the ethical use of mobile health technology in clinical psychiatry · 2020-01-29 · 1 the ethical...

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TheEthicalUseofMobileHealthTechnologyinClinicalPsychiatry

JohnTorous,M.D.1,LauraWeissRoberts,M.D.,M.A.2

CorrespondingAuthor

LauraWeissRoberts,M.D.,M.A.

StanfordUniversitySchoolofMedicine

DepartmentofPsychiatryandBehavioralSciences

401QuarryRoad,Stanford,CA94304

Phone:650-723-8290

Email:Robertsl@stanford.edu

Acknowledgements:None

ConflictsofInterestandSourceofFunding:Onbehalfofallauthors,thecorrespondingauthorstates

thattherearenoconflictsofinterest.

1 Beth Israel Deaconess Medical Center Department of Psychiatry, Harvard Medical School, 330BrooklineAve,Boston,MA02215,USA2DepartmentofPsychiatryandBehavioralSciences,StanfordUniversitySchoolofMedicine,401QuarryRd,Stanford,CA94304,USA

Abstract

Therapidriseofmobilehealthtechnologies,suchassmartphoneappsandwearablesensors,presents

psychiatrywithnewtoolsofpotentialvalueincaringforpatients.Noveldiagnosticandtherapeutic

applicationsofthesetechnologieshavebeendevelopedinprivateindustryandutilizedinmentalhealth,

althoughthesemethodsdonotyetconstitutestandardofcare.Inthispaper,weprovideanethical

perspectiveonthepracticaluseofthisnovelmodalitybypsychiatrists.Weproposethatinthepresent

contextoflimitedscientificresearchandregulatoryoversight,mobiletechnologiesshouldserveto

enhancethepsychiatrist-patientrelationship,ratherthanreplaceit,inordertominimizepotential

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clinicalandethicalharmtovulnerablepatients.Weanalyzeareasofpossibleethicaltensionbetween

clinicalpracticeandtheconsumer-drivenmobileindustry,anddevelopadecision-treemodelfor

implementingethicalsafeguardsinpractice,focusedonmanagingrisktothetherapeuticrelationship,

informedconsent,confidentiality,andmutualalignmentoftreatmentgoalsandexpectations.

Keywords:MobileHealth,Technology,Ethics

Introduction

Withover165,000healthcare-relatedsmartphoneappsalreadydeveloped(IMSInstitute,2015),

mobiletechnologyoffersnewopportunitiesforenhancingtheclinicalcareofindividualpatientsandfor

improvingthehealthofpopulations.Smartphones,tablets,andwearabledevices,suchasdigital

watchesandsensors,havebeenbroadlyembraced(Marzanoetal.,2015).Customizedprograms,called

apps,canrunonthesemobiledevices,gatheringinformationsuchasself-reportedsymptomsofmood

oranxiety,behavioraldatasuchasstepcountandgeographicmobility,andphysiologicalmeasures

includingheartrateandsleeppatterns.Otherappshavebeenproposedtoofferemotionalsupport,

behavioralcoaching,medicationreminders,andevenpsychotherapy.Thepotentialofthesemobile

technologiestotransformpsychiatrythroughexpandedaccesstocare,newmonitoringtools,andnovel

adjunctiveinterventionshasbeenwidelytouted(EapenandPeterson,2015;Proudfood,2013).

Especiallyinunderservedareas,theuseofmobiletechnologytoaddressmentalhealthneedshasbeen

identifiedasawaytoovercomesignificantbarrierstocare.Indeed,thepotentialproblemoflackof

mobiletechnologydeviceownershipamongpsychiatrypatientsisrapidlydiminishing(Firthetal.,2015).

Currently64%oftheUnitedStates’populationownsasmartphone,andownershipratesareexpected

toescalate(Smith,2015).

