Prescription Digital Therapeutics in Behavior-Driven Conditions

Megan Coder, PharmD, MBA: Welcome, we are glad to have you participate today in a roundtable discussion on prescription-based digital therapeutics in behavior-driven conditions. Today’s faculty will include 3 distinguished members: Dr John Luo, a physician and clinical professor of psychiatry at University of California, Irvine; Dr Steven Peskin, the executive director of population health and transformation at Horizon Blue Cross Blue Shield of New Jersey, and an associate clinical professor at Rutgers University; and Dr Nidal Moukaddam, an associate professor at Baylor College of Medicine. The objective today for this multistakeholder roundtable aims to provide audiences with the education they need for digital therapeutics, specifically those provided to patients by physicians via prescription.

We’ll also be dealing with more of an in-depth analysis on the optimal use and benefits of these products. To set the stage, it may be helpful to describe more of what we’re speaking on regarding digital therapeutics.

In comparison to other digital health products on the market, such as wellness and fitness apps, diagnostic tools, or even medication adherence apps, digital therapeutics use software to deliver a clinical grade medical intervention to a patient. Specifically, it is used to prevent, manage, or treat a wide variety of diseases or disorders. Since digital therapeutics address such a wide variety of conditions, from diabetes and asthma, to insomnia and substance abuse disorders, it’s important that they adhere to core principles in the industry. These principles relate to clinical evaluation, rigorous product design, human factors testing, patient privacy, security, and regulatory oversight.

Our focus today will be on those products that are being used by a patient in the context of care that is delivered to them via a formal prescription from their clinician. Now, I welcome all the panelists to our discussion. Let’s open the floor to get a sense of your experience with digital therapeutics. Dr Luo let’s start with you for a quick introduction on your area of interest in this space.

John Luo, MD: I’ve been using technology in psychiatric practice for almost 20 years. I started off with the PalmPilot, which at the time wasn’t patient facing, it was for providers. I’ve really seen a change, where nowadays via a smartphone patient pick up apps and they ask the provider, “Hey, is this something useful?” or they are just starting to use it on their own. From personal experience, I haven’t prescribed them, per se. I’ve recommended a few apps, especially for patients with metabolic [adverse] effects from their medication. Specifically, I recommend certain apps for calorie tracking or exercise tracking to help them in their weight loss management plan. For patients who need anxiety and depression therapy, many of these apps are very applicable, especially apps that help with mediation or mindfulness. I think there’s a huge uptake in interest in these, especially in the current health situation.

Megan Coder, PharmD, MBA: Dr Moukaddam, I’d be interested to hear your perspective in this area.

Nidal Moukaddam, MD, PhD: The health ecosystem is very ripe for us to use apps. Apps can be thought of as being clinician driven or patient driven. In this case, we want to focus on the clinicians prescribing the apps or recommending apps, because when a patient picks an app, it’s not necessarily for the right problem or the right solution for whatever they think the problem is. Therefore, it is important to take the clinician’s perspective in this. My interest in technology is both clinical and research. I collaborate with the School of Engineering at Rice University, and we develop applications for clinicians, and we try to study that perspective. I take the clinician’s side and try to give clinicians their wish list in terms of therapeutics.

Megan Coder, PharmD, MBA: Dr Peskin?

Steven Peskin, MD, MBA, FACP: Digital therapeutics, in kind of a subset, we had a meteoric rise in telemedicine and telehealth, which I know is not what you’re asking about in terms of digital therapeutics. There is an adjacency and juxtaposition of digital health, broadly speaking. We don’t have any payment practices that I’m aware of that specifically reimburse for a digital therapeutic. We have a tremendous amount going on in digital health, including the juxtaposition with a group called Eleanor Health that we work with that is using some digital therapeutics in their approach to substance use disorder. We certainly have some of our clinical partners who have taken it upon themselves to initiate programs and tech space applications or messaging.

Another example of where digital therapeutics or digital management are being used is in distress screening and cancer care, which obviously has significant behavioral overtones to it. We’re very sanguine about this area. We’ve had a lot of focus in expanding our efforts in telemedicine, especially in behavioral health, and have seen that to be tremendously valuable in getting better access to people in need of behavioral health. The actual digital therapeutic itself—application-based or tech space, or for that matter an iPad or tablet or computer-based digital therapeutic—is something we’re very sanguine about, but it has yet to come into the mainstream as far as the payer is concerned.

