Although I know relatively little about Zeo, I was sorry to hear this.
Why? Because insomnia complaints are a big problem in primary care, and something I’ve struggled with often as a clinician. (I’ve also personally been plagued by severe insomnia at certain times of my life.)
In fact, I would say that insomnia falls right in the space where I can see consumer digital health technologies helping us the most. That’s because this condition:
- Is a common complaint in primary care. This study found that 69% of primary care patients experience insomnia. It certainly is a complaint that I hear about often from patients (although it often comes up as a “by the way” at the very end).
- Is linked to adverse health outcomes. Insomnia is associated all kinds of problems. Diminished quality of life, decreased work performance, and increased mood disorders have been noted in research. Research has also linked insomnia with developing Alzheimer’s.
- Requires data on the symptom to effectively evaluate and treat. The proper evaluation of an insomnia complaint should not only include a history and examination — one should evaluate for an underlying/co-existing physical or mood disorder — but also requires good information on what exactly is going on with the person’s sleep. Is the problem with falling asleep or staying asleep? Every night or a few times a week? How many hours per night is the person sleeping? And of course, once an attempt is made to treat insomnia, clinician and patient will need to determine whether the insomnia is improving.
- Should be treated non-pharmacologically rather than via prescription drugs. Research has shown that behavioral approaches such as cognitive-behavioral therapy, relaxation therapy, stimulus control, improved sleep hygiene are overall safer and can be more effective than the use of sedatives. Just about every medication which makes people sleepy, such as Ambien, tends to worsen balance and cognition, and can be habit-forming. (Furthermore, recent research confirmed that older adults who use benzodiazepines — a class of sedatives often prescribed for sleep complaints — developed dementia at higher rates. Here’s a cool JAMA study on using cognitive-behavioral therapy to treat insomnia in older adults.)
- Is currently inadequately managed by primary care as usual. Although insomnia is a common issue for primary care patients, we often do a poor job managing it. Most clinicians don’t have the time or inclination to take a careful sleep history and guide patients through a comprehensive sleep improvement plan. Instead, we tend to prescribe sedatives and often never get around to following up. This means many patients end up on sedatives long-term, and the older ones in particular end up at considerable risk of adverse consequences.
In short, insomnia is a common medical complaint that many primary care providers could use help managing more effectively. And much of the evaluation and management is relatively non-medical: we need sleep diaries and other methods to get accurate data on a person’s sleep, and we need help encouraging patients to implement lifestyle changes and supporting behavioral therapies.
A doctor tries to manage her own insomnia
There’s nothing quite like suffering from a health problem to provide insights on how one might help patients with something similar.
As I mentioned above, I’ve at times suffered from pretty bad insomnia. In the fall of 2011, I was having a terrible time. I was very stressed out by my job as a medical director and PCP, and found myself unable to get enough sleep at night. I’d toss and turn for 1-3 hours every night before lapsing into fitful sleep. I felt tired and irritable most days. And I was especially frustrated by my inability to fall asleep easily: there I was with *so* much work to do and it was killing me that I couldn’t get the sleep I needed.
Like most working physicians/mothers, I didn’t have time to go see my own doctor. I figured she would just recommend the usual sleep hygiene tips, and I didn’t need her to prescribe Ambien since we already had some in the house.
Then one weekend a non-physician friend mentioned his own struggles with insomnia, and recommended a workbook written by a sleep therapist.
This I found immensely helpful. Even though none of the information was truly revelatory to me, it was terrific to see a comprehensive, effective approach spelled out in plain English, along with specific actions to take.
Of course, the author strongly recommended sleep logging, and cautioned the readers against depending on sedatives long-term.
How to log my sleep? I found an app for my smartphone and started to use that. It was so-so (sorry, can’t even remember the name) but certainly better than logging on paper or on my laptop. I also started to try to implement some of the relaxation and cognitive retraining strategies. (It’s important to try to unwind before bedtime, and one must really try to avoid anxiously lying there in bed trying to fall asleep.)
Based on my experience with the workbook, I started recommending it to patients. Although my older patients often had pain or other physical problems contributing to their sleep issues, most could also benefit from the strategies in the book. (Plus, it explained sleep logging and provided templates!) I also suggested it to some of our licensed clinical social workers, who were seeing some patients for behavioral therapy related to insomnia. They found it helpful as a tool to support the work they were doing with patients.
In the end, although my sleep improved somewhat through logging and behavioral changes, what really helped me turn the corner was deciding to leave the job. (Not sure I’d recommend an app try to help people in this manner.)
Still, this experience reinforced two key points to me:
- Behavioral and lifestyle approaches greatly benefit from symptom tracking and logging.
