Launch HN: Iona Mind (YC S21) – App-based cognitive behavioural therapy
62 comments
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.
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.
Some good points! I've been thinking about the chatbot model a lot and I echo your thoughts. I've been working with a therapist and a fiction author to combine interactive storytelling with self-reflection tools based on a variety of psychological approaches. Our main challenge has been to build a conversational engine that allows for the user's need for autonomy, agency, personalization and relatedness. This has required a lot of scripting, meaningful fixed choices and enough open-ended prompts so the users feel they are co-creating the world and having an actual conversation that goes deeper than the schematic chatbot interactions we see out there.
I'd love to talk to you about your experience at Ginger, if you're open to a chat? If so, I'm at ez.skinner89[at]gmail[dot]com.
I'd love to talk to you about your experience at Ginger, if you're open to a chat? If so, I'm at ez.skinner89[at]gmail[dot]com.
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.
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.
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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. ¯\_(ツ)_/¯
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. :)
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. ¯\_(ツ)_/¯
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. :)
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.
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.
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!
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!
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.
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.
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.
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:..."
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:..."
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.
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).
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).
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?
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?
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.
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.
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.
> 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.
> 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.
Sorry for the previous comment. I understand your in distrust in medical system and bureaucratic processes.
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> Yoga videos do not harm you. In worse case you will tear your ligament.
Ligament tearing is definitely harm.
Ligament tearing is definitely harm.
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.
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
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
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).
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).
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.
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.
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.
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.
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.
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.
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).
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).
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.
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.
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.
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.
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.
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!
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!
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.
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.
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 :)
Someone please make a standalone device for all the mental health apps, so I can take it to the park with me and detox :)
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/
"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/
Congratulations on the launch! I haven’t checked out the app yet but CBT is something close to my heart. I started doing traditional talk therapy as a teenager and it never seemed to help anything. As an adult, after years of wild ups and downs, I finally wound up working with someone who specialized in CBT. She and the experience changed everything for me. I see A handful of comments here talking about how CBT doesn’t work for everyone; however, for others, it might be the only thing that DOES work.
These days, I don’t see a therapist anymore in part because finding someone who does CBT in my area and accepting my insurance has proven impossible but I do work through a CBT workbook on occasion. It helps me manage get the ship sailing back on course when a storm messes up navigation for too long. This could just as easily be done in an app and I’d certainly reach for your product or one like it before seeing another “tell me about your problems while I sit silently and nod at you” therapist.
These days, I don’t see a therapist anymore in part because finding someone who does CBT in my area and accepting my insurance has proven impossible but I do work through a CBT workbook on occasion. It helps me manage get the ship sailing back on course when a storm messes up navigation for too long. This could just as easily be done in an app and I’d certainly reach for your product or one like it before seeing another “tell me about your problems while I sit silently and nod at you” therapist.
It's great to hear about your experiences with CBT and hear from someone in the ~50% for whom CBT works. We certainly wouldn't bill it as a panacea for all conditions, as we've discussed in the comments section here, and it's wrong to see it as such, but for those who it works for it's an excellent tool. Also great to hear that so-called bibliotherapy has been of assistance to you.
As you allude to, while there are many academic papers showing the efficacy of CBT, DBT and ACT, in various forms of trial, some other forms of talk therapy are not backed by such a robust evidence base.
As you allude to, while there are many academic papers showing the efficacy of CBT, DBT and ACT, in various forms of trial, some other forms of talk therapy are not backed by such a robust evidence base.
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
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
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
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Glad to see the mental health apps space expand.
The problem with curative healthcare apps is that it's hard to make it a sustainable business without government fund or private partnerships. App success is generally linked with usage. The longer the people use the apps, the more successful they are. In the case of curative apps that's reversed. Your app is more successful if people don't need it anymore, which makes it hard to monetize. I hope you manage to overcome this challenge and wish you great success!
It might be interesting for you to follow the story of Quirk and how they had to pivot as a company: https://github.com/Flaque/quirk
Also an interesting read, their original Launch HN thread: https://news.ycombinator.com/item?id=20646918
I am not affiliated with them, their story is the first thing that popped in my mind when I saw this.
It might be interesting for you to follow the story of Quirk and how they had to pivot as a company: https://github.com/Flaque/quirk
Also an interesting read, their original Launch HN thread: https://news.ycombinator.com/item?id=20646918
I am not affiliated with them, their story is the first thing that popped in my mind when I saw this.
Thanks for bringing those up. We're certainly aware of Quirk and the story, although we haven't as yet talked to the founders in person. Their story is very relevant to this discussion.
The points about sustainability of business model are very relevant ones, which is why we have a long term aim of building software as a medical device, which is potentially distributable / reimbursable by healthcare systems / insurance. This also opens up potentially different payment models, which can be more sustainable.
The points about sustainability of business model are very relevant ones, which is why we have a long term aim of building software as a medical device, which is potentially distributable / reimbursable by healthcare systems / insurance. This also opens up potentially different payment models, which can be more sustainable.
I've been using this app for the past few days and it's wildly good. I've compared it to MindDoc and Woebot and the exercises you offer are so much better than those two apps.
My only request is to please refrain from gating too many of the features behind expensive subscription services. There is a sustainable commercial model out there, but it's not $10 p/m to access past moodlogs (MindDoc)
My only request is to please refrain from gating too many of the features behind expensive subscription services. There is a sustainable commercial model out there, but it's not $10 p/m to access past moodlogs (MindDoc)
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".
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".
Thanks for your comment jph, "you can hack your own mind" is a really great way to frame it!
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.
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.
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.
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.
> 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.
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.
Yeah, been there, done that. SSRIs are garbage for me. Withdrawals are just time off work, though.
I used Woebot for a while and was engaging, sometimes useful CBT. Wondering if you heard of it? If yes would be good to know how does your chatbot compare. I finished all content on Woebot and wouldn't mind going through more CBT with Iona Mind.
We've most certainly heard of Woebot. Would be really interesting to hear how you feel about Iona in comparison.
Obviously we're much earlier stage than Woebot who have in fact been around since 2017, but the mission is certainly similar. We've gone for a different tone and feel to Woe at the moment and will continue to expand and improve the product and content as the company grows. I think there's a demographic for whom the tone of Woebot doesn't really appeal, which is why we've gone for a slightly different style in our content.
Obviously we're much earlier stage than Woebot who have in fact been around since 2017, but the mission is certainly similar. We've gone for a different tone and feel to Woe at the moment and will continue to expand and improve the product and content as the company grows. I think there's a demographic for whom the tone of Woebot doesn't really appeal, which is why we've gone for a slightly different style in our content.
- 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
- 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
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.
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.
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.
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?
Can you explain more about how you're able to keep the conversation on track while leveraging the adaptability of a generative system?
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.
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.
"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.
This is the need of the hour. Cant wait to sign up and try out.
Great! Any comments and feedback on Iona is always much appreciated, let us know how you get on.
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.
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.
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.
Please make your substantive points thoughtfully. We're trying to avoid the flamewar style on HN.
https://news.ycombinator.com/newsguidelines.html
https://news.ycombinator.com/newsguidelines.html
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 [email protected]
[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