CVS Health apps put sleep ther­a­pies just a click away

The Fresno Bee (Sunday) - - Insight - BY NATASHA SINGER

CVS Health wants to help mil­lions of Amer­i­can work­ers im­prove their sleep. So for the first time, the big pharmacy ben­e­fits man­ager is of­fer­ing a purely dig­i­tal ther­apy as a pos­si­ble em­ployee ben­e­fit.

The com­pany is en­cour­ag­ing em­ploy­ers to cover the costs for their work­ers to use Sleepio, an in­som­nia app fea­tur­ing a car­toon ther­a­pist that de­liv­ers be­hav­ior mod­i­fi­ca­tion les­sons.

CVS Health’s push could help the nascent busi­ness of dig­i­tal ther­a­peu­tics, which mar­kets apps to help treat con­di­tions such as schizophre­nia and mul­ti­ple scle­ro­sis. The com­pany re­cently in­tro­duced, along with Sleepio, a way for em­ploy­ers to cover down­loads as eas­ily as they do pre­scrip­tion drugs. The com­pany said it had al­ready eval­u­ated about a dozen apps.

Some in­dus­try ex­ec­u­tives and re­searchers say the dig­i­tal ser­vices should make ther­apy more ac­ces­si­ble and af­ford­able than in-per­son ses­sions with men­tal health pro­fes­sion­als.

Big Health, the startup be­hind Sleepio, is one of more than a

dozen com­pa­nies that are dig­i­tiz­ing well-es­tab­lished health treat­ments like cog­ni­tive be­hav­ioral ther­apy, or de­vis­ing new ther­a­pies – like video-game­based treat­ments for chil­dren with at­ten­tion deficit hy­per­ac­tiv­ity dis­or­der – that can be de­liv­ered on­line. Since last year, a few phar­ma­ceu­ti­cal com­pa­nies, in­clud­ing No­var­tis, an­nounced part­ner­ships with star­tups to de­velop dig­i­tal treat­ments for men­tal health and other con­di­tions.

So far, the use of treat­ment apps has been limited. But with the back­ing of CVS Health, which ad­min­is­ters pre­scrip­tion drug plans for nearly onethird of Amer­i­cans, those ther­a­pies could quickly reach tens of mil­lions of peo­ple. A few em­ploy­ers have started of­fer­ing Sleepio, and more are ex­pected to sign on this fall, CVS Health said. Like in-per­son ther­apy, the in­som­nia app does not re­quire a pre­scrip­tion.

“We are at this piv­otal mo­ment,” said Lee Rit­ter­band, a psy­chi­a­try pro­fes­sor at the Univer­sity of Vir­ginia School of Medicine who has de­vel­oped on­line health in­ter­ven­tions for more than a decade. “For years, th­ese have been bub­bling un­der the sur­face.”

Other ex­perts ar­gue that on­line ther­a­pies may not be ready for mass adop­tion. In a re­cent study in Na­ture, re­searchers warned that most dig­i­tal treat­ments lacked ev­i­dence of health ben­e­fits. Al­though first-of-their-kind med­i­cal apps that claim to treat dis­eases must ob­tain clear­ance from the Food and Drug Ad­min­is­tra­tion, health apps that make vaguer well­ness claims – like bet­ter sleep – gen­er­ally do not need to demon­strate ef­fec­tive­ness to fed­eral reg­u­la­tors.

CVS Health said it was care­fully re­view­ing the sci­en­tific lit­er­a­ture on dig­i­tal ther­a­pies to de­cide which ones to of­fer em­ploy­ers. The com­pany se­lected Sleepio first partly be­cause the app was backed by rig­or­ous, pub­lished stud­ies, said Dr. Troyen A. Bren­nan, CVS Health’s chief med­i­cal of­fi­cer.

“It’s im­por­tant for us as a pharmacy ben­e­fit man­age­ment com­pany, as a big re­tail pharmacy, to en­dorse dig­i­tal ther­a­peu­tics when they work as good as or bet­ter than med­i­ca­tions one can take by mouth,” Bren­nan said. “We can give the stamp of ap­proval from hav­ing looked at the sci­en­tific in­for­ma­tion.”

Vol­un­teers in ran­dom­ized stud­ies who used Sleepio re­ported feel­ing milder in­som­nia than peo­ple who used a placebo treat­ment app or on­line sleep ed­u­ca­tion. But the app has not been rig­or­ously stud­ied against sleep­ing pills or in-per­son be­hav­ioral ther­apy.

CVS Health is of­fer­ing Sleepio just as health ex­perts have soured on pre­scrip­tion sleep­ing pills.

