[HN Gopher] Launch HN: Iona Mind (YC S21) - App-based cognitive ...
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Launch HN: Iona Mind (YC S21) - App-based cognitive behavioural
therapy
Hi HN, we're Iona Mind. We provide app-based mental health support,
with a focus on Cognitive Behavioural Therapy (CBT). Mental
healthcare is difficult for many people to access, whether because
of cost, stigma or waiting times. According to a recent pre-covid
study in England [1] 18% of people are experiencing a mental health
issue, yet only 5% actually access help through an employer's
assistance plan (if one even exists) [2] . The majority suffer in
silence. In addition to the human cost, there are significant
economic costs. In the U.S., mental health issues cost employers
thousands of dollars per employee per year in medical costs and
lost productivity [3]. At our previous company, we lost a
colleague to suicide. Since then we've been on a mission to bring
evidence-based mental healthcare to as many people as possible. We
were surprised to find that Cognitive Behavioural Therapy is backed
by over 30 years of research, and over 250 meta-analyses [4], yet
remains difficult for people to access. CBT has been shown to be
effective for a wide range of mental health conditions, even when
administered digitally [5] or in books (so called bibliotherapy)
[6]. While we do not believe that self or app administered CBT can
replace the human touch, it does provide a convenient, affordable,
always accessible and stigma-free way for many users to access
support, when they may not have been able or ready to seek it in
person. In the UK, the NHS presents a progressive "stepped model"
of mental healthcare, depending upon severity from step 1 to step
4. We see apps playing a part in step 1, step 1a and possibly step
2 of this model [7]. While there are a number of CBT apps
available, we wanted to base ours around Low-Intensity Cognitive
Behavioural Therapy, a relatively new variant which has been used
extensively in England to treat people with mild to moderate
conditions at scale. In low-intensity CBT, the patient more or less
treats themselves by doing exercises, and the therapist supports
the process. This approach to CBT is especially suited to delivery
through a digital form. Our clinical director, Professor Paul
Farrand, was the architect of using Low-Intensity Cognitive
Behavioural therapy at scale in the UK's National Health Service
(NHS), and the editor of one of the first international textbooks
on the subject [8]. Our app presents the user with a chatbot which
guides them through CBT techniques and exercises. We went for a
chat-style UI to make the software more engaging--it's a challenge
to make an app of this kind be more than just a "content board".
Our chatbot engine is graph-based. At some nodes in the graph,
classifiers applied to the user's free text entry determine the
path through this graph, along with the user's state and past
inputs. We want the paths within the app to be predictable and
ensure that the chatbot doesn't do anything unexpected. We'd seen
more freeform generative seq2seq style chatbots produce potentially
dangerous output at times in other apps and wanted to avoid this.
Also, CBT has been shown to often work better when "therapist
drift" is minimized--this is where the therapist drifts away from
the prescribed structure of the exercises in CBT [9]. A graph-based
conversation is a good way to keep things on track. We offer the
app as an employee wellness benefit to organizations. Since only 5%
of employees tend to use the Employee Assistance Programme (EAP) at
their employer, the app offers a way to support the "missing
middle" for whom mindfulness/meditation apps are not sufficient,
but who aren't ready to access their employer's EAP. We offer use
of the app completely anonymously if the user wishes. It's in the
Apple App Store at https://apps.apple.com/app/iona-anxiety-mood-
support/id14913... and Google Play at
https://play.google.com/store/apps/details?id=com.iona.menta....
We'd be really interested to hear from the community about any
ideas or experiences you've had when it comes to delivering mental
health support digitally. We appreciate this is a sensitive topic
so if you'd rather email us we'd love to hear from you at
hello@ionamind.com [1]
https://assets.publishing.service.gov.uk/government/uploads/...
[2] https://www.eapa.org.uk/wp-content/uploads/2014/02/UK-EAPA-R...
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924724/ indicates
major depressive disorder alone costs $4426 per ill worker per
annum [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/
[5] There are a wealth of papers on so-called "iCBT" or internet
delivered Cognitive Behaviour Therapy, covering both fully digital
and human-in-the-loop variations. The approach dates back to the
days when iCBT was actually just static content delivered on CD-
ROM. I attach a couple below
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5421393/
https://pubmed.ncbi.nlm.nih.gov/23419552/ [6]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788928/ [7]
http://www.swscn.org.uk/wp/wp-content/uploads/2015/03/non-gu...
[8] https://us.sagepub.com/en-us/nam/low-intensity-cbt-skills-an...