Megan Coder, PharmD, MBA: Thank you for that perspective. We’ll loop back to some more of those notions too, as we carry on with today’s discussion.

Megan Coder, PharmD, MBA: Dr Moukaddam, regarding behavior-driven conditions, where do you see prescription digital therapeutics being most beneficial?

Nidal Moukaddam, MD, PhD: That’s a good question. Again, go back to the clinician perspective. The ideal digital therapeutic is something that is based on solid scientific and diagnostic ground, that is helpful for the patient when they are outside of the clinician’s office. A clinician, doctor, nurse practitioner, or anyone treating a patient always wishes that they could be with the patient when things happen, so they can detect what’s going on.

Caregivers cannot rely on what people tell them all the time, given that mood will affect your recollection and the presence of bias when you’re anxious or paranoid. Digital therapeutics fit very well as an extension of your clinician, which is your greater context. Regarding details, if you want to think about how we can apply this, you think of it as either teaching a skill or perpetuating a skill or behavior, which is where digital therapeutics would fit best.

You can see the applicability in terms of preventing self-harm, preventing cutting or self-injurious behavior. Moreover, you can see it in the realm of addiction. It’s very big. For example, the reSET app, using cognitive behavior principles can reinforce many of the things that we tell our patients and teach our patients. To pick the right digital therapeutic, you must know what you’re going for. However, those objectives can be hard to measure in psychiatry and mental health, so you need context. The first level of context is what am I prescribing this for, or what am I recommending this for? The second level of context is what do I expect this to achieve? If I’m expecting it to teach a new skill, you’ll need have to a starting point in the clinical encounter, which an app cannot do by itself.

Megan Coder, PharmD, MBA: That’s an excellent overview of how those processes work and how they’re integrated into that perspective. Thank you.

Megan Coder, PharmD, MBA: Dr Peskin, what unmet needs have you seen that digital therapeutics could address for health care payers?

Steven Peskin, MD, MBA, FACP: Certainly, around the area of access. Specifically, how digital therapeutics can supplement and augment the great work that our clinical partners do, whether she be a family physician, psychiatrist, or a general internist like me. So, the ability to supplement, augment, or complement the work of the clinical team. I should mention that the care team as well is much bigger than the MDs [medical doctors] and DOs [doctors of osteopathic medicine]. It includes the MSWs, [master’s in social work], and clinical counselors. We’ve certainly embraced community health workers. There are many individuals within primary care and behavioral health, which is very much a team-based effort where digital therapeutics can enhance that interaction.

I did have a physician I was talking to earlier today who, and again, this was not something that we were paying for directly, although indirectly as we pay our clinical partners on a value-based construct. He was disappointed that the particular digital intervention they were using to try to avert people with generalized anxiety disorder, depression, or bipolar from going in to seek emergency department care did not end up having a positive effect on the number of people who had received a digital therapeutic text-based message. It’s certainly not a panacea, but it holds a tremendous amount of promise.

Clearly, people have their smartphones clutched. As one person said to me in the technology arena, [a smartphone is] more intimate than jewelry. I don’t even have any jewelry, so definitely my smartphone is more intimate for me than jewelry. Smartphones are a part of a part of us, for better or for worse. Sometimes, for the worse. The opportunity is there for digital therapeutics to be very meaningful and have impact, and then augment and supplement. Additionally, the relative low cost of digital therapeutics can have a positive impact on what we look at, which is total medical expense.

Megan Coder, PharmD, MBA: I think it’s a good point you bring up. It is also interesting to point out that oftentimes what people will think of as a digital therapeutic might not actually be one. The text-based messaging therapeutic may not have been one, but that notion of using digital and having it scalable and accessible to patients is critical to what this industry can provide. Dr Luo, from your perspective addressing the same question but focusing on health care providers, what types of unmet needs do you think digital therapeutics provide to a provider type of community?

John Luo, MD: I think providers are looking for a way to help their patients, especially when you’re very busy and have a huge panel of outpatients. When there’s a crisis, how do you squeeze in the time to go see the patient? If there is a digital therapeutic that can serve as a bridge until the next time that you can interact with the patient, whether in person or via these videoconferencing solutions, I think digital therapeutics pose a great adjunct. As Dr Moukaddam mentioned, the idea is you want this to be a tool that the provider has confidence in and helps the provider with their style or method versus the patient going off on their own. I still remember when the internet was in its infancy and patients came in reading about medication [adverse] effects from a patient forum they read and decided not to take the medication.

