Sleepstation: a digital diagnostic tool and treatment for insomnia disorder

Introduction

Rubrum is a digital healthcare company, specialising in the delivery of evidence-based psychological therapies through a sophisticated, automated and scalable online product suite. The SME specialises in adapting well evidenced therapeutic interventions into digital therapies.

With support from the AHSN, Rubrum has brought to market a highly effective digital therapy for sleep deprivation and insomnia disorder – Sleepstation. The Cognitive Behavioural Therapy delivered through Sleepstation (CBTi), has been shown to be more effective than pharmacological remedies and just as effective as face-to-face therapy.

Sleepstation has been subjected to market testing over 3 years within the NHS and private sectors; it is now available on the NHS across the whole of England (via GP and self-referral). Sleepstation effectively treats insomnia sufferers from across the globe and is now in a position to be marketed globally.

The Case for Change

Sleeping well is essential to health and well-being. Insomnia remains the most commonly reported sleep disorder with prevalence estimated between 10-30% (Roth, 2007).

10% of GP consultations concern sleep related issues, this makes sleep a major clinical problem and  contributes significantly to strain on GP resources (Dyas et al, 2010).

Millions are affected worldwide from curable sleep disorders either directly or indirectly and do not receive the correct treatment for many reasons ranging from poor sleep awareness and education to a slow cycle from correct diagnosis to optimum treatment.

To treat insomnia, medications (especially hypnotics), have been used because of their quick effects in short time periods (Becker, 2015). However, medication for insomnia can present several adverse effects, (for example, headache and dizziness) during short-term use (Vermeeren, 2004) and addiction during long-term use (Takaesu et al, 2014). Moreover, medication has a limited effect on the long-term relief of insomnia (Chen et al, 2012).

The National Institute of Health and Care Excellence (NICE) advise against pharmacological intervention (NICE, 2015) and recommend CBTi as a first-line approach for insomnia treatment (Wise, 2015).

CBTi is well validated, with evidence spanning 30+ years. CBTi is shown to have similar short-term but better long-term outcomes than pharmacological interventions (Morin et al, 2012). However, traditional CBT (conducted face-to-face) has several disadvantages, including the relative lack of insomnia specialists, time and geographic limitations, and high costs (Bonin et al, 2014).

Despite the advice on treating insomnia with non-drug measures first and all the drug safety warnings, there has been no dramatic decrease in the prescribing of sedative hypnotics across many parts of England, with more than 10 million prescriptions for these drugs dispensed each year in England alone (Health & Social Care Information Centre, 2014).  Such prescribing carries many potential hazards for patients, including risk of dependence, accidents and other adverse effects on health (DTB, 2004).

The financial issues facing the NHS are well documented, with £20 billion in efficiency savings sought in this time of rising patient demand. The ingredients are now in place for technology to help deliver the ‘Triple Aim’ of healthcare (Institute of Healthcare Improvement) and make significant gains in quality, efficiency and population health.

Technology is rewriting the relationship between patients, professionals and care providers. Patients are taking greater control over their health, and tools for patient empowerment and self-management provide opportunities for patients’ active participation in their care.

Digital healthcare products can deliver customisable, quality care at a fraction of the cost of existing treatments and adoption of such products within the NHS is on the rise (NHS England, 2014).

The private market for digital healthcare is also booming. Following the release of Apple Watch and Google Health, the ‘quantified self’ movement has become more widely adopted within the general population, as people seek new ways to track personal data to understand and improve their health and wellbeing.

Insomnia and sleep deprivation are worldwide problems. The Center for Disease Control and Prevention (CDC) in the United States has declared insufficient sleep a ‘public health problem’, with more than one-third of American adults not getting enough sleep on a regular basis and estimates that at a national level (in the United States), up to 3% of GDP is lost due to lack of sleep (RAND Corporation). Sleepstation already attracts individuals from across the globe to its private product.

Research for the NHS found that for every 1% reduction in face-to-face interactions the health service could save up to £200 million (Policy Exchange, 2014).

Overview of Innovation

Sleepstation offers a way for the NHS to reduce face-to-face interactions. Sleepstation, as a treatment, is aligned with a consumer shift to accessing more products and services virtually, and fits into three key drivers identified by the NHS:

1) the improved self-management of long term conditions;
2) the need to reduce hospital admissions;
3) the increased embrace of what is becoming known as ‘digital healthcare’.

Sleepstation is a web based insomnia treatment – a digital version of the treatment that sleep doctors use in clinics across the globe to effectively treat insomnia disorder (Cognitive Behavioural Therapy for insomnia, or CBTi).

Rubrum has developed a complex diagnostic tool within Sleepstation which automatically screens for suitability, removing the need for a face-to-face assessment prior to treatment.  Self-reported data (from questionnaires completed by patients before, during and after treatment) determines baseline scores and outcomes across a range of factors.

The online course of treatment can last up to 7 weeks, with a personalised (but fully automated) video based therapy session delivered each week. The majority of patients have reported improvement in their sleep from week 3.

Rubrum has involved patients, healthcare professionals and commissioners at every stage of the product development journey to ensure that its products address patient and market needs, and are commissionable within healthcare settings.

To find out more: https://sleepstation.org.uk/

Progress to Date

Sleepstation was launched on a pilot basis in 2012, tested, revised, approved and commissioned locally within the NHS in 2013-2014.  Subsequently it was commissioned by NHS England for rollout across the country in 2015 making it available via GP referral across the whole of England.  It has also been commissioned as an IAPT service by a number of CCGs, made available on a self-referral basis.