In 2018, re­tail phar­ma­cies in the United States dis­pensed more than 29 mil­lion pre­scrip­tions for drugs like Lunesta and Am­bien. But the FDA warned Amer­i­cans in April that tak­ing cer­tain sleep­ing med­i­ca­tions had caused dan­ger­ous sleep­walk­ing and “sleep driv­ing,” re­sult­ing in se­ri­ous in­juries and even deaths. The Amer­i­can Col­lege of Physi­cians now rec­om­mends cog­ni­tive be­hav­ioral ther­apy – a proven psy­cho­log­i­cal in­ter­ven­tion that can help peo­ple change neg­a­tive think­ing pat­terns – as the ini­tial treat­ment for adults with chronic in­som­nia.

Peter Hames, the chief ex­ec­u­tive of Big Health, said he had hit upon the idea for Sleepio af­ter he de­vel­oped in­som­nia. He taught him­self to mod­ify his poor sleep habits, he said, by read­ing self-help books on cog­ni­tive be­hav­ioral ther­apy by Colin A. Espie, a sleep medicine pro­fes­sor at Ox­ford Univer­sity. He and Espie later founded Big Health to dig­i­tize the tech­niques.

“We are tak­ing ev­i­dence-based, non­drug ther­a­pies like cog­ni­tive be­hav­ioral ther­apy that are tra­di­tion­ally de­liv­ered face to face by hu­man therapists and then fully au­tomat­ing them,” Hames said.

Sleepio un­folds more like a low-key, sin­gle­player video game, where the user is on a quest for bet­ter sleep, than a clin­i­cal health pro­gram. The app fea­tures an an­i­mated sleep ex­pert. The bot of­fers peo­ple who have in­som­nia symp­toms a se­ries of six weekly on­line ses­sions.

Big Health has raised $15 mil­lion from in­vestors in­clud­ing Kaiser Per­ma­nente, the Cal­i­for­nia-based health sys­tem. In 2015, the startup be­gan sell­ing Sleepio di­rectly to em­ploy­ers, send­ing them ag­gre­gated data on their em­ploy­ees’ progress. Com­pa­nies pay a fee for each em­ployee who uses the in­som­nia app, but Big Health de­clined to dis­close its pric­ing.

Delta Air Lines and Bos­ton Med­i­cal Cen­ter, two of the com­pa­nies that work di­rectly with Big Health, said em­ploy­ees who used Sleepio re­ported im­proved sleep.

“It feels a lot more like play than work,” said Lisa Kelly-Croswell, the chief hu­man re­sources of­fi­cer at Bos­ton Med­i­cal Cen­ter, which has of­fered Sleepio since 2016. About 3,000 em­ploy­ees there com­pleted the app’s ini­tial screen­ing ques­tion­naire, she said, while 350 peo­ple fin­ished the six-week pro­gram.

In sev­eral ran­dom­ized stud­ies that as­signed some vol­un­teers to use Sleepio and oth­ers to a dif­fer­ent treat­ment, like on­line sleep ed­u­ca­tion, the Sleepio user group gen­er­ally had a greater re­duc­tion in the time it took to fall asleep and the time spent awake at night. At the end of the stud­ies, how­ever, there was lit­tle dif­fer­ence in to­tal sleep time be­tween Sleepio users and nonusers.

Ac­cord­ing to the Amer­i­can Academy of Sleep Medicine, the goal of in­som­nia ther­apy is to im­prove both the qual­ity and the quan­tity of sleep. Espie said the app’s goal was to treat bro­ken sleep, say­ing that “peo­ple who get con­sol­i­dated sleep feel the ben­e­fit of that.”

But in one ran­dom­ized clin­i­cal trial with more than 3,700 par­tic­i­pants, only 18% of Sleepio users com­pleted the in­som­nia treat­ment. In an­other study, with nearly 1,400 par­tic­i­pants, more than half of the Sleepio group did not en­gage with the app at all – sug­gest­ing that app ther­apy may be off­putting to some peo­ple.

Espie said some Sleepio users felt ben­e­fits from the app early on and stopped us­ing it.

Christo­pher L. Drake, sec­tion head for sleep re­search at Henry Ford Health Sys­tem in Detroit and a co-au­thor of the 1,400-per­son study, said many peo­ple sim­ply pre­ferred in-per­son ther­apy.

“The fu­ture will be com­bin­ing the ef­fi­ciency and ac­cess of a dig­i­tal ther­a­peu­tic with the per­son­al­iza­tion that you get from one-on-one ther­apy with a clin­i­cian,” Drake said.

IAN C. BATES NYT

CVS Health is en­cour­ag­ing em­ploy­ers to pro­vide the Sleepio sleep app, which could help push dig­i­tal ther­a­peu­tics into the main­stream.

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