[9] https://pubmed.ncbi.nlm.nih.gov/26752326/
https://pubmed.ncbi.nlm.nih.gov/19036354/
https://www.vgct.nl/stream/vr-keynote-9.15-waller.pdf
Author : phowson83
Score : 70 points
Date : 2021-08-13 13:03 UTC (9 hours ago)
| tdaltonc wrote:
| I'm curious about the middle-way chatbot you're building. Most
| chat systems are either "smart" scripts with intent recognition
| (RASA, Dialog Flow, etc) or anything-is-possible chaos (seq2seq,
| etc).
|
| Can you explain more about how you're able to keep the
| conversation on track while leveraging the adaptability of a
| generative system?
| phowson83 wrote:
| We're generally more in the smart scripts camp at present. The
| conversations are graph based, with each node being associated
| with code that can look at the state of the user and any input.
| It may be that the input is a set of fixed options, or that the
| input is freetext. Usually in the event of freetext we're
| classifying that freetext, looking at the state and using these
| two things to determine the output and next node to go to.
|
| It's still early days with the product and to date we've
| generally avoided anything that is generative, as you say, it's
| hard to keep on track and is hard to predict what the range of
| outputs can be. The next steps in development will most likely
| be to improve classification of freetext and use it more
| extensively within the app. We've also considered having
| individual nodes which use generative output (at least in part
| for the output), to go more to the generative end of the
| spectrum, but retain control of the conversation flow, however
| this is still at the concept stage for the moment.
|
| We've seen some graph based / smart script engines where you
| can enter subgraphs where the output is essentially seq2seq
| until various trigger conditions are met (e.g. the text is
| classified a certain way), before continuing to another part of
| the graph, and this is another way the two approaches can be
| blended. It's not something we're looking at at present, and
| can also be potentially quite unpredictable.
| tdaltonc wrote:
| "Generate chit-chat until the intent classifier gets what you
| need" is an interesting idea. Should work especially well in
| therapy where asking the same question for different angles
| is pretty well tolerated.
| WORMS_EAT_WORMS wrote:
| - Apple link is dead FYI
|
| - I can't imagine a harder sell than an app improving mental
| health. From own experiences, simply stepping away / hiking /
| going without a phone for a couple days is a huge empowering
| reset.
|
| Will check out and wish you best of luck
| jdavis703 wrote:
| I have doubts about their medical claims, but I have been
| helped by traditional, video-based CBT delivered over an app.
| While exercise is one component of improving mental health, CBT
| goes far beyond and is way more helpful.
| phowson83 wrote:
| Thanks for the heads up on the link! We'll update in the
| original post, but you can also try
| https://apps.apple.com/app/iona-anxiety-mood-support/id14913...
| which seems to be working from our region
|
| I would certainly agree on the stepping away and hiking
| approach. In CBT Jargon, doing an activity that you would
| normally enjoy when you're feeling low is often called
| "Behavioural Activation" or BA, and it's definitely a valuable
| self-help tool.
|
| Thanks for checking out the app, and any comments and thoughts
| on our product are always gratefully received.
| vishnumohandas wrote:
| Hey, I just checked out the iOS app and it is clear that you have
| put a lot of thought into it. As someone who has previously dealt
| with depression, I was happy to see how low effort the entire
| onboarding flow was. I do think the interface (colors, padding,
| illustrations) has scope for improvement, but there's time for
| that. I hope you guys will continue to build this while
| optimizing for long term value creation over short term returns
| to your investors.
| phowson83 wrote:
| Thanks for your feedback and really glad you liked the
| onboarding! Indeed it is very high on our priority list to
| improve the look of the app (and the general UI fit and
| finish). Up until we got onto YC we had taken no funding for
| this project and therefore have never had any input from a
| design professional (beyond the odd favour here and there).
| We're definitely aiming to create long term value, and the
| ultimate mission statement of the company is to put evidence-
| based affordable mental healthcare in the hands of as many
| people as possible.
| azinman2 wrote:
| I wish you good luck in helping people. This is a tough space --
| I spent a while at Ginger.io where we flip flopped between
| employers and consumer. Getting into that EAP money is great if
| you land it, but it's a super crowded space where when you squint
| all the offerings (to an HR rep) look the same. And many have
| been at this for years.
|
| Personally I don't find a chatbot a convincing way to go. It's
| very inflexible, but gives the illusion that you could say
| anything. If you go the woebot model of having fixed prompts, it
| becomes unclear why it's in this UX when you could have something
| more compelling. It also is difficult to do fully automated AND
| get real benefit for the people who need it. It's very rare for
| an app only approach to suffice in mental health. I know you said
| you wanted sub clinical, but even at that range you'll have a
| very long tail of needs when it comes to someone interested in
| spending real time on their mental health. This isn't just your
| average person we're talking about here.
|
| A major issue I have is both the oversimplification of CBT
| combined with every app trying to do only that. CBT can be
| effective for certain people in certain situations... but it's
| billed as a panacea. This isn't a one sized fits all situation
| where you're trying to find a universal solution. And as you have
| mentioned here, even CBT doesn't work for over half of people.