Interestinmobiletechnologyforpsychiatryisrapidlygrowingwithintheindustry,asindividuals

fromdifferentsectorsofsocietyappeartobeincreasinglyinvestedinusingtheirsmartphonesfor

mentalhealth(Torousetal.,2014a;Torousetal.,2014b).Mostappsaremarketeddirectlyto

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individuals,consistentwithageneralmovementtowardempoweringpatientsasconsumersofhealth

care.Atbest,thesedevelopmentscouldpromotemoretimelyaccesstoself-directedclinical

intervention,aswellasgreatercollaborationwithphysiciansinclinicaldecision-making.Atworst,these

technologiescouldmisinformordeceivepatientsabouttheircare,resultinginsubstandardclinical

interventionthatmayprecipitateharmfuloutcomes.InOctober2014,forexample,aBritishmental

healthgroupcalledSamaritansintroducedamobileappthatsoughttoscreensocialmediapostingsfor

signsofdepressedmoodorsuicidalideation,andtoutilizesocialnetworkmembersassafetycontacts

(USFederalTradeCommission,2016).Samaritanswithdrewtheapp9dayslater,afterabacklashof

consumerfearsthatthisnon-clinicalarrangementcouldleadtotargetingofvulnerable,depressed

individuals(Orme,2014).InJanuary2016,thecompanyLumosity,whichsellscognitivetraining

programsandappsdirectlytoconsumers,settledchargesbytheUnitedStatesFederalTrade

Commission(FTC)thatitdeceptivelyclaimedcompanyproductscoulddelaycognitivesymptoms

associatedwithdementia(USFederalTradeCommission,2016).AccordingtotheFTC,thecompany

“preyedonconsumerfears”aboutaging-relatedcognitiveimpairment,andfailedtoprovidescientific

evidencetosupportitsclaims(USFederalTradeCommission,2016).Inbothexamples,thepaceof

mobileappdevelopmentinindustryexceededtherateatwhichclinicalresponsibilitiesandevidence-

basedpracticecouldadapttothisnewtechnology.

Clinicalresearchonmobiletechnologiesinpsychiatryremainsanascentfield,consisting

primarilyatthistimeoffeasibilitystudiesforuseindepression(Bindhimetal.,2015),post-traumatic

stressdisorder(Kuhnetal.,2015),bipolardisorder(Faurholt-Jepsonetal.,2014),schizophrenia(Ben-

zeevetal.,2014),substanceusedisorders(Gustafsonetal.,2014),andmanyotherpsychiatric

conditions,althoughinitialrandomizedclinicaltrialsareunderway.Numerousquestionsremainabout

thevalidity,efficacy,sideeffects,andevensafetyofmobileapps.Preliminaryresearchsuggeststhat

smartphoneinterventionsarenotsimpledigitaltranslationsofexistingtools,butrathercomplexand

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dynamicinstrumentsandprocessesthatwillrequireseriousclinicalinvestigation.Evenbasicpsychiatric

scalessuchasthePHQ-9mayrecordsignificantlydifferentscoreswhencapturedonasmartphone

(Torousetal.,2015),andtherapiesdeliveredinpersonmaynotalwaysremainefficaciouswhendigitally

delivered(Heffneretal.,2015).Someappscanevencauseharmtopatients,asinthecaseofoneblood

alcohollevelcalculationappthatappearstohaveencouragedasubsetofpatientstodrinkmoreinstead

ofless(Gajeckietal.,2014).Thereisevenlessdataforwearabletechnologieslikefitnesstrackerswith

littleknownabouttheirbenefitsandrisksforuseinclinicalpsychiatry.

Presently,theUnitedStates’FoodandDrugAdministration(FDA)offersminimalregulatory

oversightforsmartphoneappsandwearables.TheFDAstatesthatitplanstoregulatethoseappswhich

posehighpatientrisk,orappsthatturnasmartphoneintoamedicaldevicewiththepurposeof

diagnosingortreatingaspecificmedicalcondition(U.S.DepartmentofHealthandHumanServices,

2015).Inpsychiatry,however,whereself-reportedsymptomsmaybeconsidereddiagnosticand

psychosocialinterventionsaretherapeutic,itcanbeeasyforconsumer-marketedappstoblurtheline

betweenwellnessandclinicalcare,orbetweenself-enhancementtoolandmedicaldevice.Thereare

alsolimitedprofessionalsocietyguidelinesorrecommendationsintheuseofmobiletechnologyfor

patientcare.Appratingservices,suchastheBritishgovernment’sNationalHealthServiceAppLibrary,

haverecentlyclosedduetodifficultycuratinghealthcareapps(Sunyaevetal.,2015).Therearefew

resourcesforpsychiatriststoturntoforevaluatingtherole,value,andimpactofapps.