I wish they’d have had a conversation with me. However, I learned quickly that I must accept that patients will bring things in, and I need to have a discussion with them so that we can understand what will be potentially beneficial for them specifically, because they’re not as well-trained to know what the strategy is for the digital therapeutic or whether their condition is appropriate.

Megan Coder, PharmD, MBA:Dr Moukaddam, how do these products impact the ability for patient satisfaction and improvements in clinical outcomes and health care costs?

Nidal Moukaddam, MD, PhD: We have an idea and we have some wishful thinking about this, but I don’t think we have all the scientific evidence that we want. We know that literature tells us people are happy typically when they have some sort of digital or technology follow-up, whether it be for wound care or for diabetes. We know that patients find it effective and easy once they find out how to use it.

The therapeutic decreases loneliness tremendously. The patient satisfaction element is there. The clinician satisfaction element is not necessarily present because it is something that needs time and you need to follow up on these outcomes. You need to teach people, and then reinforce that they’ve understood, and you need to ask them if they’ve used it and if they haven’t, you then must track that behavior down. As a result, I don’t think the clinician satisfaction is as high.

As the other panelists have suggested, it is a cheap intervention. It is relatively inexpensive if you have a smartphone. The trick with this whole PDT [prescription digital therapeutics] area is to make sure that we’re not just using it for people who already have a smartphone and have the support. Otherwise, you’re really highlighting socioeconomic disparities.

Megan Coder, PharmD, MBA: Looking at it from that perspective and building on from the clinician’s side, how have you seen digital therapeutics be integrated into clinical workflows or into electronic health records? I know that there are different companies that will enable this to happen, but I’m curious if you’ve had any hands-on experience with it?

Nidal Moukaddam, MD, PhD: I have a couple of instances of hands-on experience. The answer to your question is that this is a nascent field, it’s just starting, and it is still up for grabs. There are a lot of liability issues because if you add another source of information, you are adding liability. It will potentially be a problem if you miss a finding that could’ve alerted you to a bad patient outcome. I don’t think the liability aspect has been properly explored, and there are no proper guidelines for this quite yet.

Regarding time, everything you do will add time, and I don’t think people have time in their schedules for this, which must be built in. There is the integration aspect whereby people need to learn how to integrate this into their workflow. I have given a couple of lectures on this, and whenever I say to people, “You have to pull up a phone and show the person how to use an app,” I get these looks like, “What are you talking about? Where am I going to find the time?”

Overall, finding time is a problem. However, there are companies that will take the liability issue off your hands and will store that data and make it their business to integrate with your electronic health record. You can also customize your electronic health record if you are in an institution where you have this kind of say-so. Either you take on that info and you take on that responsibility, or you outsource it, which are the main 2 options in a brand-new field.

Megan Coder, PharmD, MBA: Dr Luo, looking at this from the notion of increased access and adoption, what would you think is required to increase this among patients and providers? Dr Peskin, we’ll loop you in for the payer perspective too.

John Luo, MD: Patients are ahead of us as providers already because they’re very—I don’t want to say desperate, but really looking for solutions, especially if there’s going to be a wait time to see their provider or to get access for the next appointment. I’ve seen this over the last 20 years. Initially patients were slow at adopting technologies, but now people download apps without thinking to check on issues of privacy or where or how their data are being used. It’s almost as if people believe it’s free and easy, then let’s go for it versus wanting to vet it. For patients, it’s less of an issue as along as it provides hope, which is really what they want.

They want hope that something they use will help them feel or live better. From the provider perspective, we’re getting better at adopting technology. It used to be said before that psychiatrists were notorious for being the least tech savvy, but I don’t think that’s the case anymore. However, we still exercise more of a critical judgment than patients. As Dr [Nidal] Moukaddam mentioned earlier, what is the scientific basis of this app or digital therapeutic? Has it been proven in a clinical trial?

Does the theory make sense? We’re much more hesitant, only because we really want it to be effective when we offer it to the patient. Especially using apps as an example, it’s hard to know what works well for people in addition to the security and privacy concerns. Although I’m pretty tech savvy, I cannot deconstruct an app and make sure it’s not sending data to China or Russia or elsewhere. I must depend on the store to vet and confirm that this is done in a secure and appropriate matter. The same philosophy goes for reading privacy logs and statements. No person reads 20 screens of verbiage that says your data will be stored here and done for this purpose. Most often, people scroll through these agreements, click yes, and move on.