|
| I encourage you to really survey the space and your competition.
| Nothing you've stated sounds particularly different from many
| others. Maybe there is something, but if so, you're not selling
| it well to me at least. Good luck! I hope you experiment, learn
| fast, and innovate.
| phowson83 wrote:
| Thanks and some great points here. As you say competition and
| differentiation are potentially really tricky in this sector.
| Really interesting to hear about your experience at ginger.io .
|
| We're certainly not wedded to the chatbot idea, but it's just
| the best UX/UI we've implemented so far. The key we feel is to
| avoid becoming a boring, skippable content board, and maybe a
| chatbot isn't the final iteration of that concept, but it's the
| approach that has worked the best for us so far.
|
| I agree that the key in this space will be to learn quickly and
| iterate to find a solution compelling to the user and payer.
| It's early stage for us, until the point we got into YC we had
| taken no funding, so I think there's a lot of scope for how we
| can expand and adapt our offering to the marketplace and we've
| already learned a tremendous amount.
|
| We have ultimate long term aim of building apps which are
| certified Software as a Medical Device and get device-like
| reimbursement through healthcare systems. We certainly feel
| that's a place which is less competitive and more
| differentiated, there are a few companies in this space such as
| Pear Therapeutics, but unlike them, we feel it's important to
| start at the b2b and b2c end of the spectrum to build a product
| that people love before going through the lengthy and costly
| process of adapting that product becoming a fully certified
| medical device.
| [deleted]
| asaddhamani wrote:
| Congrats on the launch!
|
| Is a chatbot the best way to accomplish this? I used the app for
| 5 minutes and barely got past the onboarding. Yes maybe it feels
| more personalised but it's much slower to get to the point.
|
| Like WORMS_EAT_WORMS mentioned, stepping away from screens I've
| found is much better for improving mental health, which also
| makes me question the premise of apps like Headspace.
|
| Would be great to hear your perspective on these points.
|
| Best of luck!
| phowson83 wrote:
| Thanks for your interest and for checking out the app. We've
| tried various approaches and I think it's one of the more
| engaging methods of delivering CBT that we've trialled to date,
| but we're certainly not married to it and we're always thinking
| of ways that we could deliver CBT in a more engaging manner.
| The main issue we find, is that when you are walking people
| through specific modules or exercises you want to keep them
| engaged and not just throw a load of content at them either as
| a block of text or a video which they will probably skip.
|
| I'd certainly agree on the idea of unplugging and stepping
| away, and as I also mentioned to WORMS_EAT_WORMS, this is a
| form of "Behavioural Activation" which has good grounding as a
| highly effective self-help skill for your toolbox. I would say
| apps can be effective for learning and practicing other "tools"
| such as "cognitive restructuring" (thinking about thoughts and
| trying to reframe them in an objective manner), or gratitude
| journaling and review, both of which are used in the practice
| of CBT.
| all_usernames wrote:
| This right here is a huge challenge. My smartphone is a
| gigantic source of my daily stress -- it transmits the awful
| news, the demands of my friends and family, a ton of garbage
| advertising, all my bills, AND all my work communications!
|
| Someone please make a standalone device for all the mental
| health apps, so I can take it to the park with me and detox :)
| all_usernames wrote:
| Eh, Apple maybe read my mind with upcoming Focus mode:
|
| "you set an activity that you're doing, such as working,
| exercising, reading, or spending time with family, and block
| out the notifications that are unrelated to those tasks"
|
| https://www.macrumors.com/guide/ios-15-focus-mode/
| all_usernames wrote:
| Just an anecdote:
|
| I did a course of CBT therapy as part of a university research
| study comparing the outcomes of CBT with mindfulness meditation
| for symptoms of social anxiety. It was 6- or 8-weeks long, and
| each week I went in to have a session with a therapist and do the
| workbooks etc.
|
| It was a profoundly memorable experience and I did, in fact, face
| a number of my fears and essentially solve them through in-person
| 'confrontations' designed to mimic the social anxiety triggers I
| had. It was fun, too; for example one of the confrontations
| involved me messily eating a huge fast-food hamburger _inside a
| phone booth_ with one of the psych lab 's grad students. Those
| poor grad students.
|
| Anyway, looking back on this experience 15 years later what
| really stands out are two things: those in-person experiential
| confrontations, and finally the tears I saw in my therapist's
| eyes during our final session as she congratulated me on my
| progress.
|
| I really think apps like this can help tremendously for self-
| motivated "normals" -- and I wonder how voice/video/VR will
| expand their effectiveness in years to come.