Impact

Sleepstation is continually assessed across a range of outcome measures and has been shown to produce a significant increase in sleep efficiency for over 80% of patients with modest non-significant improvements in total sleep time. The majority of patients (over 85%) report improved sleep quality, and compliance with therapy is very good (76%).  Patients tell us that Sleepstation changed their lives.

“This program is a Godsend for those with insomnia. I cannot recommend it highly enough. I have been fixed through Sleepstation!”  Jane, 72 from Sevenoaks

“I had given up hope of sorting out my insomnia after so many decades of failed therapies and also having seen a psychologist. I am absolutely amazed that the therapy actually worked. It really felt as if I was being personally guided by a top sleep neurologist.”  Eleanor, 61 from West Kent

“When I started Sleepstation I was at my worst moment, I just couldn’t sleep properly and was having occasional nights of no sleep, I was in an almost constant state of anxiety and was absolutely desperate, the closest I’ve ever been to taking drugs for sleep. I absolutely credit Sleepstation with helping me get my sleep back under control. The help and direction I got from Sleepstation has been invaluable to me and I’m very grateful. I will take many of the lessons from it in my life. If I go through a bad period again, I will follow the Sleepstation regime again for sure, I know I won’t try anything else.”  Andrew, 37 from Lancashire

Sleepstation has also featured in the press as one of the 6 mental health technology startups you need to know about https://www.standard.co.uk/lifestyle/health/6-mental-health-technology-startups-you-need-to-know-about-a3654121.html

Next Steps and Plans for the Future

Rubrum has identified eight specific conditions to which its proprietary technology is most suited, of which five have been prioritised. It is estimated that the cost of providing treatment for insomnia disorder alone in the UK is currently £160m.

A second product has been developed by Rubrum which treats co-morbid anxiety and depression in COPD (ReachCOPD). This was launched in July 2017.

A third product (Beat Chronic Fatigue) is in development and is due to launch in 2018.

With experience in healthcare (in both clinical and commissioning roles) and experience developing and delivering digital products, the Rubrum team are perfectly placed to address a market with significant potential and strong, fundamental cost-reduction drivers.

The size of the total addressable market opportunity is circa £5bn. Revenues are subscription-based and routes to market include direct to patients, via healthcare commissioners, private providers, employers and institutions.

Rubrum must now raise awareness and market its existing products and services and continue to develop partnerships to create and launch new products and services.

Contacts

Alison Gardiner, Chief Executive, Rubrum Limited, 0191 375 9075, 07712 180 711 alison@sleepstation.org.uk  alison.gardiner10@nhs.net

References

Becker PM (2015) Hypnosis in the Management of Sleep Disorders, Sleep Medicine Clinics, 10: 85–92 doi:10.1016/j.jsmc.2014.11.003

Bonin EM, Beecham J, Swift N, Raikundalia S, Brown JS (2014) Psycho-educational CBT-Insomnia workshops in the community: A cost-effectiveness analysis alongside a randomised controlled trial. Behaviour Research & Therapy, 55: 40–47

DTB (2004) What’s wrong with prescribing hypnotics? Drug & Therapeutics Bulletin, 42(12); 89-93,  http://dtb.bmj.com/content/42/12/89.abstract

Health & Social Care Information Centre (2014) Prescriptions Dispensed in the Community, Statistics for England – 2003-2013,  http://content.digital.nhs.uk/catalogue/PUB14414

Institute of Healthcare Improvement, IHI Triple Aim Initiative, http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx  (accessed 30.8.17)

Morin CM & Benca R (2012) Chronic insomnia, Lancet, 379: 1129–1141, doi: 10.1016/S0140-6736(11)60750-2

NICE (2015) Insomnia Management, Clinical Knowledge Summaries, http://cks.nice.org.uk/insomnia (accessed 30.8.17)

NHS England (2014) Five Year Forward View, https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (accessed 30.8.17)

Policy Exchange (2014) Can doctors prescribe apps instead of medicine?  https://policyexchange.org.uk/can-doctors-prescribe-apps-instead-of-medicine/ (accessed 30.8.17)

RAND Corporation, Why Sleep Matters: Quantifying the Economic Costs of Insufficient Sleep, https://www.rand.org/randeurope/research/projects/the-value-of-the-sleep-economy.html (accessed 30.8.17)

Roth, T. (2007) Insomnia: Definition, Prevalence, Etiology, and Consequences, Journal of Clinical Sleep Medicine, 3 (5 Suppl): S7–S10,   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978319/

Takaesu Y, Komada Y, Asaoka S, Kagimura T, Inoue Y. (2014) Factors associated with long-term use of hypnotics among patients with chronic insomnia, PLoS One, 9: e113753, doi:10.1371/journal.pone.0113753

Dyas JV, Apekey TA, Tilling M, Ørner R, Middleton H & Siriwardena, AN (2010) Patients’ and clinicians’ experiences of consultations in primary care for sleep problems and insomnia: a focus group study, British Journal of General Practice, 60 (574): e180–e200, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858551/

Chen PL, Lee WJ, Sun WZ, Oyang YJ, Fuh JL. (2012) Risk of dementia in patients with insomnia and long-term use of hypnotics: a population-based retrospective cohort study, PLoS One, 7: e49113, doi:10.1371/journal.pone.0049113

Vermeeren A (2004) Residual effects of hypnotics: epidemiology and clinical implications, CNS Drugs, 18: 297–328

Wise J (2015) Cognitive behavioural therapy can help chronic insomnia, review finds, BMJ, 350: h3076

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