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The reduction of the number of suicide attempts is the goal set by the Ukrainian startup Bicovery. The team is developing an algorithm to help people with bipolar disorder to recognize the signs of an upcoming of depressive or manic episode in time, which means to adjust the treatment in time. In an interview with Bicovery CEO Alexander Sharko, we discussed essential information about this disease, MedTech startups and the history of the app.
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The Bicovery app has been developed by a team from Ukraine since 2019. It collects information about the user’s condition through a fitness tracker, a smart ring or smart watch and a smartphone.Fixing simultaneous changes in heartbeat, walking, sleep duration, and social behavior allows us to conclude us about a possible approaching episode of depression or mania and warn the patient, his confidant, and the doctor.Closed beta testing is planned to be held in March 2021, the set of applicants is already open.
— Why did you decide to create a startup in the medical field?
— I and our partners approached the choice of the direction systematically: we collected 15 ideas in completely various industries, then narrowed them down to 5, then to 3. We made 3 market research for three finalists (and the rest of the projects, except for Bicovery, didn’t affect medicine at all).
— Does it mean that the direction of Mental Health is more in demand?
— Yes, this is a global trend: a large amount of investment is directed to it. Gradually, society is recognizing that mental diseases really exist and are worth paying attention to, the number of diagnoses is growing. But the topic of bipolar disorder is still not sufficiently covered ― which means there is potential for work on this problem.
— Why did you decide to create a project for people with bipolar disorder?
— Because precisely in bipolar disorder (opposed to depression,for example), it is possible to detect changes in behavior with the help of sensors, which are a clear sign of this diagnosis.
Bipolar disorder (BPD) causes personality disorders such as depression, mania, and hypomania. A person’s activity increases and decreases, and emotional instability appears. Lack of treatment can lead to serious consequences, including suicide. According to statistics, in the United States, at least 4.5% of the population at various ages suffered from bipolar disorder, in Europe ― 1.5%, and in Israel about 7%.
By observing many of the patient’s indicators for several weeks, we conclude that one of the episodes is approaching (mania/depression) or there is a violation of remission. Besides, there are many bipolar patients in the world.
— How did you pay attention to the problems of people with BPD?
— 3–4 years ago, I was in Israel with one of our partners, whose wife worked in a rehabilitation center for patients with severe mental disorders. Two of her patients, after six months of therapy, were returned to the “big world” by the decision of the council, but two months later they attempted suicide ― and this was a very hard blow for her as a person and a professional. Then the conversation began that it would be a good idea to create a system to help monitor the condition of patients who have come out into society.
Our mission is to reduce the number of suicide attempts among our users. Our slogan is empowering bipolar people. We want to provide a tool with which people with BPD can improve their quality of life, stop being afraid that tomorrow they will lose their job, harm themselves or a loved person, and that manic or depressive episodes may repeat.
— How does the diagnosis of BPD develop?
— Many people live with this disorder and are still unaware of it. However, the number of diagnoses is increasing in both America and Europe. But, probably, the reason is not that there are more patients. In my opinion, the reason is in medical and political decisions and improved diagnostics.
The recognition of the disease itself and the development of a legal basis for it have a positive effect on the number of BPD diagnoses. But not every country is ready to diagnose BPD in a social sense: sometimes a doctor instead of BPD diagnoses a disease with similar symptoms (clinical depression, schizophrenia, borderline disorder), but more generally accepted in his medical environment. There is also the aspect of Asian countries with strict social discipline, such as Japan. In this society, mental disorders are hard to accept, it is not usual to talk about them openly, even with close people.
But even the recognition of the disease does not lead to an easy diagnosis: now more than 80% of patients receive a diagnosis of BPD second or third after the first false diagnoses (usually depression or schizophrenia). This is due to the similarity of symptoms and the lack of knowledge and experience among doctors. The problem works in the other direction, and the diagnosis of BPD can be made to the patient by mistake.
Diagnosis of bipolar disorder is difficult not only in Ukraine, but also in the developed countries of Europe, especially in small cities, where there are no specialists who work with BPD and can make a diagnosis.
Among other things, there are features of the economic and political structure of the medical industry. For example, in Ukraine, according to the law, a BPD is not subject to disability, and schizophrenia is subject to it, which means subsidies from the state in case of job loss, but with a diagnosis of bipolar it is not. Sometimes the doctor can put schizophrenia instead of BPD for the benefit of the patient ― it is also distorting the statistics.
— Are there any bipolar people in your team and what are the risks of the employer?
