Introduction & overview
Hi all! I'm Sam, a US-based web developer & designer. My apologies for the clickbait title, but some basic research has led me to think that insomnia is a neglected, burdensome problem on a global scale with a tractable solution. Specifically, based on assumptions laid out below, I think insomnia has a burden of ~130 million QALYs (Quality-Adjusted Life Years) annually (compare to malaria's 55 million for scale). Furthermore, I think a (technically simple) implementation of a proven therapy intervention can drastically reduce the above number. I'm building a project to attempt the very thing (www.dozy.health) and am looking for some EA aligned team members.
Insomnia annual QALY loss estimation
Estimates on the prevalence of insomnia vary widely, according to definition and methodology. According to one 2008 paper, numbers range from 10% to 40%, and "Given all the information available, the prevalence of insomnia symptoms may be estimated at 30% and specific insomnia disorders at 5–10%".
A 2018 paper estimated the QALY burden of insomnia at 5.6 million QALYs per year. This estimate only counts quality of life effects, not length of life, so the real number may well be larger than this. Its methods are not extremely robust but they end up with an insomnia prevalence of 28%, which is close to the number from the previous paper.
If we assume the QALY burden of insomnia is similar among global populations (may or may not be true), then we can expand the US number to ballpark the global annual burden of insomnia at 130,000,000 QALYs lost per year.
QALY burden in perspective
A Gates Foundation-funded report in 2015 estimated the global DALY burden of malaria at 55M QALYs per year. All cardiovascular diseases together were estimated at 347M/year, depressive disorders at 54M/year, drowning at 17M/year, and interpersonal violence at 21M/year. By these estimates, insomnia has a comparably serious burden to some major issues facing humanity.
The report doesn't have insomnia as one of their 315 evaluated conditions, so I can't get a direct number for accuracy, but I can provide some estimates. For example, the report says that depressive disorders have a burden of 55M QALYs/year. If we divide that down to the US population, that's 2.3M QALYs/year. This is more conservative than the 2018 insomnia paper, which estimates depression's impact at 4M/year in the US. Same order of magnitude, but a bit less than twice what the Gates report estimated. Their anxiety burden estimate differs by a similar amount.
If we construct an (informal, statistically invalid) confidence interval for this, it might range from 30M QALYs/year to 200M QALYs/year, again depending on definitions and methods.
Tractability of insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-i) is a therapy treatment that takes 4-10 weeks, has 2-3x the impact of sleeping pills, and whose benefits are essentially permanent. We have a handful of meta-analyses to show that Cognitive Behavioral Therapy for Insomnia (CBT-i) is effective for nearly all sleep indicators - it speeds sleep onset, reduces nightly wakefulness, improves quality, reduces daytime symptoms. It works even in cases where the insomnia is comorbid with other medical or psychiatric issues.
The problem with CBT-i is it's currently inaccessible. In the entire United States, where ~60M people deal with insomnia annually, there's a total of ~250 certified providers of CBT-i. To make matters worse, many of them are researchers, or not accepting new patients, and neither patients nor doctors are aware of the treatment in the first place. This is especially shocking considering it's usually the first-line treatment recommended by relevant governing bodies. The problem is similar in other developed countries, and like other mental health treatments, completely lacking in developing countries.
Researchers who've studied the issue are excited by the potential of digital CBT-i (dCBT-i), but the issue encountered with existing solutions is a lack of personalization. It's like trying to get surgery done on yourself by taking a class on how to do surgery. Researchers suggest that further personalization options and custom treatment could result in much better retention and outcomes.
Such a digital solution would be extremely scalable, with a primarily automated treatment system supported by human attention to answer questions and reduce churn. In principle, the treatment could even be delivered over SMS.
Long story short, despite its non-communicable nature, I (and researchers in the field, plus my sleep therapist advisors) believe it's possible to dramatically reduce the DALY burden of insomnia by creating effective tools and rapidly improving them with RCT-type experiments.
Introduction to Dozy (an attempted solution)
Hence, why I'm working on my current project, Dozy. Using my existing design & development expertise, I'm creating an app that does exactly what I talked about above - automated, personalized treatment, ideally like a sleep therapist in your pocket (with human support).
Have only run a few people through my prototype so far but initial results are mostly on par with the meta-analysis on human therapists. One user went from moderate severity insomnia to no clinically significant insomnia within 6 weeks (sleep efficiency 60% > 94%, sleep duration 5.6 hours > 6.6 hours).
I'm not profit driven on this, so am looking for alternative legal structures for maximum positive impact (such as a steward ownership structure). Have been working on it unpaid full-time since May/June 2019, living extremely cheaply.
Some asks
First, is this estimate / are these assumptions reasonable to you? I don't have much formal EA research experience, so would love to know if I'm missing anything obvious.
Second, I'm actively looking for cofounders on this project to help me speed up development & iteration. If you're a mobile developer who's impact-motivated (and possibly interested in sleep science), or know anyone who fits that description, please reach out - am ready to offer an equal equity split (with cliff etc) to the right person(s).
Finally, legal structures - is a startup the best structure to scale quickly & thoroughly address the problem? Are there charity or non-profit structures that would work? I'd like to be paid eventually but will donate most of what I make anyway (already took the Founders Pledge, will likely raise my pledge later), so personal financial return is not a primary concern.