For providers, we tend to be a little more hesitant because we like to have some help in knowing that the product that we’re recommending has been useful. Comparatively, these apps are like new medication that’s available. We want to see the studies. We want to see what the reports are in terms of benefits and adverse effects before we’re comfortable with prescribing it.

Megan Coder, PharmD, MBA: Given that these have FDA clearance for the most part, especially those that are prescribed, I imagine that’s another level of confidence you have as a provider, knowing that it has undergone a study and has clearance with HIPAA [Health Insurance Portability and Accountability Act] and other aspects of security to protect patients.

John Luo, MD: I agree. The FDA approval is a gold stamp that says, “Yes, this is actually a product that we have confidence in.” That reassurance would help providers in recommending them to patients.

Megan Coder, PharmD, MBA: Dr Peskin, I would be interested to hear what you believe the challenges are and the ways to improve access to widespread adoption of these products.

Steven Peskin, MD, MBA, FACP: It certainly is one of those Clay Christensen disruptive innovation possibilities. I agree with Dr Luo when he mentioned folks going to “Dr Google” and all the other junk out there. There’s a book a friend of mine wrote, called Tabloid Medicine, that covers anti-vaxxers and other conspiracy theories that have been debunked. Yet for digital therapeutics that are vetted, as you mentioned by the FDA, I do see it as an opportunity for very significant interventions that will not disruptively disintermediate health care professionals. I do see it as a harmonization.

Certainly, there could be some opportunities where most of the behavioral health in the United States is delivered by family physicians and general internists. Psychiatrists are significantly overwhelmed, and it would be great to give psychiatrists an opportunity to do more than prescribe drugs. Perhaps digital therapeutics can help bring back some of the cognitive behavioral therapy and the talk therapy that is so important.

Regarding depression, SSRIs [selective serotonin reuptake inhibitors] and NSRIs [serotonin–norepinephrine reuptake inhibitors] are just barely better than the placebo. I’m optimistic about the prospect of digital therapeutics improving outcomes in major depressive disorder, generalized anxiety disorder, bipolar 1 and 2, and substance use disorders.

Megan Coder, PharmD, MBA:I once had a company representative come up to me who—not a digital therapeutic—and say, “Oh, it’s just the smile on the patient’s face that matters at the end of the day.” I asked about security, privacy, the clinical evaluation, the random controlled trials, FDA clearance, etc. He responded, “You don’t need that.” As a result, I realized he was not going to be a digital therapeutic. From a payer perspective, what requirements are you looking at before you say yes, I want to put money behind this and I want to take risks and use this for my patients?

Steven Peskin, MD, MBA, FACP: We’re looking at it on several levels. One, we have our own behavioral health, which we took in house. Additionally, we have several physicians—we have an entire team—that are now part of Horizon Blue Cross Blue Shield, as opposed to using a third party, with what is called a managed behavioral health care organization. Overall, we’re looking at many options, whether it’s Eleanor Health or Mindoula Health. We also work with Quartet Health and several others.

There are several that I would call enhancers, such as telemedicine and telehealth, which is different from digital therapeutics. Therefore, my colleagues and I are constantly scanning the environment within behavioral health. In physical health we also have an investment arm, and we look at making investments in these types of companies. I heard a presentation by an individual from Blue Venture Fund. Coincidentally, she shared several behavioral health–related organizations, specifically some that are juxtaposed to digital therapeutics that the Blue Venture Fund is investing in.

Megan Coder, PharmD, MBA: This may be a more technical question—before we move back to the patient-provider space—but have you seen these covered under a specific benefit, whether it’s pharmacy or medical or even value-based contracting? Have you seen anything starting to emerge in terms of these different types of digital therapeutics?

Steven Peskin, MD, MBA, FACP: Some of our partners are adopting digital therapeutic-type innovations with the cost on their nickel. Our partners are in a value-based model, so they’re saying that this is worth it for us to invest in because we’re looking at how it can affect total cost of care and total medical expense. We’ll evaluate any digital therapeutic just as we evaluate any technology, such as a new surgical device. A friend of mine is working on a wearable technology from MIT [Massachusetts Institute of Technology]. If it holds up, it will have at least as good an impact on insomnia as Ambien, maybe better.

We’ll be looking at digital therapeutics the same way we look at everything, specifically on grounds of evidence, FDA approval, or what other authoritative organizations are saying, such as the American Psychiatric Association. We’ll approach digital therapeutics the way we approach a new cancer drug, a new medical device, or something new in wound care.