— We have a person with BPD in our team ― a writer who runs the “Bipolar Diary” blog on our website about how a person with BPD lives in Ukraine, and at the same time acts as a tester and helps to connect with other bipolar people.
I am aware of the risks of having such a person in a team, but I also understand how hard it is to be bipolar. In our team, we structure the tasks in such a way that if an employee has an episode with the BPD tomorrow, the task is pushed back or transferred to another person, and she takes a sick day.
— Can such an employee be considered reliable?
— In a built-up working environment and processes, yes, but this requires additional effort on the part of the employer. Whether managers are ready to take on these efforts is no longer a question of business, but of ethics. There are many companies that don’t dismiss bipolar colleagues, but also consider it their responsibility to take care of them, not just to monetize their resources.And I believe that this is a more appropriate way to live and run a business.
— How exactly will the app recognize the user’s state?
— We adhere to the principle of minimal invasiveness in the user’s life ― he has enough difficulties without us. Therefore, among other things, we refused to create our own devices (for example, our own fitness bracelet). Our algorithm works on sensors that are already present in most existing devices (smartphones or wristbands), and which are already familiar to the user. We differ from our competitors in that user input is the data that the patient shares with us purposefully ― this is only 10% of the total amount of information about the user, on the basis of which the service works. This is important, because just at the most difficult moments, people with BPD begin to have cognitive deformations, when a person cannot adequately assess their condition.
— Do you depend on the vendors of the devices through which you receive user data?
— If we are just talking about data collection, we are independent in any way. Fitness bracelets work using an open Bluetooth protocol, and data can be read from there independently. Even if the manufacturer hasn’t opened the protocol structure, it can be analyzed ― there are a number of libraries for this, and you can also use an ecosystem like Apple Health and Google Fit.
Though we strive to be device-agnostic and work with any tracker, we can work with major manufacturers as partners. For example, in a certain region, our app can be distributed by default in a pair with a device of a specific partner-a manufacturer of bracelets.
— Can your product worsen the situation and harm the person?
— I must say that the risk of user death was one of the top 5 risks we identified back in the idea selection phase. Statistically, adults with bipolar I (a clinical condition of bipolar disorder) are 6 times more probably than people without the disease to attempt suicide, and in young people under 18 with BPD have an even higher risk.
So we are guided by the principle of non-invasiveness in our product development. Our system does not diagnose, does not change the course of treatment, does not give medical recommendations. We do not assume the responsibility of a psychotherapist. Our task is to detect changes that are not visible to the patient, his relatives or his doctor, and to inform them that they are there. We do not treat, but give a signal that something is going wrong and it is worth paying attention to it.
If we send a notification about a weak depressive or manic trend to the attending physician or caregiver-user, listing the factors on the basis of which the trend was detected (for example, changes in the dynamics of sleep and physical activity), we only inform the patient that the moment may have come when he needs to see a doctor ― no more, no less.
A caregiver is a trusted carrying person, it is not really a guardian and not necessarily a family member. A caregiver can be close friends, spouses, or even colleagues.
— Is there something like an emergency button in the app?
— Yes ― emergency button, and we have also developed another important feature ― bipolar friends. With the user’s consent, when his condition worsens, we notify the caregiver, the doctor, and a group of “stable” bipolar people (also with their prior consent) ― and they volunteer to come to his aid.
This support model is clearly visible in the bipolar communities we work with. As soon as one participant publicly writes that he is having a hard time, the others respond with comments, supportive posts, and joint action, which often turns out to be more effective than medication. However, a depressed patient is not always able to write a post about help or press an alarm button, so we provided for the notification of others without the patient’s direct request.
— What risks do you foresee for yourself as a developer?
— Of course, due to the specifics of our app, there is a risk of claims from the user’s relatives in case of suicide. But we tried to provide for all legal aspects and built a clear user agreement structure, where we described as much detail as possible. Both our areas of responsibility and the user.
There is also the risk of our product not developing according to our chosen business model, because we don’t have yet the actual data to confirm the market fit and aggressive growth dynamics that we are counting on.There are also several technological risks, such as data distortion by various devices. We will handle these issues at the customer support level.
Another risk is the validation of the algorithm. In case of unsuccessful beta testing, we are ready to redo the algorithm and repeat the Beta. The heart of our system is the ability to detect changes in behavior and at the same time not give too many false positive and false negative diagnoses. The main task of the beta version is to confirm this ability.
— How do you plan to earn money?