Sources
Prevalence of insomnia and insomnia burden:
2008, Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504337/
2018, Insomnia and Impaired Quality of Life in the United States (no public full text, message me and I can send it to you). https://www.ncbi.nlm.nih.gov/pubmed/30256547
2015, Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 https://www.ncbi.nlm.nih.gov/pubmed/27733283
Efficacy of CBT-i:
2018, Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. https://www.sciencedirect.com/science/article/abs/pii/S1087079217300345?via%3Dihub
2015, Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/26054060
2015, Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/26147487
2019, Digital Delivery of Cognitive Behavioral Therapy for Insomnia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546653/
Hi EdoArad!
Thanks for your comment. Unfortunately there are a lot of unknowns with both of these questions but I can lay out some context of the current environment.
As things stand, a relative minority of people seek medical treatment for their insomnia. E.g. while estimates put the prevalence of insomnia itself between 10-40%, the actual number who seeks treatment and gets diagnosed is around 5-10% (mentioned in the first citation above). There may be several factors for this, but the one I've heard most commonly from user interviews is people (reasonably) don't want to go on sleeping pills, and that's what they'll get 90% of the time in most medical establishments.
So honestly, the current rate of people seeking treatment through official medical channels is bad, though seeking informal solutions is quite common and going up. The biggest example of this is the "sleep stories" and other sleep-focused features in Calm and Headspace, which have reportedly expanded to be a giant chunk of their userbase (no numbers released unfortunately). My hypothesis is that having an effective, well-reviewed app out there will keep that barrier to entry low and get a much larger percentage of the insomniac population to attempt a fix.
The other factor I'm shooting for re: awareness is word of mouth. (Nearly) very insomniac I've spoken to knows multiple others, and the users I've treated so far have both spread the word about Slumber without me asking them to. The kind of improvements that are possible in fixing insomnia have potential to create a lot of superpromoter users, who (maybe coupled with some kind of referral incentive) can spread the word more effectively than any other channel.
Regarding marginal contribution: The major existing player (Sleepio) has several key flaws that I believe keep it from being the solution we need.
1. As mentioned above, Sleepio functions more as an online class on how to administer yourself CBT-i than a therapist who administers it for you. You watch lectures, take home homework, and try to figure things out yourself for the most part (though I believe they do have a human chat available for questions). This approach has a very high churn rate (how many people start an online class and never finish?) and around 70% of the efficacy of in-person therapy. For example, on this study on dCBT-i, the churn rate was 35% (https://www.researchgate.net/publication/280584339_Predictors_of_dropout_from_internet-based_self-help_cognitive_behavioral_therapy_for_insomnia). In others, it was as high as 49%.
I'm still experimenting with the format, but my hypothesis is that flipping the perspective - creating an app that functions as a therapist (with custom treatments & decision trees), plus social measures for churn - will produce a solution that approaches or matches that of in-person therapy (churn rate of ~12%).
2. The price. Sleepio doesn't show the price of their program without digging, but a quick Google search suggests it's currently around $400. They don't seem to take insurance. This puts it out of financial reach of many, and I'd guess it gives them a *very* healthy profit margin - especially considering the percentage of users who never complete the program, and the amount that's completely automated. It's my goal with Slumber to make something substantially more affordable, probably at least half the cost for more developed countries and less for places with less purchasing power.
You'd think Sleepio would have greater market penetration than they do - the company got started in 2012 and has raised $15M+, but their product still looks like it was made in Flash player, their mobile app is broken for what seems like half of their users, and society as a whole doesn't seem more familiar with CBT-i as a result of their efforts and funds.
3. I've interviewed a few people who've gone through the Sleepio program, and my sleep therapist advisors tell me they get many patients who've tried it. Common threads seem to be it's hard to finish, it didn't work for them, or (to one person) the content was presented condescendingly, and they didn't have the flexibility to change their sleep schedule or know when they'd be off restricted sleep. So have heard a number of complains. Additionally, Sleepio doesn't have financial incentive to help a user once they've bought in - it's just the upfront fee, with no money back guarantees or anything of the sort. Those people who it didn't work for still made Sleepio money. From a profit perspective, the company seems well off.
There are few other options in this field worth mentioning. A company called Pear Sleep is developing an app from a pharma view, with the goal of getting it prescribed in doctors' offices. This is good in terms of institutional acceptance but the product is inaccessible as a regular consumer - another barrier to entry. The freely available online resources are garbage - it's necessary to dig into the literature to find guides on treatment.
Even if everything I build is only as good as what's already out there, drawing more people into treatment and offering an alternative to sleeping pills is worth a lot, given the health cost of sleeping pills (50k ER visits in the US, in one year, from one brand) and the relative lack of improvement they bring (avg 11 mins reduced sleep onset, or ~1/3 to 1/2 as effective as CBT-i). Solving the problems of awareness, growth, and scaling would make a big dent in the QALY burden.
I think Slumber can address the above by being
Hope this answers your questions, or at least the state of my current answers to them. I'm aiming to have more solid evidence re: efficacy and churn within the next few months, which should help me assess marginal impact with more confidence.