An Adjuvant Role for Mobile Health in Psychiatry.

On October 29, 2014, a British mental health charity called Samaritans launched “Radar,” a mobile app to assist individuals in severe emotional distress.1 Aimed at users of the social media website Twitter, the app scanned a person’s network for member postings that indicated signs of depression or suicide and would alert the user to contact any potentially concerning member. Samaritans hoped this would turn social networks into “safety nets,” but to their surprise, the app generated uproar over questions of privacy and potential targeting of vulnerable individuals, and the app was shut down 9 days after launch.1 Thousands of mental health–related mobile apps are currently available to the public, and many profess to serve as clinical diagnostic, monitoring, or therapeutic tools. With an estimated investment of $4 billion thus far,2 the pace of mobile health (mHealth) growth has rapidly exceeded that of the clinical evidence base regarding the technology’s usefulness, safety, or efficacy. The current situation is reminiscent of the emergence of direct-to-consumer genetic testing offered by the company 23andMe, founded in 2006 to introduce personalized genomic analysis to a public market. In 2013, however, the US Food and Drug Administration suspended the company’s genetic testing for 2 years, raising concerns that product inaccuracy or misinterpretation could cause indirect consumer harm through poorly informed personal decision making and lack of appropriate follow-up care.3 Additionally, consumers may be harmed directly by confidentiality breaches and commercial exploitation of personal genetic data.4 More recently, the US Food and Drug Administration has begun investigating the company Theranos, which offers direct-to-consumer laboratory testing of blood samples, owing to similar concerns.5 In both examples, the deployment of highly scalable technologies exceeded the extent of the products’ known clinical significance and privacy safeguards, creating opportunity for harmful health outcomes and exploitation (particularly of vulnerable patients). A parallel process is unfolding for mHealth technologies in psychiatry . The rapid introduction of mHealth in psychiatry has created an emergent crisis of imbalanced information and marketing to consumers, lack of sufficient protections, and little clinical guidance for psychiatrists faced with mounting commercial and public interest in the technology. Whereas mHealth may enable psychiatrists to support patient efforts toward selfcare and wellness and enhance access to care when possible, there are presently no guidelines regarding professional imperatives to safeguard individuals within appropriate standards of care. Apprehensions over direct-to-consumer genetic testing resulted in medical and ethics guidelines recommending that genetic testing should be provided only in the facility of an informed and qualified health care professional.6 We propose similarly that mHealth technologies should be deployed ideally and perhaps only in the context of the psychiatrist-patient relationship and should function as “adjuvants” to the psychiatristpatient relationship. Much like how a vaccination or chemotherapy adjuvant enhances the biological effect of the primary therapeutic ingredient but does not constitute a treatment by itself, mobile technologies at this time are best suited for enhancing the therapeutic relationship or augmenting the capability of the psychiatrist to deliver high-quality care. Where the potential for harm exists, the therapeutic context can serve as a platform for appropriate implementation of safeguards, including confidentiality discussions, informed consent, and alignment of technology with treatment goals. For especially vulnerable or at-risk individuals, such as a patient with a serious disability in a psychotic episode or an impulsive patient with thoughts of self-harm, the therapeutic relationship is protective. We propose guidelines that emphasize the transparency of mHealth products, the importance of ongoing clinician education, and the imperatives of further research and inquiry regarding the efficacy, safety, and societal implications of mobile technologies in human health. These recommendations can assist psychiatrists, patients, and companies to unite behind a path toward safe and clinically appropriate adoption of mHealth into daily practice.