Megan Coder, PharmD, MBA: Dr Moukaddam, regarding the provider side, what is your experience, and what you would want to see in an experience with patients? Given that we are talking about products that are used in the context of care with the clinician, I’d be interested to find out what you would like to have as a part of that engagement with your patients and this product?

Nidal Moukaddam, MD, PhD: I would want something that provides me with objective data that are scalable. I would like to be able to try it out and use it to know that it’s beneficial and the scalability comes in when I say as a specialist, “This is great, but I can give it to everybody who’s a PCP [primary care physician] and everybody who is doing this on a larger scale.” That is important. The main issues in mental health, insomnia, and addiction are that what we’re going for is not measured very well. Psychiatry still follows a categorical approach. If I say you’re depressed, it might mean you look sad, but technically what it means is that you meet the criteria for a certain number of symptoms in a duration.

Digital therapeutics do not give you that. Digital therapeutics give you a wealth of information about how much you move, sleep duration, and sleep quality. Instead, digital therapeutics give information on how many times you’ve turned your phone on or off. This is the kind of thing I can use to track your activity and your sleep cycle. What we do in our research is we use privacy preserving methods. Even so, I don’t know who you talked to, but I can still draw a social map. Therefore, I can see how this helps predict the relapse when you start calling random people and I notice this is not your usual pattern.

The field of digital therapeutics should give me something objective that would be useful. To achieve that, I’m going to stick to the example of apps and wearables because this is what most people are used to. Let’s assume your phone, just like your wristband that measures your activity. These devices are all things that are very intimately paired with your lifestyle. This device can give you 2 inlets. It can ask you how you’re feeling, which is called ecological momentary assessment. Additionally, it can ask you if you cough in your sleep, what you’ve eaten, if you’ve had a problem physically or a symptom. Or it doesn’t have to ask you anything, and it just detects your patterns. That pattern detection is a prolific and powerful tool, which is what we need as clinicians. We need that analysis to bridge the gap of what we think of as symptoms. Am I making sense?

Megan Coder, PharmD, MBA: Yes. Going back to some of these questions in general, what is a digital therapeutic, and how does it relate to the broader ecosystem? My background is in pharmacy, so sometimes I’ll hear patients ask, “Is it something that will just track my medication adherence?” The answer is the software in a digital therapeutic does deliver the medical intervention, but it could be paired with a wearable or a fitness tracker or a monitoring or diagnostic component. What I love about the industry is that digital therapeutics are delivering an active intervention to a patient, yet they’re working in conjunction with remote patient monitoring and telehealth and all other products to enable holistic care. That’s what you’re getting at—this notion of holistic care and something that provides actual data to decide on, so you don’t feel as if you’re working in a vacuum.

Nidal Moukaddam, MD, PhD: That is called adjusted time intervention. It takes a typical AI [artificial intelligence] algorithm 10 to 14 days to learn your patterns. Notably, the people who do this are so smart, and I can’t follow 10% of what they’re saying, but they give me wonderful algorithms. We can track patterns, and the idea of adjusted time intervention is to take this pattern and say, “Today you’re not doing what you usually do. Today you did not do your usual 2 miles of walking.” From there, you can link it to whatever condition you think this patient has. Are you sick? Are you depressed? Are you not feeling well? Is your asthma acting up? You have the detection component.

The diagnostic component obviously is a lot trickier, and you must have a lot of regulatory oversight for that because we don’t want to jump from detection to diagnosis, which is a big area. First, we have to get those algorithms and validate them. For mental health and addiction specifically, the field is going to have to see a much larger switch from categorical diagnosis. Specifically, do you have this dimensional diagnosis? The dimensional would consist of rating your depression only, or specifically rating your appetite. We’re not talking about the symptom cluster but rather 1 symptom.

Megan Coder, PharmD, MBA: Dr Luo, what type of education would be needed to really enable you to have confidence to use these types of tools?

John Luo, MD: Papers published and FDA clearance or approval. When I was a junior faculty member and the PalmPilot came out, 1 of the ways I increased adoption—and these were not digital therapeutics or anything close to that—is I would teach a course. In 1999, 100 psychiatrists would vie for a seat to learn how to use their PalmPilot, just to use it in providing basic access to information.

Finding a way to reach psychiatrists and help them be comfortable prescribing it or using it or showing it to their patients reminds me that like electronic health records, much of medical education has been outsourced to these third-party vendors, which create videos to help the patient with lumbar punctures for example.

