The promise of technology to revolutionize mental health is surrounded by hype. As an example, the Academy of Medical Sciences described digital health as a fast-developing technology that will “transform the way that health and social care is delivered” . This hype is understandable as such a revolution is warranted. It is recognized that it will not be possible in the near future to address the burden of mental health through training professionals alone, and even if we could, some people might desire (or require) alternative modalities to receive mental health support. However, this hype also serves to detract from potential drawbacks of the application of technology to mental health. Mental health technology comes with a responsibility to determine appropriate ethical standards in the development, research, and integration of these technologies into society and clinical care. Doing so will require a careful review of which existing standards are relevant for these technologies and should balance each issue or problem alongside relevant benefits, cultural norms, and values.
In this treatment of ethics, we adopt both an aspirational as well as a pragmatic approach. We are not ethicists, but rather are mental health and mental health services researchers who have extensive experience in the digital mental health space and have worked with consumers, developers, clinicians, healthcare organizations, evaluators, and payers.
Our pragmatism starts with defining what we are referring to by digital mental health. A narrow definition would consider only technologies intended for those who have a mental health diagnosis. Many products, however, attempt to avoid liability by stating that they do not provide medical advice, diagnosis, or treatment and then proceed to offer content and tools that address mental health issues. We, therefore, adopt a comprehensive definition of digital mental health that includes all technologies that provide treatment and management of mental health problems. This includes technologies that address social, psychological, and biological factors that contribute to mental health, such as apps, wearable devices, and virtual reality products. We also do not define mental health as only the presence or absence of a mental health diagnosis but include emotional, psychological, and social well-being that spans a continuum from flourishing to languishing . Therefore, we are pragmatic in that we recognize that the technologies being advertised to people on the promise of mental health benefits are much broader than those that directly address mental health diagnoses, so our ethical guidelines must address this broader array of technologies.
We are aspirational in believing that ethical guidelines developed today could guide the development and uses of technologies in the future. If we develop ethical guidelines only in response to technology, we will likely always be developing guidelines in the midst of disasters—ineffective technologies pushed on uninformed consumers, data breaches, and failures of people to seek effective care in the face of flashy alternatives.
Multiple ethical codes are relevant to this space including those drawing from health professionals as well as technology developers. First, ethical codes support the development and application of digital mental health. For example, the American Medical Association’s principles of medical ethics require that physicians “support access to medical care for all people.” Similarly, the General Principles of the American Psychological Association’s Ethics Code  includes the principle of Justice, which indicates that services be made accessible to all. Insofar as digital mental health meaningfully extends the reach of services to those with more limited access, incorporation of these technologies into practice is inherently part of our ethical obligation. Most importantly, however, these codes define acceptable behavior to protect the client, especially in the context of power differentials inherent in the client-clinician relationship. We need to be careful not to develop and spread technologies because we think it is the right thing to do as the “experts” without consideration of the most critical issues for those who will be affected by these technologies. In light of this, we have previously suggested four simple Transparency for Trust (T4T) principles [4••] which were published in May 2019. These are based on patient and regulatory perspectives, recent systematic reviews, and experimental studies (e.g., [1, 5,6,7, 8•, 9, 10•, 11, 12•]. These principles include privacy and data security, development characteristics, feasibility data, and benefits. They were developed in order to fill the void on information to the consumer available at the point of download where we know that consumers trade-off information to make choices; e.g., they may want strict privacy or they may choose apps with more efficacy information.
The T4T principles are a starting point, but in this paper, we comment on additional ethical concerns that expand on these principles by highlighting other areas that need to be addressed when considering the design and use of technologies for mental health purposes.