Prescription Digital Therapeutics: Reimagining Care in Behavior-Driven Conditions - Episode 6

Durability of DTx and PDTs

Drs Whittle and Podesta discuss the durability and stability of DTx and PDT treatment.

John Fox, MD: The other thing that insurers, payers, and providers are worried about is the durability of the effect. These are prescription digital therapeutics. Patients use them for 3 to 6 months, and then they’re done. Payers are [thinking], “You’ve shown me 6 months of data. That’s terrific. It looks like it’s effective, but I want to know what the effects are at 12 months or 2 years. Do I have to pay for re-treatment?” How do we address that issue?

Scott Whittle, MD: Let me jump on that. Collectively, we as an industry have no place to talk. Arwen, your point about the therapy being given and having no clear strategy to know whether it’s meeting the need from an evidence or quality perspective is absolutely accurate. Because from a claims-based perspective, I’ve looked closely at this question, and the results aren’t encouraging for business as usual. Because what business as usual looks like, if you dive into claims [from my geographic area], which I believe is absolutely representative [of what is happening] nationally, starting a prescription for medication-assisted treatment and asking somebody to go to therapy usually fails 7 to 9 times before somebody sticks.

The problem isn’t the lack of quality. Usually, the problem is engagement. It’s all the things you’ve mentioned when you speak about the patient experience. You’ve all said it very eloquently. When somebody is struggling with depression, opiate use, or alcohol use disorder, it isn’t the moment in the therapist’s office that we’re trying to manage, it’s that individual feeling connected enough to build recovery capital in a longitudinal basis. Frankly, nothing accomplishes that better than a digital strategy available to you at 2 AM. Nothing does that better. The criticisms of business as usual aren’t directed at the specific therapist [in terms of] whether their therapy is good. It’s directed at the system we built that fails to engage people in the way they want to be engaged.

John Fox, MD: I’ve never heard the term recovery capital. Is recovery capital a measure of patient engagement and willingness to self-manage?

Scott Whittle, MD: Absolutely. An evidence-based strategy for recovery from SUD [substance use disorder] is fluency. It’s understanding the elements of recovery that I need to take with me so that I can manage my recovery and have a good relapse prevention plan. Building that fluency, knowledge, and connection is essential. When a therapist is available once in a while, building that knowledge base and fluency is very challenging.

Arwen Podesta, MD: That takes a long time. It’s exactly as you said. You said the number is 7 to 9 times before they actually go to therapy after I’ve recommended it every appointment for the last 5 years. I even do a lot of hot handoffs, in which the patient calls the therapist from my office as they’re sitting in front of me, so that helps. It helps the salience and the introduction, but it doesn’t stick all the time or even half the time for a variety of reasons. It’s part and parcel to the disease processes that we’re trying to treat. A brain that isn’t thinking 100% clearly isn’t going to want to do the things that professionals know help. That’s part of the disease process. That’s where this easy onboarding process with some of the digital therapeutics through text messaging can help, because we all know that a lot of patients with addiction and depression in particular don’t have their voice mail set up. A lot of my colleagues don’t either. It’s hard to connect with people with therapeutics if you’re trying to connect outside the office.

Another comment about that is that people appreciate having this strategy that’s being used in the apps to augment and overcome these specific disease states and symptoms. The fluency that you talk about, Scott, is imperative because that makes it integrate into their system and into their mindset. Some of the programs, such as the ones for addiction that I use most often, also have contingency management, which gives them a reward. It’s one of the other things in addiction that has been proven to be very effective for continued adherence. At 4 AM, if they wake up thinking that they want to get a drug to help them go back to sleep or calm their nerves, and then they use the app that I’ve been so clear that needs to be part of it, then they get an Amazon gift card. More salience occurs to get them to do it again, so the health-forward thinking is improved.

Transcript edited for clarity.