Giventhegapsinclinicalknowledgeaboutspecificbenefitsandrisksofmobileappsin

psychiatry,andthegenerallackofregulatorystandardsinthisarea,howshouldpsychiatristssafely

incorporatemobiletechnologiesintoclinicalpractice?Howcanpsychiatristsbestprotectpatientsfrom

anticipated,butcurrentlyunprovenorunofficial,clinicalharmsfromatechnologythatdoesnotyet

constitutestandardofcare?Weproposehereanethicalframework,groundedinananalysisof

potentialethicalconflictsbetweenclinicalpracticeandtheconsumer-drivenmobileindustry,tohelp

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guidetheuseofmobileappsinpatientcaretoday.Wepresentanethicalrationaleforthisframework

withselectedcaseexamplesofmobileappuseinpsychiatry,andproposesafeguardsthatpsychiatrists

canapplytoensuresafeandethicallyappropriateincorporationofthisnovelmodalityintostandard

clinicalpractice.

Ethicaltensionsbetweenpsychiatryandthemobileindustry

Therearemanyconceivablesituationswherebusinessmotivationsandpsychiatriccare

prioritiesoverlapinmobilehealth,andtheadoptionofmobileappsinthesecaseswillbe

straightforward.However,therearealsopossibleareaswhereethicalconflictsmayarise–specifically

alongfaultlineswhereethicalvaluesdonotalignprecisely–anditisthesesituationsthatmayleadto

ethicalriskandevenclinicalharmatlaterstagesofpatientcare.

Fortheconsumer-drivenmobileindustry,conflictsmayariseinhowpatientautonomyis

balancedwithclinicalcareneeds.Direct-to-consumerproductsassumethatcustomersareautonomous

individualswiththerighttochoosewhichproductstopurchaseatanygiventime(CarrollandBuchholtz,

2003).Incontrast,clinicalpsychiatryviewseachpatientasamedicalimperative–anindividualwith

uniquevulnerabilities,resiliencies,andgoals,exhibitinganunmethealthneedforthephysicianto

address(BeauchampandChildress,2001).Thephysician’sdutiesareto“dogood”andto“donoharm”

inservingthehealthandwellbeingofthepatient,whichmayinvolvevaryingdegreesofaccommodating

patientpreferenceswithinappropriatestandardsofcare(Siegler,1981).Insomecases,thebusiness

paradigmwillbeatoddswiththeaccommodationmodelofthephysician-patientrelationship,

particularlyinsituationswhereapatient’smentalhealthconditionlimitshisorherinsight,and

thereforeaffectstheauthenticityandrigorofpersonaldecision-making.

Pharmacologicalagentssuchasantipsychotics,forexample,areoftenmarketeddirectlyto

consumers,butcannotbeaccessedbypatientswithoutaphysician’sprescription.Thismeasureallows

forappropriatemedicalevaluationofthepatient,whomaybeexperiencingsymptomsofseveremental

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illness,andforcarefulbalancingofclinicalrisks,benefits,goals,andnecessitiesinanopenand

professionalmanner(Siegler,1981).Thesamedoesnotapplytomobileappsthatareavailabledirectly

toconsumers,creatingagapinprotectionforvulnerablepatients.

Conflictsinconfidentialityarealsouniqueconcernstomobilehealth.Physiciansmustadhereto

privacyguidelines,mostoftenwiththeexpectationthatpatientconsentisrequiredpriortodisclosing

privateorclinicalinformationtoathirdparty,withimportantlegalexceptions(Beauchampand

Childress,2001).Purchasingaconsumerproduct,however,involvesanimplicitassenttotheproduct's

presencewithinaconsumer'sdailylife.Foramobileapp,thismayincludeanentire"behind-the-

scenes"mechanismfordataencryption(ifany),handling,storage,analysis,andevensharing.In

additiontoself-reporteddata,thesesystemscanalsocapturepassivelyacquireddata,withvariables

suchasgeographiclocationofthemobiledevice,calllogs,purchasinghistory,orwirelessconnection

signalsthattheuserdoesnotneedtoactivelyinput.Together,theselargeaggregatedatasetshave

becomeacommoditytoday,astechnologicaladvancementsindataminingofferanenhancedabilityto

predictconsumerbehaviors,motivations,andinterests.Mobilecompaniesandappdevelopersmay

basetheirentirebusinessmodelaroundandreapsignificantfinancialrewardsfromaccesstoandthe

sellingofpersonaldata,forexample,inprovidingpatientprofilestothepharmaceuticalindustry(Glenn

andMonteith,2014).Fromabusinessperspective,thereisoftengreatincentivetocollectconsumer

datathroughmobiledevices,incontrasttothemedicalobligationtoupholdpatientconfidentiality

(Carrns,2013).

