phowson83

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.

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.

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.

Great! Any comments and feedback on Iona is always much appreciated, let us know how you get on.

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.

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.

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.

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

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.

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.

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).

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.

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.

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.

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).

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.

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.

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:..."

Thanks for your comment jph, "you can hack your own mind" is a really great way to frame it!

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.

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.

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