Affectech
A Call for Integrated Ethical Approaches to Mobile Mental Health

By Dionne Bowie, AffecTech Researcher

Mental health professionals are guided in their work by ethical principles and codes of conduct. These ethical codes clearly outline standards of practice, professional behaviour, and key issues that relate to good and fair delivery of care. Simply put, ethics relates to what is good or moral for individuals and society. When we speak of ethical practice in mental health, we therefore mean actions that are “good” and in the best interest of the client, the profession, and society.

This includes: acting in the best interest of others and doing no harm; being trustworthy and responsible for one’s actions and decisions; ensuring competence in skills and practice; being honest and transparent in one’s actions; being fair; and respecting individual freedoms, rights, and equality.

Under these broad ethical principles lie more specific standards which guide mental health professionals in areas such as: privacy and confidentiality; record keeping; competence and training; conflicts of interest; advertising and self-promotion; assessment, therapy, and research; and human relations. The purpose of these comprehensive ethical standards is to protect individuals who may often be vulnerable and at-risk of harm. Ethical frameworks are therefore important to ensure best practices, non-abuses of power, and public assurance and confidence in the quality of mental health care available.

With the emergence of new mental health technologies comes a need to further consider the ethical implications of their use and to develop relevant ethical standards. In the past decade, there has been great investment in the potential of mobile devices to assist in the management of mental health. Mobile applications, smartphones, and wearable devices have been highlighted for their potential to reduce barriers to treatment. Yet, much research is still needed to demonstrate that these mental health technologies are valid, effective, safe, and in line with client needs. Aligning with this is the need for continued discussion regarding the ethics of mobile mental health, and the development of frameworks to guide the design, development, and use of these new treatment modalities.

In reviewing the existing literature on the ethics of mobile mental health, it is clear that much of the same considerations for traditional mental health apply. These discussions however diverge in line with the varying industries and sectors. Mobile mental health is a wonderfully multidisciplinary field uniting mental health, computing, bioengineering, and human computer interaction. Each field therefore brings with it its own ethical considerations and standards. For computing, much of the ethical debate centres on privacy and confidentiality in the realm of data security and protection. This includes issues such as the need for clear privacy policies, transparent informed consent practices, and regulations protecting against the unauthorised sharing of information with third parties.

The introduction of technology to mental health care further creates debate around the commercialisation of health and motives underlying the development of new technological treatments. These questions are proven valid in light of research which shows that of the thousands of ‘mental health’ applications in the app stores, many do not do what they claim. Moreover, a substantial number of mental health applications lack evidence to support their effectiveness, safety, and use. This is fundamental given that a key selling-point of mobile mental health is its potential to increase the self-management of mental health problems, with several of these technologies developed to be used without clinical support. Beyond safety, we must therefore also consider issues of liability, responsibility, and fairness in determining: 1. How to protect individuals from possible harm from the use of such devices, and 2. Who is truly responsible for protecting and managing the risk of vulnerable populations. We can therefore see that whilst the ethical themes remain the same, the specific issues involved go beyond those of traditional mental health care.

Added to this are the broader ethical considerations of mobile mental health outside of individual treatment. The accumulation of personal health and lifestyle data from mobile devices unlocks the potential to increase our understanding of human behaviour through big data, data mining, and predictive analytics. But – we cannot truly fathom all the future uses and unintended consequences arising from these practices. When we consent to using technology in our daily lives – be it, sharing information on social media, tracking our activity and health, or monitoring our mood on an app – we do not necessarily foresee what will happen to our data beyond that present moment. Outside of the issues of data security, we must also consider the potential for this wealth of data to be used for purposes we have yet to conceive of, such as determining eligibility for insurance or future employment. How then do we give informed consent to use technology when we do not fully know what that use may entail? Ethical standards and regulations must therefore serve to protect individuals and society now and in the future.

While a number questions remain, what is apparent is that our current ethical standards do not adequately address the complexity of mobile mental health. There is a need for greater integration of all disciplines involved and a more unified approach to understanding these shared and unique ethical concepts. A systems approach to ethical and social considerations of mobile mental health is therefore proposed, representing the relationships between key stakeholders and the most pertinent ethical issues they may face. An initial formulation of this idea focusses on ethical issues in the areas of: privacy, safety, treatment, competence, legal issues, social and human relations, autonomy, and commercial considerations. These are illustrated in the diagram with select examples of their relevance to each stakeholder.

This is an initial conceptualisation of this idea with further research needed to better understand and represent the complex ethical issues facing the field of mobile mental health. It should be noted that whilst much discussion of ethics in mental health focuses on potential harm, the aim is to achieve good, fair, and safe care. As such, there are many benefits to be gained from mobile mental health such as increased individual autonomy, decision making, and more stringent regulatory policies. By further exploring ethical concepts, we will be able to develop integrated frameworks and clear recommendations to guide the design, development, use, and implementation of “good” mobile mental health and future innovations in healthcare.

1-American Psychological Association (APA) (2017). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/ethics-code-2017.pdf
2-British Psychological Society (BPS) (2018). Codes of ethics and conduct. Retrieved from https://www.bps.org.uk/news-and-policy/bps-code-ethics-and-conduct
3-Karcher, N. R. & Presser, N. R. (2018). Ethical and legal issues addressing the use of mobile health (mHealth) as an adjunct to psychotherapy. Ethics and Behaviour, 28(1), 1-22. https://doi.org/10.1080/10508422.2016.1229187
4-Christovich, M. M. (2016). Why should we care what Fitbit shares? A proposed statutory solution to protect sensitive personal fitness information. Hastings Communications and Entertainment Law Journal, 38(1), 91-116. Retrieved from https://repository.uchastings.edu/hastings_comm_ent_law_journal/vol38/iss1/4
5-Anthes, E. (2016). Mental health: There’s an app for that. Nature, 532, 20-23. https://doi.org/10.1038/532020a
6-Bauer, M., Glenn, T., Monteith, S., Bauer, R., Whybrow, P. C., Geddes, J. (2017). Ethical perspectives on recommending digital technology for patients with mental illness. International Journal of Bipolar Disorder, 5:6. https://doi.org/10.1186/s40345-017-0073-9
7-O’Doherty, K. C., Christofides, E., Yen, J., Bentzen, H. B., Burke, W., Hallowell, N., … Willison, D. J. (2016). If you build it, they will come: Unintended future uses of organised health data collections. BMC Medical Ethics, 17:54. https://doi.org/10.1186/s12910-016-0137-x

Author

Dionne Bowie is an AffecTech PhD Psychology Research Fellow at Lancaster University and Leeds Teaching Hospital NHS Trust, in the UK. Dionne’s research focus is concentrated in the area of proof of concept studies for real world use, experiences and effectiveness of personal technologies for affective health.

AffecTech

The AffecTech project was established to conduct international research and development into personalised technologies for mental health. AffecTech is a multidisciplinary network that brings together academic and industry partners in the research and development of accessible and affordable personal technologies for affective disorders, notably depression, anxiety and bipolar disorder. AffecTech is funded by the European Commission under the Horizon 2020 Marie Sklodowska-Curie Innovative Training Networks (ITN).