Companiesmayalsoengageindeception(asinthecaseofLumositymentionedabove),where

informationaboutproducttechnologyordataaccessisselectivelydisclosed,orevensilenced,inan

attempttoattractacustomer.Thisstandsincontrastthephysician’sdutytobetruthfulandtonotleave

patientswithmisimpressionsoftheirclinicalcare(Roberts,2016).Physiciansalsohaveadutytohonor

theircommitmenttopatientcare(Roberts,2016),whereascompanieshavealegalobligationtohonor

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theircontracts–writtenagreementsthatmaysuitpatientneedsataspecifictimepointintheirillness,

butwhichmaynoteasilyadaptaspatientgoalsevolve.

Mobilehealthasanadjuvanttool

Asafoundationforethicallysoundcare,weproposefirstthatmobilehealthtechnologiesserve

asanadjuvanttothepsychiatrist-patientrelationship(Hsinetal.,2016).Toillustrate,weprovidea

seriesofcaseexamples(Table1).Idealuseofthesetechnologies,asexemplifiedinCase1,occurswhen

thesetoolsenhancethepsychiatrist’sabilitytodeliverhigh-qualityclinicalcare.Opendiscussionand

useofmobiletechnologieswithinthetherapeuticrelationshipensuresthatpotentialbenefitsand

harmscanbeweighedwhileremainingfaithfultostandardofcare,andwhileappropriatelybalancing

patientautonomywithclinicalneeds.Thetherapeuticcontextalsoallowsforconfirmationofthemobile

app’sveracity(Case2),andtheproactiveexaminationofconfidentialityconcerns(Case3).Finally,the

therapeuticcontextcanclarifyhowmobiletechnologyalignswithtreatmentgoals,soasnotto

introducepotentialgrayareasoftherapeuticmisconception(Appelbaumetal.,1982)wherepatients

maybelievethattheirinteractionwiththemobileappconstitutedstandardofcare,wheninfactitdid

not(Case4).

Table1.Casesofmobiletechnologyuseinpsychiatriccare

Benefitexceedsrisk Riskexceedsbenefit

Therapeutic

roleof

mobile

health

Case1:A22year-oldmanstruggleswith

new-onsetpanicattacks,butisunableto

findalocaltherapist.Heseesa

psychiatristwhoprescribesfluoxetine,and

recommendsthathedownloadamobile

applicationforcognitivebehavioral

Case2:A33year-oldmanwithpost-

traumaticstressdisorderfromchildhood

physicalabuseexperiencesarecurrenceof

flashbacksafterhewasviolentlyassaultedin

thestreet.Hispsychiatristprescribeshim

sertralinebutheisunabletofindalocal

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therapy.Guidedbythistechnology,the

patientisabletoidentifytriggersand

automaticthoughtsassociatedwitheach

panicattacksuccessfully,andtoperform

cognitivere-appraisaltechniquesonhis

own.Fourweekslater,thepatientfollows

upwithhispsychiatristandhissymptoms

haveimprovedgreatly.

therapist.Hedecidestodownloadamobile

appforcognitivebehavioraltherapywhich

hefoundthroughawebadvertisement,and

doesnotdisclosethistohispsychiatrist.As

heproceedswiththistreatment,however,

hebecomesincreasinglydistraughtby

difficultchildhoodmemories,andhebegins

tohavethoughtsofsuicide.Eventuallyhe

disclosestheapptohispsychiatrist,who

findsthatitmerelyasksthepatienttorecord

hismosttraumaticmemories.

Monitoring

roleof

mobile

health

Case3:A56year-oldwomanwitha

historyofchronicdepressionandlow

suicidalriskhastroublerecallingher

moodfluctuationsatherclinic

appointments.Shealsooccasionally

forgetsherdailydoseofmedication.Her

psychiatristrecommendsshedownloada

mood-monitoringapponhermobile

device.Heremindsherthathewillkeep

anyrecordedclinicaldataconfidential;