| phowson83 wrote:
| Great to hear about your positive experience with CBT. I think
| there's a lot of innovation that's possible in this sector. If
| we look at CBT, a lot of the core concepts and exercises
| haven't changed all that much (from the perspective of the
| average spectator) in the last 20 or so years, which leaves a
| lot of potential research opportunity that can be explored
| using new technologies which weren't available when CBT
| emerged.
| jdavis703 wrote:
| Are you FDA approved? You're distributing a medical product and
| making claims that 86% of people feel less stress, depression or
| anxiety. In the US at least, I believe you either need FDA
| approval, or a disclaimer that you're not approved.
| phowson83 wrote:
| It's an excellent point and why we're very careful with the
| claims we make. The claim I think you are referring to is "86%
| of users report feeling better after their first session with
| Iona Mind" , which is based upon feedback the users give within
| the app, but does not relate to any specific measurements
| relating to any conditions within the DSM-5 which is the
| standard manual which defines mental health disorders within
| the United States. We are indeed not a medical device, and we
| do make it clear to users during sign up that Iona Mind is a
| self help tool.
|
| If we were making that claim that we treat specific diseases
| such as Major Depressive Disorder (MDD) or Generalised Anxiety
| Disorder (GAD) then you are correct in assuming that would
| require FDA approval as a medical device, although for the
| duration of the covid-19 pandemic the FDA published the
| following guidance on low-risk self help and general wellness
| apps: https://www.fda.gov/media/136939/download
|
| which states: "... Given these public health benefits, for the
| duration of the COVID-19 public health emergency, FDA does not
| intend to object to the distribution and use of computerized
| behavioral therapy devices and other digital health therapeutic
| devices for psychiatric disorders, which are described in
| Section III.A, without compliance with the following regulatory
| requirements, as applicable, where such devices do not create
| an undue risk in light of the public health emergency:..."
| debarshri wrote:
| You answer makes me believe you really know what you are
| talking about and you have de-risk lot of stuff from investor
| point of view. But with that answer, as a customer now I have
| trust issues with the app as I am not sure if what you are
| claim is actually true and feels like you have hacked around
| a regulation that is meant to keep unfair and false app and
| service in check. It gives me snake-oily vibes.
| chalst wrote:
| I haven't fact-checked the article yet, but the fact that
| this is an area with low-hanging fruit and the apparent
| expertise of the team leads me to think we should have some
| confidence here.
|
| Cf. from the OP:
|
| > Our clinical director, Professor Paul Farrand, was the
| architect of using Low-Intensity Cognitive Behavioural
| therapy at scale in the UK's National Health Service (NHS),
| and the author of one of the first international textbooks
| on the subject.
| wutbrodo wrote:
| A much more articulate and informed take than I'm capable
| of was recently written by a practicing psychiatrist, about
| the medicalization of CBT apps and how absurd it is.
|
| https://astralcodexten.substack.com/p/welcome-to-the-
| terribl...
|
| > feels like you have hacked around a regulation that is
| meant to keep unfair and false app and service in check.
|
| Blind faith in every excess of the FDA's obstructionism and
| other bureaucratic pathologies was always insane to me, but
| it really, really shouldn't have survived for anyone paying
| even casual attention to the global pandemic we're in the
| midst of. Agencies like the FDA are taking on the herculean
| task of standardizing the messy landscape of scientific
| knowledge into bite-size, oversimplified answers that the
| dumbest layman can make use of. This is hard enough to
| begin with, and gets even worse when you remember that
| they're as subject as any institution to politics, inertia,
| bad organizational culture, etc etc etc. I get that most
| people have a powerful, almost-foundational urge to avoid
| critical thinking, but it's a fantasy to think that you can
| outsource 100% of your cognitive function to bureaucracies
| that can provide maximally-simplified, crystal-clear access
| to The Truth. When it comes to your health or that of those
| you care about, it's downright negligent to do so.
|
| To be clear: I think the FDA does a massive amount of
| necessary, fundamental work that the medical system depends
| on, and I'm not suggesting people go hog-wild trying every
| random substance without regards to efficacy and safety
| guidelines.
|
| But the approach you take in your comment is a dramatic and
| farcical example of bureaucracy-as-religion. Consider what
| we're talking about: you're concerned about non-medically-
| approved use of a chatbot that (reductively) helps you
| think about things more positively. Is there a principled
| reason that you're (presumably) okay with people watching
| yoga videos at home without a prescription? Or picking up a
| book on meditation? Or reading Couch-to-5K and starting
| jogging? Is there any difference between these activities
| and a CBT chatbot, beyond the fact that the latter has been
| medicalized by our regulatory bureaucracy?
| ramraj07 wrote:
| I can see you have (probably justifiable) beef with FDA
| regulations, and the politics they play. But the posters
| worry is real. CBT is offered as a therapy to many mental
| disorders. It can indeed be done by yourself, so in
| theory it makes sense that you don't need to regulate it,
| but it sits right at the border of that demarcation if
| you ask me. Questions about whether it should be
| regulated is valid, and the answer offered is also
| somewhat valid though perhaps not opportune.
