samstowers

samstowers's Comments

Insomnia with an EA lens: Bigger than malaria?

Thanks for your reply! I agree, CBT-i is super promising and I'm all about finding effective ways to spread it.

Almost got confused as to which Overcoming Insomnia book before I added the author title - first result is a $50 therapist manual lol.

I think it's possible to treat yourself this way if you're decently analytical (as I suspect most visitors in this forum to be), but quite difficult to stick to otherwise. E.g. I can't really imagine telling my aunt with insomnia to read the book and apply the techniques to herself, both from a comprehension perspective and a habit maintenance perspective. It's kinda similar to how there's a lot of high-quality books out there on fitness, but classes or personal trainers provide more value to most people.

Regarding the CBT-i guidelines, different techniques are more or less useful in different circumstances. For instance, what you describe in the first bullet point is known as Sleep Compression Therapy - a useful technique, but it takes longer and has less empirical support than Sleep Restriction Therapy (SRT, where you immediately restrict time in bed based on a baseline of time sleeping). The slower Compression edition is helpful in cases where patients have trouble with the sudden schedule shift, so it's quite useful, but not always ideal.

Similarly, sleep hygiene education is actually significantly less impactful than other core CBT-i techniques such as Stimulus Control Therapy (SCT), which is all about turning the bedroom into a strong environmental trigger for sleep. And sometimes the above doesn't click without additional help from relaxation training (usually Progressive Muscle Relaxation) or some cognitive interventions (such as Paradoxical Intention Therapy).

It looks like Espie addresses much of these in his book, which is great, but it's harder to distill into core techniques. If one did distill into core techniques, sleep hygiene probably wouldn't be mentioned due to that being the first advice anyone with insomnia gets. The sleep therapists I've talked to usually emphasize SRT, SCT, and relaxation training where necessary (covering other bases like hygiene over time).

tl;dr: There are many potentially helpful techniques and a lot of information to consider, but it's cognitively demanding to do so and manage your own treatment. The app will take away that cognitive strain by customizing treatment and offering behavioral support along the way, so the user only sees the information they need and can reach out for support when necessary. We've all seen research on how much convenience affects behavior - I want to take this therapy and make it extremely convenient, thus improving treatment outcomes and reaching a larger audience.

Does that make sense / illustrate the value I think the app provides?

(am definitely on board with convincing more doctors to push CBT-i instead of sleeping pills - the book would be a far better option than the pills (though with more cognitive effort required)).

Insomnia with an EA lens: Bigger than malaria?

Thanks for sharing - can I ask in what form you tried CBT-i? (e.g. with an in-person therapist, online course, book etc).

Have run into ACT for insomnia in an article or two, but haven't met anyone like you who's used it. Have downloaded the book and will give it a read!

Insomnia with an EA lens: Bigger than malaria?

Hi EdoArad!

Thanks for your comment. Unfortunately there are a lot of unknowns with both of these questions but I can lay out some context of the current environment.

As things stand, a relative minority of people seek medical treatment for their insomnia. E.g. while estimates put the prevalence of insomnia itself between 10-40%, the actual number who seeks treatment and gets diagnosed is around 5-10% (mentioned in the first citation above). There may be several factors for this, but the one I've heard most commonly from user interviews is people (reasonably) don't want to go on sleeping pills, and that's what they'll get 90% of the time in most medical establishments.

So honestly, the current rate of people seeking treatment through official medical channels is bad, though seeking informal solutions is quite common and going up. The biggest example of this is the "sleep stories" and other sleep-focused features in Calm and Headspace, which have reportedly expanded to be a giant chunk of their userbase (no numbers released unfortunately). My hypothesis is that having an effective, well-reviewed app out there will keep that barrier to entry low and get a much larger percentage of the insomniac population to attempt a fix.

The other factor I'm shooting for re: awareness is word of mouth. (Nearly) very insomniac I've spoken to knows multiple others, and the users I've treated so far have both spread the word about Slumber without me asking them to. The kind of improvements that are possible in fixing insomnia have potential to create a lot of superpromoter users, who (maybe coupled with some kind of referral incentive) can spread the word more effectively than any other channel.

Regarding marginal contribution: The major existing player (Sleepio) has several key flaws that I believe keep it from being the solution we need.

1. As mentioned above, Sleepio functions more as an online class on how to administer yourself CBT-i than a therapist who administers it for you. You watch lectures, take home homework, and try to figure things out yourself for the most part (though I believe they do have a human chat available for questions). This approach has a very high churn rate (how many people start an online class and never finish?) and around 70% of the efficacy of in-person therapy. For example, on this study on dCBT-i, the churn rate was 35% (https://www.researchgate.net/publication/280584339_Predictors_of_dropout_from_internet-based_self-help_cognitive_behavioral_therapy_for_insomnia). In others, it was as high as 49%.

I'm still experimenting with the format, but my hypothesis is that flipping the perspective - creating an app that functions as a therapist (with custom treatments & decision trees), plus social measures for churn - will produce a solution that approaches or matches that of in-person therapy (churn rate of ~12%).

2. The price. Sleepio doesn't show the price of their program without digging, but a quick Google search suggests it's currently around $400. They don't seem to take insurance. This puts it out of financial reach of many, and I'd guess it gives them a *very* healthy profit margin - especially considering the percentage of users who never complete the program, and the amount that's completely automated. It's my goal with Slumber to make something substantially more affordable, probably at least half the cost for more developed countries and less for places with less purchasing power.

You'd think Sleepio would have greater market penetration than they do - the company got started in 2012 and has raised $15M+, but their product still looks like it was made in Flash player, their mobile app is broken for what seems like half of their users, and society as a whole doesn't seem more familiar with CBT-i as a result of their efforts and funds.

3. I've interviewed a few people who've gone through the Sleepio program, and my sleep therapist advisors tell me they get many patients who've tried it. Common threads seem to be it's hard to finish, it didn't work for them, or (to one person) the content was presented condescendingly, and they didn't have the flexibility to change their sleep schedule or know when they'd be off restricted sleep. So have heard a number of complains. Additionally, Sleepio doesn't have financial incentive to help a user once they've bought in - it's just the upfront fee, with no money back guarantees or anything of the sort. Those people who it didn't work for still made Sleepio money. From a profit perspective, the company seems well off.

There are few other options in this field worth mentioning. A company called Pear Sleep is developing an app from a pharma view, with the goal of getting it prescribed in doctors' offices. This is good in terms of institutional acceptance but the product is inaccessible as a regular consumer - another barrier to entry. The freely available online resources are garbage - it's necessary to dig into the literature to find guides on treatment.

Even if everything I build is only as good as what's already out there, drawing more people into treatment and offering an alternative to sleeping pills is worth a lot, given the health cost of sleeping pills (50k ER visits in the US, in one year, from one brand) and the relative lack of improvement they bring (avg 11 mins reduced sleep onset, or ~1/3 to 1/2 as effective as CBT-i). Solving the problems of awareness, growth, and scaling would make a big dent in the QALY burden.

I think Slumber can address the above by being

  • A therapist in your pocket with custom, flexible treatment plans via decision trees & human support
  • Mobile-first (Sleepio has an iOS app but it's at 2.6 stars)
  • Affordable (sub $100 at least) with subscription model, or with money-back guarantee

Hope this answers your questions, or at least the state of my current answers to them. I'm aiming to have more solid evidence re: efficacy and churn within the next few months, which should help me assess marginal impact with more confidence.