Considering DTx and PDTs as Part of Treatment


Arwen Podesta, MD; Timothy Aungst, PharmD; and Scottle Whittle, MD, explain the considerations they think about before using or prescribing DTx and PDTs.

John Fox, MD: Arwen, what do you tell a patient about these tools when you're advising them or asking them to consider use of a tool like this?

Arwen Podesta, MD: If I'm able, on either my telehealth platform or in office, I will show them the main website for whichever [PDT] [prescription digital therapeutic] that I'm speaking of and talk to them about how we want the cognitive behavioral therapy for the conditions. The 4 that I use most comprehensively are for opioid use disorder, alcoholism, pharmacy use disorder, and insomnia. I give them a good overview and let them sit with the website, so they can review it. That's in my private practice. That way, I don't want people that feel like it's a burden. A lot of my patients are busy, as everybody is, and I don't want them to feel it's something I'm asking them to do, so they feel bad that they won't do it. One of the things that I always express is that I'm going to be watching them. I'm going to be monitoring the clinician platform, and they tend to be more excited and feel more accounted for when they get that information. It's different in the intensive outpatient space because I don't onboard it very frequently in that space right now because of coverage and fulfillment barriers, but when I do get to onboard it, it's usually in a small group. I'll have the therapist or nurse introduce it, and then we'll do the prescription and have an onboarding process together.

John Fox, MD: One of the things that people must understand is there are a number of sessions on these tools, and they might be 20, 30 minutes, but there's an expectation that this is going to be a time-limited treatment. It might be 3 months, 4 months, 6 months, but this isn't a lifelong therapy necessarily. How do other people describe that?

Timothy Aungst, PharmD: I look at how society is changing with the pandemic. We saw a lot of people jump into digitalization of many different services. Telehealth is one; telepsychiatry, telemedicine, remote patient monitoring, all that creeped in. People wanted that for the past decade, and it ramped up exponentially during the pandemic because of the scalability of reaching patients where they're at. I think reaching people where they're at is where society has changed. Do I want to go to the store and drive 30 minutes one way and back and spend my time shopping around? Do I want to search what to watch, or do I want an algorithm to tell me what I'm going to watch because of past use? I think that's where we come back to that consumerism approach. To that point, digitalization of care is what's been creeping into it. Talking about cognitive behavioral therapy, do I want to spend time driving to someone to provide me that care schedule, or do I want this on my own time? Do I want to do this? We know these sessions are long. Do I have to go to a clinic and get this done? Do I have to ask for time off from the day? Is my employer going to get angry at me? What am I going to do about childcare vs when can I do this on my own and guide, in a way? The key thing is that we are having this digitalization of different services come up in new routes of administering and giving care that can provide treatment but also provide different ways of doing this type of outreach. That, to me, is what I look at with digital health and digital therapeutics that really stand apart compared with standard of care right now.

John Fox, MD: You make a great point, and oftentimes, patients use these when they need them most. When they need them most is not 8:00 am on a Tuesday morning with your psychiatrist. That highlights another issue about increasing equity and reducing health care disparities. Scott, do you want to expound upon that?

Scott Whittle, MD: One of the challenges we face today, and I think this was painfully underscored during COVID which we’re still, at least to some extent, still in, is that health care equity is nowhere where we thought it was. The gaps between who has access and who doesn't, who has access to engagement and who doesn't, was made painfully clear. Beyond that, the human resource crisis we're facing nationally in terms of human resource to apply to the problem was further accentuated. If we're trying to treat any collection of behavioral health care conditions, some estimates are between 10% actual access up to 40%, 50%, but nothing more optimistic than that. For example, Intermountain Healthcare recognizes that if we didn't double access to behavioral health care services within the next 3–5 years, we would be seeing a further deterioration of our ability to meet these needs. When you're building out a digital strategy, that digital strategy must have several different components to it. It must have the actual telemedicine pieces plugged into it. It must have a potentially asynchronous, coaching, or engagement-type strategy—a very focused strategy that prescription digital therapeutics feel uniquely. The challenge is you may be having some access to brick and mortar, access to care. You may be having some access to synchronous or asynchronous digital, but if those providers don't have something to refer to, something to go to when they recognize a specific medical condition, then that's a major dissatisfier for both the provider and patient. I was in a conversation this morning with the senior medical director of behavioral health of the Intermountain Healthcare system and his comment was that we need to be putting this in our access centers, our receiving centers. We need to be putting this at the front end, not a carefully guarded back end of care because the access crisis is real.

John Fox, MD: Very well said. Already, there were issues with access even before the health care crisis, and it's only going to get worse. As you pointed out, the COVID-19 pandemic has highlighted the access issues, but there's also been a stigma attached to psychiatric services. You don't want to be seen in the psychiatrist’s office and maybe a few other places, but that's a safe one to say. [It can] reduce that stigma.

Transcript edited for clarity.

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