| wutbrodo wrote:
| My rhetorical questions apply to your point too. Do you
| think information on how to do yoga, how to be mindful,
| and how to get started running should also be
| medicalized, made inaccessible without going through our
| byzantine medical system and paying a thousand dollars
| (or trying to convince insurance to do so)? How about
| books on how to eat and cook healthily? Or a self-help
| lecture on positive thinking?
|
| If not, why? All of these things are common parts of a
| treatment plan for mood disorders, and yoga and jogging
| bring with them infinitely more risk of harm than self-
| CBT does.
|
| Your claim is that if something can help with a disorder,
| people should be prevented from accessing it easily. This
| seems precisely backwards to me! Something being "offered
| as a treatment" is a terrible, terrible basis for
| throwing up substantial medical barriers, and causes much
| more harm from reduced access than it provides benefits.
| As I said, I'm not imagining away the need for the FDA:
| The risks of accidental misuse or other safety concerns
| are a legitimate basis for medical barriers, costly
| though they may be. But I think the onus is on the ban-
| happy folks to explain why a chatbot that helps you think
| positively is closer to Fentanyl than it is to a YouTube
| video on beginner's yoga.
|
| The answer is simply path-dependence. The reason you
| categorize CBT differently is that it was developed
| through the formal scientific establishment while (eg)
| yoga and mindfulness were developed externally and
| validated post-hoc by the establishment. This is
| decidedly irrelevant to the best interests of the
| patient, and there are a trillion and one examples of the
| FDA[1] acting in ways that are explicitly harmful to
| patient welfare.
|
| My ultimate point here is that if your concern is the
| health of yourself and your loved ones, the barriers the
| medical system throws up around treatments serves as a
| weak prior that often needs working around and should
| never be blindly and slavishly followed without at least
| a bit of basic research giving you an understanding of
| _why_ the barrier exists. My sister and brother-in-law
| are doctors, and a decade+ of conversation with them
| about medical culture has given me a healthy respect of
| how pants-on-head stupid and/or ignorant some patients
| can be[2]. These poor folks have no real choice but to
| follow the FDA blindly, even despite the heavy tax on
| their physical and mental wellbeing that they pay for
| doing so. But if you've got anywhere near an average IQ
| and/or basic, basic cognitive ability[3], it's simply
| negligent to follow this strategy.
|
| [1] I'm using the FDA as an evocative metonymy for the
| medical system writ large, as everything from med school
| culture to our insurance infrastructure contributes to
| this status quo. The FDA isn't a fully agentic actor in
| this scenario, and while it has severe cultural flaws
| that I'd love to see improved upon, it and especially its
| staffers can't be fully blamed for the status quo.
|
| [2] This is where many physicians' God complex comes
| from. They have to deal with the masses day-in and day-
| out, and have too keen a sense of just how rock-bottom
| cognitive ability can get. Most of the rest of us end up
| with social interactions that are pretty substantially
| segregated by cognitive ability.
|
| [3] to the point that anyone who can read and understand
| this comment thread more than qualifies
| phowson83 wrote:
| Some excellent points. As you say, what is the difference
| between a book on CBT (as mentioned in the original post
| "bibliotherapy" is known to be effective in peer-reviewed
| studies) and a CBT app? And at what point do you draw the
| line between these two (assuming the claims made are
| equal)? I feel this is a question regulators globally are
| somewhat grappling with currently, and it's clearly going
| to be an focus going forwards in this space.
| debarshri wrote:
| Fair enough. I understand you distrust in FDA and their
| regulations. Yoga videos do not harm you. In worse case
| you will tear your ligament.
|
| Person with depression and suicidal tendency (because we
| are talking about CBT) on the other hand is not
| comparable to yoga video. It is more dire than you think.
| Redirecting them to an app (because it is more easily
| accessible) is pretty bad idea when they should be going
| to an actual therapist.
|
| Having lived with a person for 5 year with chronic
| depression, your comment trivializes the disorder that
| many people in the world are dealing with.
| travisjungroth wrote:
| > Yoga videos do not harm you. In worse case you will
| tear your ligament.
|
| Ligament tearing is definitely harm.
| wutbrodo wrote:
| > Person with depression and suicidal tendency (because
| we are talking about CBT) on the other hand is not
| comparable to yoga video. It is more dire than you think.
|
| > Having lived with a person for 5 year with chronic
| depression, your comment trivializes the disorder that
| many people in the world are dealing with.
