Envisioning a Path toward Equitable and Effective Digital Mental Health

Digital mental health technologies have been promoted with the promise of delivering wide-scale access to more efficient and effective mental health diagnosis and care. During the pandemic, the rapid and largescale shift to telemental health, and increased use of digital mental health tools and apps, tested that promise. While there were some digital mental health tools that provided safe and effective care (Marshall, Dunstan, and Bartik 2021); there were also many organizations, communities, and individuals that had insufficient infrastructure or resources to access or utilize effective digital mental health tools (Abraham et al. 2021). Skorburg and Yam (2022) outline important issues regarding safety, effectiveness and equity in digital mental health tools, with justifiable skepticism. In order to consider whether and how digital mental health tools may be used toward building an improved system of mental health care, it is useful to engage the broader social and systemic challenges in digital mental health. Safety and effectiveness have been longstanding concerns, with ethicists and digital health researchers pointing out the harms that come from a digital health ecosystem in which the majority of mental health apps are not backed by evidence that they work (Anthes 2016; Martinez-Martin et al. 2020). The frameworks for establishing safety and oversight for digital mental health depend upon the context for which the digital mental health tool is developed and used, such as whether the tool is meant for directto-consumer, clinical or research applications. Digital mental health tools that would be used for clinical purposes generally are categorized as medical devices, subject to regulatory oversight and clinical validation to establish safety and accuracy, as is the goal with digital therapeutics (Martinez-Martin 2021). Many of the safety concerns raised by the target article are most applicable to mental health apps that are directed at consumers and that are in the “wellness” category, not subject to regulatory oversight for establishing safety. While there are ethical arguments that would support the need for these consumer mental health apps to be evaluated by government agencies, there are also practical concerns regarding how to regulate an area that includes tens of thousands of apps. Recommendations for safe and effective use of mental health apps often involves some human oversight, with a focus on tools that support specific skills or goals, such as using an apps that aid people with mindfulness practices. People may look to mental health care organizations with an established track record in digital mental health, such as the Veteran’s Administration in the US, as trusted sources for evidence-based mental health apps (Jaworski et al. 2021). We may also look to models like that in Germany, in which a digital health tool must establish its effectiveness in order to be eligible for health insurance reimbursement (Gerke, Stern, and Minssen 2020). At the same time, in the US, mechanisms that rely on clinical oversight or health insurance for establishing efficacy could likely reinforce existing inequities in mental health care access and services. Safety and efficacy issues go beyond the technical aspects of the digital tools, and encompass systemic issues, as well as what the tools are being used for and in what contexts. For example, telehealth platforms can provide remote mental health care effectively, with indications that some people even prefer