Trouble falling asleep? You could take sleeping pills, but they’ve got side effects. Guidelines recommend you try Cognitive Behavioral Therapy For Insomnia (CBT-i), a medication-free process where you train yourself to fall asleep by altering your schedule and sleep conditions.

The journals are full of articles begging doctors to use CBT-i instead of potentially-dangerous sleeping pills. Doctors rarely comply: getting patients CBT-i is hard. The usual sound bite is that “there are 60 million people with insomnia in the US but only 75 licensed CBT-i therapists.” What can you do? Not much.

Until now! Late last year, Pear Therapeutics released a CBT-i app (formerly “SHUT-i”, now “Somryst”) which holds the patient’s hand through the complicated CBT-i process. Studies show it works as well as a real therapist, which is very well indeed. There’s only one catch: you need a doctor’s prescription.

Wait, you can prescription-gate an app? Yes! Although you can download Somryst off your normal App Store, it won’t work until a doctor writes you a prescription to “activate” it. Until then, it just shows you ads for how great CBT-i would be if you could get it.

And it’s not just Somryst. I know of at least three other prescription apps. reSET and reSET-O are 12-week courses to help addiction and opioid addiction, respectively. EndeavourRx is a video game which is supposed to help manage ADHD in kids. I guarantee you there are a lot more of these in the pipeline.

In theory, an app is a great solution to accessibility issues. Some people can’t afford to see a professional. Or they have complicated schedules that make it hard to see a professional. Or they’ve been traumatized by the medical system and don’t want to see a professional. Or they have executive function problems and can’t schedule a appointment with a professional. Or they have bad insurance that doesn’t have many professionals in-network, and all of them have six month wait lists. Freddie de Boer, who has more resources and know-how than most people, describes his experience trying to get a therapist here:

I have had deeply imperfect access to mental health care over the past two decades, given that this is the American medical system, but I have had superior access to most people. And I still have consistently struggled to get into therapy. I should have been in therapy constantly given my mental illness and my biography. But I’ve barely been in it at all. Consider immediately after my last hospitalization. I was highly motivated to get a therapist; my life was a wreck, after all. I had time away from work to look. And I had access to NYC union health insurance, which is well-known to be strong despite years of erosion of benefits. What’s more, New York has one of the highest therapist/analyst/mental health professional densities in the world. I don’t have kids and my schedule was more flexible than that of most.

And yet trying to find a therapist was a nightmare. A truly discouraging number of places didn’t take my insurance or take insurance at all. Out of pocket costs that were cited were like $300 and up. Tons and tons of promising-seeming options were not taking new patients and several told me there were waiting lists. Also, many told me that they were “not the right therapist to meet your needs” when I told them about my bipolar disorder and recent psychotic episode. Two more discouraging stories. First, I went to one place, had an intake appointment, everything seemed fine, at the end the guy said “your appointments will be Mondays at 2:00 PM.” I said, that doesn’t work for me; back then I worked 8 to 4 PM, and it would be an hour commute on either side, meaning I’d be leaving work at 1 PM every Monday and not returning. I couldn’t imagine asking that of my boss. I’m sure I could have forced them to let me for ADA compliance but I was already in a very awkward situation given everything that had happened, and for the record I liked that boss. So that was out.

The other one really pissed me off. I had been having so many problems with insurance that I made sure that the therapist I was going to see was in-network. I went, had the intake appointment, it went great, she said they could be flexible with my work schedule, and then she said “your therapist will be Dr. X.” I was surprised. It turned out she just did that intake appointment and would not be my full-time therapist. That was annoying as I just shared a lot with her, but fine. I then found out that the therapist she assigned me to did not take my insurance , despite being part of the same group/place/whatever as the woman I had researched. Let me remind you that an intake appointment typically involves delving into some personal and traumatic background information. That incident left me feeling completely powerless.

I know people don’t mean to do harm but “why don’t you just get a new therapist?” is a callous and unhelpful thing to say. It’s really fucking hard even under good circumstances, that’s why.

And when you do get a professional, half the time they tell you that you just need to lose weight / quit marijuana / find Jesus / find wokeness, and refuse to treat you until you qualify as virtuous enough to deserve their help. If they do want to provide treatment, there’s a decent chance they’ll demand a bunch of unnecessary tests and scans before they’ll do the basic empirical treatment they should have started with.

I’m not some kind of anti-doctor extremist. I’ve been a doctor for ten years, my whole family is doctors, doctors are good people. It’s just that one in every X of them is some kind of lizard-person infiltrator, charged with making getting health care as difficult and unpleasant as possible. I wish I could explain this better - I think a lot of healthy people who have never visited doctors are reading this and thinking “Oh, come now, it can’t really be that hard”, and your skepticism is understandable. It’s only through working with thousands of psychiatric patients in every situation imaginable that I’ve started to understand exactly how much of a burden the requirement to see a doctor can be.

Therapy apps are a perfect solution to this problem. Except that if you make people go to a professional to get a prescription to use the app, you’re kind of clutching defeat from the jaws of victory.


So why are health apps starting to become prescription-only?

Maybe you’ve read my old post on Lovaza? Lovaza is prescription fish oil. You can get non-prescription fish oil from any supermarket or supplement store for $10 per Giant Jar. Or, if you prefer, you can go to a doctor and get prescribed Lovaza for $300 a month. Is there a difference between Lovaza and regular fish oil? Other than the 30x markup and prescription-gating, no. Nor is there much difference between regular methylfolate and prescription Deplin. You can get some effective treatment for very cheap as a supplement. Or you can get the same treatment for much more money as a prescription medication.