|
| Bold of you to assume that I have no personal or
| otherwise direct experience with mental disorders, or
| that I'm otherwise trivializing it. Were I in a grumpier
| mood, I'd tell you to go fuck yourself : D
|
| I've seen plenty of friends give up on finding therapists
| because of the seemingly-universal nightmare of delays
| and bureaucratic incompetence, and I've watched the
| medical system spend _decades_ chronically mismanaging
| the mental healthcare of a severely-mentally-ill
| immediate family member until I took over his care.
|
| > Redirecting them to an app (because it is more easily
| accessible) is pretty bad idea when they should be going
| to an actual therapist.
|
| The logic you express in this comment also seems unsound.
| You claim that access to an effective and highly-
| available treatment should be severely reduced because it
| prevents people who need more intensive, less-available
| treatment from seeking it. It's quite an extraordinary
| assertion that we should _reduce_ access to care, leaving
| only the highest-cost, highest-hassle, lowest-
| availability options, and then to further claim that this
| will _help_ patient outcomes overall. What's your
| reasoning here?
|
| Again, I refer you to my previous examples. Do you think
| information on yoga, mindfulness, and jogging should be
| banned? Why do you assume that access to a chatbot will
| displace more intensive mental healthcare but access to
| yoga and mindfulness won't? If anything, yoga and
| mindfulness are far more widely-known as a form of
| treatment for mood disorders; the average person probably
| hasn't even heard of CBT.
|
| You can extend this even further. Should cardiovascular
| exercise be medically-gated so that the severely obese
| don't avoid gastric bypass surgery? Should we make it
| more difficult to get SSRIs (and hell, therapy itself!)
| so that the severely mentally ill don't avoid electro-
| convulsive therapy? Doesn't following your logic imply
| that both of those moves would increase patient welfare?
|
| Truly, I'd like to understand how you think this logic
| fits together. I'm quite baffled by it.
| debarshri wrote:
| Sorry for the previous comment. I understand your in
| distrust in medical system and bureaucratic processes.
| [deleted]
| exdsq wrote:
| It's a CBT app - if it helps people feel better that's good
| enough for most. Perhaps a message at the beginning saying
| "Remember this isn't a replacement for licenced therapy so
| if you're feeling particularly bad contact your GP or
| <suicide hotline>" could be useful.
|
| But for those who haven't got access to anything, something
| is better than nothing, and there is evidence even journals
| tracking your feelings help (which this appears to be,
| albeit in a more advanced form).
| phowson83 wrote:
| Indeed, the general availability of something like an app
| means we can reach people who otherwise wouldn't have
| been reached and may not have learned about this kind of
| self-help skill, and there is a good evidence base that
| journalling and tracking feelings can really help people.
|
| Great feedback on the message at the beginning, actually
| the next version will have an upgraded "crisis line" /
| SOS section in the app for people who need it. While we
| are clear that Iona is not a crisis service at the
| beginning screens, it also makes sense to have
| appropriate signposting throughout the app in case people
| ignore or don't read the warnings.
| phowson83 wrote:
| That's good feedback and there is a lot of snake-oil in the
| industry in general, which is why we base our app around
| evidence-backed practices such as CBT ( as mentioned in the
| post, there's much evidence that CBT-based apps are
| beneficial e.g.
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727354/ ). I
| think you're getting at an open question for regulators,
| which is the ongoing regulation of "wellness" apps, a
| category which this app currently falls into. The EU
| actually published a green paper about the Digital health
| space several years ago, in which they touch on the
| "wellness apps" space, with an possible eye to potential
| stricter regulation in future, although they are yet to
| enact anything in this space. https://digital-
| strategy.ec.europa.eu/en/library/green-paper...
|
| The ultimate long term aim for the company is to actually
| work towards regulation as a medical device as this also
| unlocks more ways in which the app can be distributed (e.g.
| through healthcare systems).
| lisa_marie wrote:
| Sounds like a great idea! I think access to services is a huge
| problem so having something like this might help in the interim/
| for low intensity purposes. It can be really difficult to leave
| the house/make appointments and iCBT as part of IAPT in the UK
| seems to be successful. Whereas I agree with some of the other
| comments that time away from screens and being outdoors might be
| more helpful - listing gratitudes as suggested in your app has
| also been shown to improve mental health. We probably all know we
| should get out more/ go to the gym to make ourselves feel better,
| but doing it isn't always easy. Having an app might be an easier
| way or at least a starting point to feeling better. Journaling in
| morning or eve to set goals/ intentions for the day could be a
| neat feature for it too.
|
| Germany's health insurances also pay for similar products (e.g.
| selfapy) and I've heard good things. They include CBT style
| homework and journaling - but are limited to 6 weeks (i think?)
| and offer a weekly check in with an assistant psychologist - have
| you considered adding check ins? I'm also not quite clear on
| whether its aimed at any "diagnosis" in particular
| (anxiety/depression) or general low intensity work?
