018, Insomnia and Impaired Quality of Life in the United States (no public full text, message me and I can send it to you).

2015, Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

Efficacy of CBT-i:

2018, Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis.

2015, Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis.

2015, Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis.

2019, Digital Delivery of Cognitive Behavioral Therapy for Insomnia.