- A behavioral/lifestyle approach can be challenging to implement on one’s own.
Couldn’t digital health technologies help us with the above?
What I would’ve told Zeo
I’m a physician and in the business of responding to patients’ health concerns, and of managing multiple chronic conditions.
So if Zeo had sat me down and said “We have this consumer technology that tracks how people sleep,” I would’ve said “Great! Patients complain to me about sleep all the time! And I have so much trouble getting people to track their sleep symptoms. But I need them to do it in order to evaluate the problem, and see if treatment is helping.”
The thing is, as best I can tell, Zeo did not fundamentally conceive of themselves as a company in the business of equipping patients to effectively get better care from clinicians.
Instead, here’s their mission statement:
“The Company’s mission is to help people discover new, science-based ways to lead more an active and healthy lifestyle by taking control of the awesome and restorative power of sleep.”
In other words, Zeo was part of the quantified self movement.
Whereas what countless patients could use would be a quantify-the-problem and engage effectively with the healthcare system movement.
Now, I can see why consumer health companies might be a little leery of getting involved in the patient-clinician encounter. I imagine they are worried about having to appeal to physicians, about whether the device will have to be medically regulated, about liability, about clinical proof that the device provides a medical benefit, and about whether they’ll have to try to get the device paid for by insurance, etc. All reasonable concerns.
Still, I feel I can envision opportunities for companies such as Zeo, to help with problems like insomnia. Why can’t companies serve consumers by:
- Helping them track symptoms. In this case, it’s providing the sleep log.
- Helping them identify and summarize valuable pre-visit history. Is it practicing medicine to tell a person that if they want to ask their doctor about sleep issues, here are the questions they should be ready to answer? (i.e. How long has it been going on? How much does it affect daytime functioning? Any pain, cough, shortness of breath, etc at night.) I would be so happy as a PCP if patients could access a sensible pre-visit insomnia questionnaire before bringing a problem to my attention. Would make my life easier!
- Suggest proven non-pharmacological alternatives to discuss with the doctor. Let’s face it, doctors tend to prescribe pills. It’s fast, it’s what we’re used to doing, plus pharma keeps spending money encouraging us to do it. Why not help equip patients to politely remind physicians to consider alternatives?
- Support implementation of proven lifestyle interventions. In this case, it could be something like providing the user with support in implementing relaxation exercises, and reminders regarding good sleep hygiene.
What clinical studies would I need to use something like this with my patients?
My main concern would be regarding the validity of the tracking tool. A smartphone based log is just like people writing things in a notebook: you take their word for it and hope they were reasonably accurate.
For a physiological tracker, like Zeo’s headband, I’d want to know how well its sleep assessment corresponds with other technologies often used in clinical medicine, like actigraphy and polysomnography. (Am just noticing that Zeo currently has such info here.) This information should be easy to find on the company’s website, and should summarize the results of validation studies in nice easy-to-read English. (Don’t just plunk the abstract there; get a health writer to reformulate. Everyone, including doctors, prefers to not read scholarese.)
Otherwise, if the device proposes pre-visit questions that are in line with what expert articles say are the key history elements — best if these articles are tailored toward a PCP’s initial eval of a complaint; which is a different standard than an expert specialist evaluating a complaint — I wouldn’t expect clinical studies. After all, these questions are meant to be an aid to a successful clinical encounter, not a substitute or a form of medical therapy in of themselves.
In other words, I would’ve told Zeo to make sure it’s easy for clinicians to trust the data provided by the device, and I would’ve encouraged Zeo to focus on equipping patients to track their symptoms and constructively preparing for visits.
But all this is just, of course, one practicing doctor’s opinion, and I have no idea how viable a business proposition this would’ve been.
What I do know is that in primary care, we sure need help helping patients with insomnia. So I hope future companies will build on Zeo’s strengths and bring us some assistance soon.
Summing it up
Insomnia is the kind of primary care concern that a consumer health tech company like Zeo could’ve eventually helped me with. It’s a common complaint with significant health consequences. It’s a problem that really benefits from a data diary. And it’s a problem that often should be treated via lifestyle/behavior changes, rather than through prescription drugs.
Patients and clinicians need tools that support better clinical management of common primary care problems. Rather than focus on the wellness/fitness market, consumer health companies may want to consider ways in which they can support better clinical care. There are surely opportunities to do this by helping consumers track data for certain common health concerns (such as insomnia), and by helping people better prepare for clinical visits related to these concerns.
Consumer health technologies could also serve patients by equipping them to ask doctors about evidence-based, non-pharmacological management of conditions such as insomnia.