|
| Best of luck!
| phowson83 wrote:
| Thanks for your comment Lisa. We do do daily checkins within
| Iona, but we're always looking for ways to improve the app, and
| the idea of doing morning and evening checkins to set goals /
| intentions is definitely an interesting one.
|
| We have an "anxiety" and "low mood" track within the app at
| present, but we're mostly aimed at general mild to moderate
| usage where we feel such apps can be most effective.
|
| We've heard about Germany and it's usage of apps, it's
| certainly a country which very advanced in this area. Using the
| app to improve adherence between in-person appointments is also
| a great use-case.
| [deleted]
| y- wrote:
| Seems like soon you will be able to show numbers of how many more
| people didnt seek treatment because they looked at some app and
| thought "Now I know CBT. Its crap". Please make sure to publish
| those numbers.
| phowson83 wrote:
| Thanks for bringing this point up, and it's a point which is
| often cited in favour of greater regulation of the sector in
| general - do such apps in fact stop people seeking help when
| they may have otherwise done so? Similar criticisms can be
| levelled at Calm and Headspace - did people not seek advise
| from a clinician when they actually needed it because they had
| Headspace? Could the existence of such apps be worse than
| nothing? As an emergent field of research there is not yet much
| definitive evidence on this subject.
|
| It is also worth noting that this is not a new phenomena. The
| same could be true of people buying CBT textbooks, like the
| famous "Thinking good, feeling better" and other titles from
| the same author Paul Stallard, which have been around for many
| years. Maybe some people who bought that book got nothing out
| of it and were put off seeking therapy because they read it.
| There is little definitive hard data on the subject, but we do
| know that both app-based CBT and bibliotheraphy can both be
| effective (citations in original post).
|
| If a user churns, there are many confounding variable
| associated with the loss of that user. You do not know the
| exact reason why they stopped using the app, and whether the
| impression of the app influenced their overall view of CBT in a
| positive or negative manner. Additionally, since durable
| recovery rates from in-person CBT are around 50% (citation
| elsewhere in this comments thread), you do not know if that
| user was in the category who would've benefited from CBT in the
| first place. They may have got a similar impression had they
| seen an in-person CBT therapist. Short of capturing the user
| post-churn and asking them in person, it is difficult to get a
| firm handle on such figures, but it's certainly an interesting
| and important statistic which hopefully will become clearer as
| research on the area progresses.
| dang wrote:
| Please make your substantive points thoughtfully. We're trying
| to avoid the flamewar style on HN.
|
| https://news.ycombinator.com/newsguidelines.html
| jph wrote:
| Congratulations! Cognitive Behavioral Therapy (CBT) and related
| treatment areas can be excellent ways to help people help
| themselves.
|
| As a heads up, what I've seen is some tech folks can be greatly
| encouraged to try mind-improvement apps; it turns out one phrase
| works wonders: "you can hack your own mind".
| phowson83 wrote:
| Thanks for your comment jph, "you can hack your own mind" is a
| really great way to frame it!
| bserge wrote:
| A worthy endeavour, but CBT doesn't help the physically broken.
| Brains break and malfunction just like other organs and no amount
| of telling them to fix themselves will work.
|
| I built my custom "therapist", I know exactly what I need, but it
| worked sporadically for a while then just seemed like a complete
| joke.
|
| Perhaps someone could fund a startup that would connect people
| with suppliers of medicine that is non addictive yet prescription
| only, like most antidepressants, anxyliotics and DNRIs.
|
| There are still some countries where some are OTC, which is a
| godsend, but having to physically travel there is hard, slow,
| expensive and not for everyone.
|
| And for absolutely asinine reasons governments got to eBay and
| online payment processors and all the sellers have disappeared.
| phowson83 wrote:
| I agree, CBT is certainly no panacea, and as mentioned in the
| post, for those at the moderate to severe end of the spectrum,
| or for those where CBT is ineffective, it may be the case that
| medication is the only viable solution.
|
| Y Combinator has actually funded several companies looking at
| the usage of various drug-based mental health treatments,
| including Osmind (S20) and another company in this batch (S21)
| who are looking at the use of psychedelic therapeutics for
| mental health, although none are addressing your specific issue
| with availability / accessibility which is a tricky one with
| respect to legislation and regulation.
| GordonS wrote:
| > Perhaps someone could fund a startup that would connect
| people with suppliers of medicine that is non addictive yet
| prescription only, like most antidepressants, anxyliotics and
| DNRIs.
|
| While many antidepressants are not psychologically addictive,
| it's worth noting that they many cause physical dependence due
| to receptor up/down regulation, and can cause horrendous
| withdrawal symptoms.
