The Role and Value of Prescription Digital Therapeutics in Behavioral Disorders - Episode 3

Successes and Challenges With Using PDTs

Dr Podesta calls on her experience using PDTs with patients to describe what successes and challenges are common.

Arwen Podesta, MD: I'm a psychiatrist. I specialize in a whole slew of things: holistic integrative medicine, addiction medicine, forensic psychiatry, adult general psychiatry. I love using all tools in the toolbox. I want my patients to use something that is available to them 24/7. I want my patients to have therapy available, and it just hasn't been, especially with closures and people stepping back and not having live visits through the pandemic. I have adopted using prescription digital therapeutics for both my practice in the field of addiction and sleep. Everyone has sleep issues. Everyone wants a medicine for sleep. I use things that have very few-to-no adverse events, and most medications have an adverse event that could be possible.

I have used reSET, which is addiction cognitive behavioral therapy and contingency management app. I've used that in my practice for a while, as well as reSET-O, which is the same but is FDA approved for those with opioid use disorder—specifically those on a medication-assisted treatment for opioid use disorder; an example is buprenorphine. There is 12-week cognitive behavioral therapy on your app. It's about an hour a week per patient. I look at my clinician dashboard and keep up with what the patient's doing, see how they're progressing, see their pressure points and relapse potentials, and then orient my treatment accordingly. This is great because 90% of relapses don't occur when they're leaving my office. They [can] feel great then, but I'm [not] seeing them every day and not even every week, necessarily. Most relapses occur when stress happens, when people are not able to sleep, so their brain is going back to the easiest path of least resistance: going and getting that drug. Most relapses happen outside clinic hours, so they are able to use this tool on their device 24/7.

With addiction, we need treatment on demand. If someone has to wait to get into therapy, then their addiction is probably going to make rationalized excuses as to why they shouldn't go and should continue to use. Often, we mistreat on demand and when we don't have something like a 24/7 digital therapeutic. I don't know many sponsors that are going to be available at 2 A.M. every morning. [Because I use reSET and reSET-O,] I was oriented to PSM [propriospinal myoclonus at sleep onset] risk, which is a cognitive behavioral therapy for insomnia. It is wildly successful and has a different type of cognitive-behavioral therapy that is very specific and oriented for insomnia. It's been used by the VA [US Veterans Affairs Department] for [years, as well as] sleep specialists that are trained in it, but it is [programmed] for those that use this FDA-authorized prescription digital therapeutic.

What are some challenges that I've had with getting patients to buy in? First, patients are on their phone frequently, but a lot of my patients in psychiatry and addiction feel that when I'm speaking about phone use, they’re judged. They feel like [using the] phone is bad and that I'm going to want them to be off of their device. That's not true. I use motivational interviewing to discuss everything new with patients, and that's what I do for discussing prescription digital therapeutics. How long are they going to have to use it? How many hours a day? What's required? What's interesting about reSET & reSET-O? Is it also contingency management? When patients get onboarded, which is a super easy process, they get a gift card depending on the prescriber. That makes it more salient, so the patient wants to use it more. They also get a prize at random times when they finish certain modules, so there's that for those two therapeutics.

Most of my patients want a quick fix for sleep. It might take 12 weeks before they’ve improved their sleep, but it usually takes much less than that. I use different types of non-scheduled medication to help them get sleep [immediately, as well as] supplements and other tools, and then use the app in tandem. I’ve had several CEOs, attorneys, etc, come to me for sleep issues that know they're smart and have read about sleep hygiene, but then a particular module just got them. I get to see it on the clinician dashboard. I see that in module 2, she went from poor sleep efficacy to much higher. I ask her how that feels, how it's sustainable, and bring that to the therapeutic alignment.

There have been some barriers in adopting and adapting with PDTs [prescription digital therapeutics]. There’s a concern as far as how we're going to get this paid for. There's some attention deficit—prescription digital therapeutics for kids that I know some parents are apt to pay out of pocket for because they work well. [Paying out of pocket is] not [common for] every patient. Most of this is based on some sort of cognitive-behavioral therapy, and payers tend to pay for therapy but not algorithmize therapy through a prescription digital therapeutic at this time. [Both payers and prescribers are barriers.] This can't be prescribed by a therapist or nutritionist. It can't be prescribed by a nurse. It must be prescribed by someone who has their license to prescribe medications. What do prescribers know about PDTs? When I've brought this to message boards and ask, “What does everyone feel about a prescription digital therapeutic?” something like 60–80% of the physicians and psychiatrists responded {~100 people], said they don't know enough about them.

Trainings are essential. This started in 2016; it's new, and if we don't learn it in medical school, we're not going to use it in our practice unless we get access to it or hear success stories. If we don't have a mentor during medical school or residency that is teaching us, we're not going to use it. To have adoption of PDTs, we need great messaging with the prescribers but to also let the patients lead the way. We're at the beginning of the wave, and we've got some more education to do.

This transcript has been edited for clarity.