— The bipolar user will pay for the service or their caregivers which happens more often. Subscription mode is monthly or annual. Our product is expensive ― €50–80 per month for Europe and America, $25–35 per month for the CIS countries. We understand that a high price is likely to increase the rejection rate, and we put this into the financial model. But if you consider that an American adult with a BPD spends about $12 000 — $ 13 000 a year to fight the disease, of which only 60% is covered by insurance, then our service will help significantly reduce the cost of stabilizing the mental state.
— For how long will people with BPD use the app, taking into account long periods of remission?
— The LTV (Lifetime Value) of the client is expected to be quite long: the remission of a bipolar user can last from 8 to 24 months. However, the manic or depressive episode that follows is not only dangerous, but also very costly in social and monetary terms: loss of work, relationships, aggressive medical intervention, stronger and more expensive drugs. And if our system allows us to avoid such a situation, then according to the feedback received, bipolar users and caregivers are ready to pay for it.
— Are you planning to work in the b2b direction?
— We plan to develop this area, first of all, together with small clinics and private practitioners with a small number of patients. Another format is Corporate Health, when large companies try to minimize the risks of episodes in employees who occupy key positions and do some dangerous work, as well as to reduce payments for long-term sick leave.
To work more effectively in the b2b direction, we need a medical status ― for this purpose, after the Beta is completed, we plan to start medical tests that take up to 18 months. And because of the length of this process, we are now more focused on the b2c direction, where we will make the initial market entry in the as is mode ― that is, the user will use the app at their own risk.
In the United States, there is the term software as a drug, when an app receives the same degree of responsibility to the patient as a medical drug. On the one hand, such apps should give the promised effect, but if the buyer uses this “tablet” for other purposes, the manufacturer is not responsible for this. In Europe, there is no such legal form yet, but it is possible to formalize such an agreement at the level of the installation agreement provision.
— When will the app be ready to launch?
— We were supposed to launch it back in November, but due to the coronavirus and difficulties in developing the algorithm, we slowed down. Now we are preparing to launch beta testing in mid-March, it will take 1.5–2 months. In 4 months after the Beta launch, we plan to be publicly available on the market.
— Last year, you attracted an investment of $80 000 from “Farmak” and the angels. Do you plan to increase the amount of funds raised?
— One of the scenarios of our financial model is to close the Pre-seed round in its entirety and no longer invest until round A (with a capitalization of up to $20M. Early money is very expensive, and the more shares in a startup you give away in the early stages, the more you will lose later.
— What is the structure of your team and are there any doctors in it?
— Our team consists of 3 partners, 4 developers (2 mobile, 1 front-end and 1 back-end), as well as a designer, marketer, content writer and translator. Also in the team there are medical workers ― Svetlana Morozova, the head of the Center for Psychosomatic Pathology at the Dnipro Regional Hospital named after I. I. Mechnikov, and her staff, who are project’s advisors. And in the near future, to bring the first versions of the product to the market, we don’t plan to involve a doctor to the team for a permanent job.
Since our product is a software solution, we are focused on formalizing the experience of the doctor and the patient, rather than realising the medical method of treatment in accordance with approved protocols.We have already sufficiently described the necessary algorithm and set the foundation for the machine learning layer. And now, the closer we are to entering the market, the more doctors become users for us, rather than analytical experts.
But in the future, with the commercial success of the first product, we plan to organize a separate area of medical research, the purpose of which will be to bring changes in the diagnosis and treatment of the disease itself and the modernization of medical methods. Undoubtedly for this purpose, we will need expert doctors.
— What should the founder, who decided to enter the field of Mental Health, pay attention to?
— The funder should be prepared for the fact that Mental Health is expensive, long and complicated. Mature investors are sympathetic to this, but there are also those who are shocked by the size of the investment and the timing of product development. Well, it is expensive because it requires certifications and medical tests ― for example, conducting medical tests under the European protocol will cost from $40 000 to $100 000, depending on the nationality and composition of the participants and will take from 8 to 14 months.
On the other hand, the field of Mental health is now on the rise: the situation with COVID-19 and self-isolation has greatly warmed up this market ― people around the world have increased anxiety and tension.
There are a lot of medical diseases in the world and many of them do not have reliable or 100% effective solutions ― you need to look for where you can benefit and where the market is really waiting for technological solutions. Today, the solution of mental problems is even more expensive for patients than cancer, if you take into account the spread of the problem.
In the medical field, more than anywhere else, you realize exactly the benefits that you can bring ― and this is very inspiring!