|
| I have personal experience of this - when coming off a TCA
| (which are _effectively_ SNRIs) I felt like I was dieing - I
| vomited for days, had hallucinations, the whole works. And
| perhaps worse, there is a 2 week gap in my life where I don 't
| remember a thing.
|
| As someone who has tapered off (prescribed) opioids before,
| coming off opioids was easier for me than TCAs or SNRIs (which
| I also, unfortunately, have experience of).
|
| And all that is before considering the common side effects,
| such as dizziness and vertigo, headaches, vision problems etc.
| I'm really not sure it's a good idea for people to take meds
| like these without medical supervision.
| gentleman11 wrote:
| I think something a lot of customers will hesitate because of is
| the state of privacy and security in the software industry, and
| employers spying on employees in general. People will be very
| hesitant to trust such a system
| phowson83 wrote:
| In fact, privacy is a concern that sometimes even puts
| employees off using their employer's Employee Assistance
| Program (EAP), even though that's often in the form of a crisis
| telephone number which you phone.
|
| There are a number of apps in this space who sell to employers
| but there's no industry wide survey of utilization numbers for
| such apps, so it's difficult to judge to what degree this is an
| issue across the entire sector. We do what we can, offering
| completely anonymous sign up, no requirements to enter name,
| demographics etc., no location tracking etc. and it's certainly
| an important issue for users which we're cognizant of
| fishtoaster wrote:
| Very cool!
|
| I worked on an app-based CBT startup for a number of years. The
| core business problem is that adherence to self-guided CBT of any
| sort (workbooks, apps, etc) is super low compared to in-person
| therapy.
|
| We solved this by having a live non-therapist "coach" to call you
| periodically and encourage clients to continue through the
| program. That set a lower bound on how much we could charge
| users, and made our product too expensive for consumers. We were
| eventually forced to switch to the employer market, with mild
| success before we ran out of money and soft-landed.
|
| It's promising to hear that you've landed on the employer market
| earlier than we did, but honestly you might have luck in the
| consumer space. Since your cost per user is pretty low, you could
| potentially get the app subscription down to something workable
| for the average person without dealing with insurance.
|
| I think you're probably still going to run into the core problem,
| though: engaging people. I think you're making the right call to
| stick with predictable chatbots, but I suspect you'll lose some
| of the engagement you'd get with a more advanced bot. I always
| wondered how Woebot got around that. -\\_(tsu)_/-
|
| Another thing to watch out for: you'll have constant pressure to
| drift away from the science - to build something that consumers
| like, but is not well-supported and/or hurts efficacy. Fight it!
| Keep evidence-based medicine in your core values. Lean on your
| clinical director for content review. It's too easy to build a
| feel-good, do-nothing app, I hope you can stick to your evidence-
| based convictions long-term. :)
|
| Anyway, best of luck! Software-delivered CBT is a super promising
| field and I wish you the best. :)
| phowson83 wrote:
| Thanks for your comment, support and advice! I think that's a
| really good point that the main challenge here is engagement
| and adherence, and it's obviously something we're always
| looking at and trying to improve.
|
| In terms of drifting away from evidence based approaches,
| that's definitely a risk and a temptation for everyone in this
| space, and links to some of the other commenters fears here as
| well. It's a slippery slope we're well aware of and which we
| don't want to slide down.
| weego wrote:
| I have an informal background in learning and cognitive
| psychology and a decade in volunteer crisis support and mental
| rehabilitation back into a modified normal life.
|
| The pointlessness of online, self-motivated, CBT has been a
| constant source of anger and frustration in mental health
| communities for years. Granted I most likely only see the people
| these tools fail for and are then further down the track so I
| can't claim of any knowledge on what % of people CBT or DBT
| works.
|
| I wish you well of course, but mental health is not an area that
| 'scales' well in this way. Self-motivation and reflection are
| usually the first tools to fall away when someone is in need of
| mental health support. I think too much emphasis is placed on
| replicating academic 'truths' in the absence of the actual issues
| people face.
| phowson83 wrote:
| Thanks for your comment and sharing your experience. I think
| you make a number of valid points - CBT is sometimes
| incorrectly seen as a panacea for treatment of many disorders,
| but even face-to-face CBT does obviously not achieve a 100%
| recovery rate (I would argue no treatment does), and in fact
| 50% durable recovery rates are generally considered good. The
| UK in-person IAPT system which uses CBT to treat people has a
| target of 50% and achieves something around this level (
| https://www.nuffieldtrust.org.uk/resource/improving-access-t...
| ).
|
| As mentioned in the original post, we do not see app-based
| solutions being appropriate for individuals at the moderate to
| severe end of the spectrum, and I think this is also reflected
| in your personal experience. I also don't feel that app based
| exercises and a human therapist are mutually exclusive, and our
| users have self-reported that about 15% of them are also seeing
| a therapist (most declined to answer that question).
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