You certainly can have the same vendor teaching digital therapeutics. You probably don’t want it on YouTube, but those are the ways providers will become more comfortable. Patients are way ahead of us because they’re eager. They really want support, especially because access to mental health providers is somewhat limited.

Megan Coder, PharmD, MBA: Dr Peskin, I’m be curious to get your perspective, especially now that we’re in this COVID-19 [coronavirus disease 2019] era, and it looks like we’ll be in it for some time. I’m curious what type of increased need have you seen for these products given their scalability and accessibility. I’m interested to hear your thoughts on the COVID-19 side.

Steven Peskin, MD, MBA, FACP: We did a tremendous amount on telemedicine. I realize that is not digital therapeutics, but it was something that stood up very rapidly. We worked with some of our clinical partners to expand access for urgent care, primary care, acute care, longitudinal care for diabetics, and people with chronic conditions. Telehealth has also been widely embraced by behavioral health professionals, which was a COVID-19 response. Regarding digital therapeutics, we have not specifically developed payment scheme or model, but COVID-19 has certainly accelerated our efforts to look at what might be called nontraditional. The traditional model is 1 person in an office. I was seeing patients on Tuesday with a mask on and a shield, which was very encumbering and a tough thing to do for 6 hours. Regardless, this area of digital therapeutics juxtaposed to telehealth and other ways to provide or deliver services virtually is very compelling, and COVID-19 is certainly an accelerant.

Megan Coder, PharmD, MBA: Dr Luo, it would be interesting to hear your thoughts.

John Luo, MD: I would echo that because I work on the consultation service in the emergency department [ED] and in the main hospital. I can tell you that our volumes are high. We have many patients who had no premorbid psychiatric conditions who now have depression and anxiety related to COVID-19. Our systems of mental health care, especially here in Southern California, because of the high numbers are stretched thin.

Not everybody has adopted videoconferencing technology. People still doing visits by phone and patients are dissatisfied. They oftentimes become noncompliant with medications, so they end up in my ED and I must see them and try to figure out how to bridge the gap of care. Providers like myself, and my colleagues in the outpatient and inpatient settings, desperately want more tools to provide patients with a way to keep them well. Moreover, we want a way to keep them needing either inpatient hospitalization or showing up in our ED. The pandemic unfortunately has really magnified this huge need.

Steven Peskin, MD, MBA, FACP: I would echo that. We’ve seen a tremendous increase in benzodiazepine prescriptions, for example.

Megan Coder: Dr Moukaddam, any words on your perspective of digital therapeutics and COVID-19?

Nidal Moukaddam, MD, PhD: COVID-19 has simply accelerated the need for us to use the technology we already have if you want this technology to help you for detection and diagnosis and treatment. For detection, we are woefully underusing telemedicine. I don’t mean we’re not doing enough telemedicine, but I work with engineers and they always tell me, “All you do is use the video part. Why don’t you use the other part? Your screen can measure your vital signs, but nobody uses that.”

No big system has adopted it. It’s very hard to get through 3 IRBs [institutional review boards] to do that. You can also use it to measure gait. There are a lot of gait measurements that can be done remotely. That way, you could use your encounter to have some gait-based measurement. That would be helpful. We don’t do that either. The screen is not used, and the phone has a little sensor that can measure blood flow; therefore, you can measure flushing.

That’s how they measure vital signs. We don’t do that either. We are woefully underusing technology for detection. We’re not even talking about diagnosis. In terms of detecting mental issues, the apps, phones, and wearables could help us so much. We have a study called CovidSense at covidsense.org. Our question was: can we follow people and see who’s going to get depressed? We’re seeing a very distinct pattern in who gets to be in that depression or anxiety group that we didn’t have before that is getting us so much work.

I’m very grateful for the job security, but the conversion into depression and anxiety has been very clear for individuals with preexisting conditions, even if the condition is arthritis.

We have more than 1000 people in that study, which you can see because we’re measuring with a quiz for depression, and you can see that conversion. Clearly, the digital therapeutic could help us with detection and even with diagnosis because we are able to do a fully acceptable questionnaire that’s validated, and we are able to diagnose.

In terms of treatment, we have not implemented just-in-time adaptive intervention, which is certainly something that could be added very easily. We are not using that enough, so the pandemic hopefully will trigger all these advances being put into place.

Megan Coder, PharmD, MBA: I want to thank each of you. I appreciate your perspectives. They are very different but very valuable, and they really work well together in terms of the different perspectives. Thank you for your time and thank you for joining us.