Research Into Digital Health Intervention for Mental Health:25-Year Retrospective on the Ethical and Legal Challenges

Digital mental health interventions are routinely integrated into mental health services internationally and can contribute toreducing the global mental health treatment gap identified by the World Health Organization. Research teams designing anddelivering evaluations frequently invest substantial effort in deliberating on ethical and legal challenges around digital mentalhealth interventions. In this article, we reflect on our own research experience with digital mental health intervention design andevaluation to identify 8 of the most critical challenges that we or others have faced, and that have ethical or legal consequences.These include: (1) harm caused by online recruitment work; (2) monitoring of intervention safety; (3) exclusion of specificdemographic or clinical groups; (4) inadequate robustness of effectiveness and cost-effectiveness findings; (5) adequatelyconceptualizing and supporting engagement and adherence; (6) structural barriers to implementation; (7) data protection andintellectual property; and (8) regulatory ambiguity relating to digital mental health interventions that are medical devices. As wedescribe these challenges, we have highlighted serious consequences that can or have occurred, such as substantial delays tostudies if regulations around Software as a Medical Device (SaMD) are not fully understood, or if regulations change substantiallyduring the study lifecycle. Collectively, the challenges we have identified highlight a substantial body of required knowledge andexpertise, either within the team or through access to external experts. Ensuring access to knowledge requires careful planningand adequate financial resources (for example, paying public contributors to engage in debate on critical ethical issues or payingfor legal opinions on regulatory issues). Access to such resources can be planned for on a per-study basis and enabled throughfunding proposals. However, organizations regularly engaged in the development and evaluation of digital mental healthinterventions should consider creating or supporting structures such as advisory groups that can retain necessary competencies,such as in medical device regulation