Really appreciate the work that you are putting into this app, and this write-up. Iâm excited by your app, and hope that it will help a lot of people to solve their sleeping problems! John Halstead also wrote a post on CBT-i a while ago, and while I assume that youâve reached it independently, itâs great to see attempt at real-world solutions and impact assessments.
There are two points that I think are missing from your analysis. First, regarding Tractability, Iâm curious as to what would cause people with insomnia to seek help and find the CBT app. That is, even if CBT is very effective, it might still be very hard to reach people and to put the treatment in practice.
Second, Iâd like to see an assessment of the marginal contribution for Slumber over existing efforts. There seem to be other apps for CBT-i.
Thanks again! Iâve suggested Slumber for a friend to try out :)
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 Iâve heard most commonly from user interviews is people (reasonably) donât want to go on sleeping pills, and thatâs what theyâll 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 âsleep storiesâ 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 Iâm shooting for re: awareness is word of mouth. (Nearly) very insomniac Iâve spoken to knows multiple others, and the users Iâve 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://âwww.researchgate.net/âpublication/â280584339_Predictors_of_dropout_from_internet-based_self-help_cognitive_behavioral_therapy_for_insomnia). In others, it was as high as 49%.
Iâm still experimenting with the format, but my hypothesis is that flipping the perspectiveâcreating an app that functions as a therapist (with custom treatments & decision trees), plus social measures for churnâwill produce a solution that approaches or matches that of in-person therapy (churn rate of ~12%).
2. The price. Sleepio doesnât show the price of their program without digging, but a quick Google search suggests itâs currently around $400. They donât seem to take insurance. This puts it out of financial reach of many, and Iâd guess it gives them a *very* healthy profit marginâespecially considering the percentage of users who never complete the program, and the amount thatâs completely automated. Itâs 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.
Youâd think Sleepio would have greater market penetration than they doâthe 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 doesnât seem more familiar with CBT-i as a result of their efforts and funds.
3. Iâve interviewed a few people whoâve gone through the Sleepio program, and my sleep therapist advisors tell me they get many patients whoâve tried it. Common threads seem to be itâs hard to finish, it didnât work for them, or (to one person) the content was presented condescendingly, and they didnât have the flexibility to change their sleep schedule or know when theyâd be off restricted sleep. So have heard a number of complains. Additionally, Sleepio doesnât have financial incentive to help a user once theyâve bought inâitâs just the upfront fee, with no money back guarantees or anything of the sort. Those people who it didnât 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 doctorsâ offices. This is good in terms of institutional acceptance but the product is inaccessible as a regular consumerâanother barrier to entry. The freely available online resources are garbageâitâs necessary to dig into the literature to find guides on treatment.
Even if everything I build is only as good as whatâs 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/â3 to 1â2 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 itâs 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. Iâm 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.
(Nearly) every insomniac Iâve spoken to knows multiple others
Just want to highlight a potential selection effect: If these people spontaneously tell you that theyâre insomniacs, theyâre the type of people who will tell other people about their insomnia, and thus get to know multiple others. There might also be silent insomniacs, who donât tell people theyâre insomniacs and donât know any others. Youâre less likely to speak with those, so it would be hard to tell how common they are.
Really appreciate the work that you are putting into this app, and this write-up. Iâm excited by your app, and hope that it will help a lot of people to solve their sleeping problems! John Halstead also wrote a post on CBT-i a while ago, and while I assume that youâve reached it independently, itâs great to see attempt at real-world solutions and impact assessments.
There are two points that I think are missing from your analysis. First, regarding Tractability, Iâm curious as to what would cause people with insomnia to seek help and find the CBT app. That is, even if CBT is very effective, it might still be very hard to reach people and to put the treatment in practice.
Second, Iâd like to see an assessment of the marginal contribution for Slumber over existing efforts. There seem to be other apps for CBT-i.
Thanks again! Iâve suggested Slumber for a friend to try out :)
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 Iâve heard most commonly from user interviews is people (reasonably) donât want to go on sleeping pills, and thatâs what theyâll 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 âsleep storiesâ 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 Iâm shooting for re: awareness is word of mouth. (Nearly) very insomniac Iâve spoken to knows multiple others, and the users Iâve 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://âwww.researchgate.net/âpublication/â280584339_Predictors_of_dropout_from_internet-based_self-help_cognitive_behavioral_therapy_for_insomnia). In others, it was as high as 49%.
Iâm still experimenting with the format, but my hypothesis is that flipping the perspectiveâcreating an app that functions as a therapist (with custom treatments & decision trees), plus social measures for churnâwill produce a solution that approaches or matches that of in-person therapy (churn rate of ~12%).
2. The price. Sleepio doesnât show the price of their program without digging, but a quick Google search suggests itâs currently around $400. They donât seem to take insurance. This puts it out of financial reach of many, and Iâd guess it gives them a *very* healthy profit marginâespecially considering the percentage of users who never complete the program, and the amount thatâs completely automated. Itâs 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.
Youâd think Sleepio would have greater market penetration than they doâthe 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 doesnât seem more familiar with CBT-i as a result of their efforts and funds.
3. Iâve interviewed a few people whoâve gone through the Sleepio program, and my sleep therapist advisors tell me they get many patients whoâve tried it. Common threads seem to be itâs hard to finish, it didnât work for them, or (to one person) the content was presented condescendingly, and they didnât have the flexibility to change their sleep schedule or know when theyâd be off restricted sleep. So have heard a number of complains. Additionally, Sleepio doesnât have financial incentive to help a user once theyâve bought inâitâs just the upfront fee, with no money back guarantees or anything of the sort. Those people who it didnât 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 doctorsâ offices. This is good in terms of institutional acceptance but the product is inaccessible as a regular consumerâanother barrier to entry. The freely available online resources are garbageâitâs necessary to dig into the literature to find guides on treatment.
Even if everything I build is only as good as whatâs 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/â3 to 1â2 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 itâs 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. Iâm 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.
Just want to highlight a potential selection effect: If these people spontaneously tell you that theyâre insomniacs, theyâre the type of people who will tell other people about their insomnia, and thus get to know multiple others. There might also be silent insomniacs, who donât tell people theyâre insomniacs and donât know any others. Youâre less likely to speak with those, so it would be hard to tell how common they are.