It’s hard and expensive to get a product into the official medical system. You need to produce studies for the FDA (it doesn’t matter if dozens of studies already show fish oil works, you need to do new studies) and prove you’re complying with various regulations. By the time you’ve done all those things, you’ve spent a lot of money. And also you have a sort of monopoly, in that you’re the only company whose fish oil is FDA approved and able to interface with organizations who will only work within the regular medical system (eg insurance). So you increase the price by 30x. Patients are fine with this, because their insurance foots the bill. Insurance companies are fine with this, because the law demands that they be fine with it. Even if you or I know that normal fish oil is just as good as Lovaza, the official medical system doesn’t know this, and the insurance company is not allowed to make use of this knowledge.

You or I could create a CBT-i app tomorrow and sell it for $1 or $10 or whatever the normal price of an app is. But it wouldn’t be official, and insurance companies wouldn’t pay for it. Pear Therapeutics created a CBT-i app, put in the work to make it official, and now they’re selling it for $899. “Our support team, PearConnect™, will help determine insurance coverage eligibility during onboarding”, says their website.

My guess is that prescription-gating is necessary because it’s the last step in the process of transforming it from an app ($10 price tag) to a “digital therapeutic” ($899 price tag). The magic words for forcing insurance companies to pay for something is “a doctor said it was medically necessary”. Make sure that every use of Somryst is associated with a doctor’s prescription, and that’s a whole new level of officialness and charge-insurance-companies-lots-of-money-ability.

The good news is, Somryst has partnered with telemedicine provider UpScript. I know nothing about UpScript, but I suspect they are a rubber-stamping service. If you don’t have a doctor of your own, you can pay their fee, see a tele-doctor, and say “I would like a prescription for Somryst”. The tele-doctor asks if you have insomnia, you say yes/no/maybe/no hablo inglés, and the tele-doctor hands you a Somryst prescription and charges you $45.

On the one hand, at least this saves you from Doctor Search Hell. On the other, it involves paying $45 for the right to pay $899. So it’s kind of a wash.


Who killed the democratization of mental health?

A few years ago, I was so optimistic about therapy apps. I thought they would empower patients to take mental health care into their own hands, free from gatekeepers and big corporations.

But CBT-i is the killer app here, and people have spent the last few years bungling it. And now when something finally comes out that I can have confidence in, it’s designed to replicate all the worst features of the old system. Why?

I can’t really blame the FDA here. Their regulatory guidelines for medical apps are clear as mud, but I think they would let people make non-prescription CBT-i courses. You would have to replace claims about “treating insomnia” with weasel language like “supports healthy sleep”, but you could do it. As far as I can tell the FDA is doing the right thing - agreeing to certify apps that put in the extra work to go through their approval process, but not banning ones that don’t.

And I’m philosophically opposed to blaming Pear Therapeutics, the company behind Somryst. If you let a for-profit company charge $899 for an app, of course they’ll be all over that. I’m less interested in Somryst being greedy enough to charge $899 for an app - I assume most app makers would charge $899 if they thought they could get away with it - and more interested in why this is apparently a price that the market will bear.

I think I mostly blame the US health care system. Patients don’t pay for any of their own care, the government regulates insurance companies to the point of effectively deciding what they have to cover, and nobody is allowed to exercise common sense at any point. The system is set up so poorly that it incentivizes companies to prescription-gate their apps and charge $899 for them, and once you make that an option, of course somebody’s going to do it. This is part of why I am dedicating my life to building an alternative, non-insurance-based system of mental health care.

I secondarily blame all the people who should have made the $10 app but didn’t. There is just an appalling shortage of freely available CBT-i material right now. This person sells a $50 CBT-i course/workbook, and I hear it’s pretty good. The Veterans Health Administration has some CBT-i apps, although I believe one of them is very limited, and the other is only designed to supplement a therapist rather than to replace them. None of these is exactly a CBT-i app, but they’re proof that you can do good work in this field, and potentially someone could tie it all together and make an affordable and accessible version of Somryst. I think this would be a worthy cause for any public-spirited entrepreneur. Maybe I’m wrong about the regulatory environment and you can’t actually do this legally, in which case you should do it anonymously and take payments with crypto.

And you should do it soon. Alexander Pope writes:

Vice is a monster of such frightful mien
As to be hated, needs but to be seen.
But seen too oft, familiar with its face
We first endure, then pity, then embrace

Any loss of freedom stings for a few months. Then it’s just The Way Things Have To Be. Oregon somehow ended up with a law banning self-serving gas stations. In 2018, someone tried to repeal the law and legalize them, and was met with outrage: what if there were gas-related injuries? What if people got confused and couldn’t fuel their cars? What if it increased inequality somehow?

Right now, in the heady youth of the industry, I feel angry about prescription-gated apps that cost $899. CBT-i is so good, and so important, and we were so __ close to being able to make it accessible to everyone. Then we snatched defeat from the jaws of victory. Getting your CBT-i will remain as financially and logistically inaccessible as everything else in medicine. Diphenhydramine, one of those risky, tolerance-building sleeping pills we want patients to avoid, is sold over-the-counter at every drugstore for a few cents a pill. But if you want to learn how to get good sleep naturally with no side effects, you’re out of luck unless you have the resources and willpower to hunt down an in-network doctor and beg them for permission.

On the other hand, CBT-i is really good. Apparently nobody was incentivized to offer it electronically without this system. And this system ensures the electronic version will be high-quality and evidence-based. Insurance will pay the costs in some hard-to-follow way that will never make any individual person feel like they’re spending the extra money. I can already feel myself beginning to endure and pity and embrace this.

So do something with your anger while it’s hot. In a few years, $899 prescription-gated apps will seem good and normal.

(a few years after that, people will be outraged that some apps are still available without prescriptions. Isn’t that a public safety hazard?)