Digital treatments such as Sleepio for insomnia and Daylight for anxiety by Big Health have demonstrated their ability to deliver lasting recovery for two of the most common mental health conditions at scale. 1,2 But how exactly do these treatments work, and why are they so valuable? To answer these questions, we spoke with Dr. Michael Otto, Professor of Psychological and Brain Sciences and Senior Fellow at the Institute for Health System Innovation and Policy at Boston University, in a recent video series.
The efficacy of digital treatments
A1 | Dr. Otto: Ideally, digital mental health treatments have a fundamental building block rooted in cognitive behavioral therapy (CBT). CBT is the most validated psychosocial treatment out there, and starting with this building block means you have the right tools to provide the individual with an effective treatment. Then, you just need engagement. The art of a good digital product is one that engages people to use the provided tools, which seems to be the one-two punch of an effective digital treatment.
A2 | Dr. Otto: I had to think this through because I am one of those face-to-face clinical providers of CBT. Why can a product do as well as I can? I think the answer is: If you see me, you see me once a week, at a mutually agreed upon time between our busy schedules. You have to travel to see me or use telehealth — and the moments that I capture with you may not be the moments that you most need help applying the skills that CBT can offer. On the other hand, your digital device is in your back pocket. It’s there when you do want to log in or have some increased difficulties and delivers the intervention in a very unique way. So while we both offer CBT skills, this fits in your life in a way that is very interesting and I think it helps underlie the efficacy of a digital solution.
A3 | Dr. Otto: You’ve probably heard me say multiple times that validation in a clinical trial, research, and research background are essential in choosing a digital product. Sleepio in particular has been recommended in three clinical guidelines with a fourth recommendation for the digital delivery of CBT based on outcomes in clinical trials involving Sleepio. These include the National Institute for Health and Care Excellence, the British Association for Psychopharmacology, and the European Sleep Research Society, with the fourth recommendation coming from the American College of Physicians. The word is out, it’s in the guidelines, and it’s an important way of choosing which product your population should receive.
Identifying the best solution
A4 | Dr. Otto: It really is the “wild west” out there with all of the new digital health options available. The problem is, they are not all validated. So my answer: Research, research, research. That’s how you know which products are going to do well for your patients because they’ve already done well in clinical trials. And Big Health in particular has taken steps to ensure its products work. They are now at 14+ clinical trials to show for people with sleep disturbances or anxiety, the digital solutions that they offer really do work for patients like yours.
A5 | Dr. Otto: There really is no bad time to consider a digital treatment. My clinic has a three-month waitlist, and doing something to get those people off the waitlist is a great option. They can get started on the skills that may resolve their disorder so they never need to come to someone like me for treatment or practice skills that may get them ahead on what I might help them with in treatment. That’s the lowest level of stepped care. But also, offering it as a choice for those who may seek out different kinds of psychotherapy or people who have tried a medication option and either want to move over to a psychosocial treatment or want to augment their care by getting the CBT skills that can help them with their disorder. There’s no bad time or case to consider a digital option.
A6 | Dr. Otto: There are a lot of wellness products out there and it is important to distinguish digital treatments like Big Health’s products from those. Big Health has taken the time to do the research, validating that the treatments are efficacious in clinical populations. So that gives you the full seat change — not just wellness, not just general populations, but it works for the patients that you have and the patients that need treatment in your systems.
Who can benefit from digital treatments?
A7 | Dr. Otto: I think there really has been a change since COVID. COVID has helped all of us become much more comfortable with telehealth and interfacing with physicians through digital means, answering online questionnaires, etc., which has been a boom for digital health by getting everyone more oriented toward the ways in which they can get care. Even when we send surveys out now, we find that digital care and face-to-face care are tied for preference. There really is no wrong answer or patient for a digital health solution. In the past, younger patients were more likely to embrace digital health while older patients and certain ethnic groups were more resistant, which no longer seems to be the case. We’re on a much more level playing field and that is excellent news for getting more care to more people.
A8 | Dr. Otto: Let’s take a moment to address the issue of to whom digital treatments should be targeted. The first thought I have is for those on waitlists. We know waitlists are an issue, especially in the post-COVID era when there are higher rates of anxiety and depression, and sleep disturbances are at around 30%. There are not enough people like me to go around to see those patients. So, applying a digital solution for those on the waitlists is a great way to start care and give them the skills they need in a relatively short amount of time and get them to stay with those skills, as the skill development is what gives CBT treatments its long-term efficacy. Now also, what about those patients who have tried other treatments? For example, those who have tried pharmacotherapy and not responded adequately. There is great evidence that CBT offers benefits to those patients, and likewise, we can expect that digital CBT offers the same benefit.
A9 | Dr. Otto: One of the concerning failures of healthcare in America is the degree to which preventive interventions are offered. They’re typically not offered very much. The beauty of a digital solution is that it can be offered to the entire range of individuals who need it. Subsyndromal cases as well as very severe cases, as well as treatment-refractory or people who have not responded to pharmacotherapy and are now ready for CBT. So the beauty of the scale of a digital treatment is you can get it to the whole range of people who can make use of interventions, preventing or treating a worse disorder, depending on the need.
The perspective of a clinician
A10 | Dr. Otto As a clinician, I’m well aware of the gaps in our mental healthcare system. There certainly are not enough CBT providers. People always speak to me about the issue of knowing CBT works, but not knowing how to get someone to a provider. Digital treatment is an excellent way of making sure to provide care for people that need it, and also making that care broadly available. It is always a challenge for someone who is interested in care to go through multiple steps to get there: They have to go to their primary care provider and try to remember all the things they want to discuss in their brief 10-minute visit in order to get a referral for care. I do like multiple pathways, prescription-level care, direct referral for care, and making sure people can more easily access the care they need.
A11 | Dr. Otto: I want to talk about the importance of getting CBT outside of mental healthcare. We know that people with all sorts of physical health conditions need help with the mental health components, particularly sleep and anxiety which are associated with so many other comorbid conditions. So, a solution that provides care without more appointments and added professionals to the mix and can offer treatment is beneficial for everyone.
A12 | Dr. Otto: It’s important to remember that treating sleep disturbances and anxiety can have an outside influence on health. Sleep and anxiety can have a large impact on other disorders. If you disrupt sleep, for example, the likelihood of bad outcomes for cardiovascular disease rises dramatically, and that’s true across many disorders. By targeting insomnia and anxiety and the avoidance that comes with these conditions, you could be avoiding worse health outcomes over time. So, when you provide a digital treatment for insomnia and anxiety, you are also providing broader health benefits to patients than just the outcomes in the mental health domain.
Value beyond clinical outcomes
A13 | Dr. Otto: In my work, I am concerned about the efficiency of treatment. This means that for every month someone goes with a disorder, the impact of that disorder on the patient and their families and their work functioning continues. So early treatment is best for everyone. Being able to rapidly get somebody access to a digital health solution that has benefits for the whole system and effective short-term focused CBT to get the skills to someone right away so they can apply them over time is an excellent health solution for payers and health plans.
A14 | Dr. Otto: The work we have done on patient preference has shown that psychotherapy has a 2:1 to 3:1 (depending on which disorder you’re talking about) preference by patients — meaning they would rather be in psychosocial care than pharmacotherapy. A digital solution allows people to get to CBT early — getting past waitlists, referrals, and issues of trying an unpreferred treatment and then waiting to switch to a preferred treatment. So, the value of digital treatment is getting people the care they need right now, right away.
A15 | Dr. Otto: Disparities in care is a very complex issue but let me mention just a few things relevant to disparities in care and solving those disparities that a digital solution can help solve. First of all, in terms of referral to care, allowing a digital health solution to have broad accessibility bypasses the issue of different referral for care rates that may impact disparities. Second, barriers to care are reduced. You don’t have to travel to the clinic or take time off of work to get access to your care provider. Third, acceptability: The data on acceptability across races and ethnic groups is strong for Sleepio, that’s why Sleepio has been evaluated to show it can get care to people of different races, cultures, and ethnicities. That is a very important and nice additional feature of digital care.
Dr. Otto has an ongoing business relationship with Big Health as a consultant.
Sleepio and Daylight are available as an adjunct to usual medical care for insomnia disorder or generalized anxiety disorder, respectively, for adults ages 18 and older, without FDA review under their COVID-19 policy.
DOC-2594 Effective 03/2023
1. Espie et al. (2012). Sleep
2. Carl et al. (2020). Depression and anxiety
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