however,theapp’stermsandconditions

indicatethattheapp’screatormayrecord

herdataanonymously.Thepatient

Case4:A19year-oldwomanwithchronic

depressionandborderlinepersonality

disorderdownloadsamood-monitoringapp

sothatherpsychiatristcanmonitorher

symptomsremotely.Shefrequentlyreports

thoughtsofself-harmatbaseline,butdoes

notalwaysactonthem.Onedayher

boyfriendbrokeupwithherandshefeelsthe

urgetocutherselfagain.Whenhermobile

phoneautomaticallypromptshertorecord

hersymptoms,shereportsthoughtsofself-

harmandthenbeginstocutherarmwitha

razor.Herpsychiatristreceivesnotificationof

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consentstouseoftheapp.Withdaily

promptsfromthisdevice,sheisableto

recordhermoodandthedatais

automaticallyuploadedtothe

psychiatrist’scomputer.Theappalso

promptshertotakehermedicationsdaily,

therebyboostingheradherence.Ather

nextvisit,thepsychiatristnotesthather

moodmeasurementshaveimprovedon

hercurrentdoseofpsychotropic

medication,andconsequentlyhe

continueshercurrenttreatmentregimen.

herlastmobileentrybutdoesnotrespond

becauseitappearsnodifferentthanher

previousentries.

Providereducationisacriticalcomponentofmobilehealth.Muchlikehowaprovidermust

understandthepharmacologyofamedicationbeforeprescribingit,providersshouldeducate

themselvesaboutthefunctionsandtermsofamobileappbeforetheyrecommendit.Forprovider-or

healthsystem-basedmodelsofmobilehealth,physicianvettingandtrainingofmobileappsmayalready

bepartoftheproductpackage.Forthethousandsofdirect-to-consumerapps,however,thismaynotbe

thecase.

Anethicalframework

Forthepsychiatristfacedwithincreasingpatientinterestinmobilehealth,whataresome

safeguardsthatcanbeimplementedinpracticetopreventpotentialharms?Aframework,suchasthe

safeguardsproposedforoff-labelnovelusesofpharmacologicagents(Hoopetal.,2009),wouldbe

usefulinthisrole.Withinthecontextofthepsychiatrist-patientrelationship,therefore,weproposea

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seriesofstepstohelpensureethicaluseofmobiletechnologiesinpsychiatriccare(Figure1).First,the

psychiatristshouldbeginbyaskingwhethermobiletechnologyusecouldprovideabenefittothe

patientunderhisorhercare.Isthereapotentialforthemobiletechnologytoimprovepatienthealth,

ortoenhancetheefficacyofthepsychiatrist-patientrelationship?Intheabsenceofclinicaloutcomes

data,clinicalbenefitcanbereferencedwithrespecttothetherapeuticrelationship.

Figure1:Ethicalsafeguardsforuseofmobiletechnologiesinclinicalpractice

Ifthereisapotentialbenefit,thepsychiatristcannextaskwhethertherearepotentialrisksto

thepsychiatrist-patientrelationship.Thisinvolvesconsiderationofboththelimitedevidencebase

Wouldmobiletechnologyprovideabene$ittothetherapeuticrelationship?

Arepotentialriskstothetherapeuticrelationship

manageable?

Wasadequatelystringentinformedconsentobtained?

Wastherediscussionofcon$identialityconcerns?

Istheremutualalignmentofmobiletechnologywithtreatment

goalsandexpectations?

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documentingpotentialclinicalrisksofmobiletechnologyuse,aswellastherecognitionofthebroad

spectrumofseveritycharacterizingpsychiatricillnesses,whichoftennecessitatesapersonalized

approachtocare.Patientsathighsafetyrisk,forexample,orpatientswithchronicmentalhealth

conditionswithhighriskofrelapseorrecurrenceandpotentiallylimitedinsightorjudgment,maybe

uniquelyvulnerabletoperturbationsinthetherapeuticrelationship.Attheextreme,apatientmaynot

havethecapacitytoprovideinformedconsenttousemobiletechnology.Otherpatientsmayhave

decisionalcapacitytoconsent,butaresoimpulsivewithahistoryofdangerousconsequencesthatthe

addedsub-contextofmobilehealthmaycomplicateclinicalcare,orcreateunwantedspacefor

misimpressionsormiscommunicationtoflourish.Wecanconceptualizea“slidingscale”ofpatient

vulnerability,subjecttochangeovertime,withrespecttothetherapeuticrelationship.Athigherlevels

ofvulnerability,thepsychiatristmayconsiderwhethertoincorporateadditionalriskmanagement

strategies,suchasincreasingaccesstothepsychiatrist,involvingpatientcollateralorfamilymembers,

orliaisingwithadditionalsafetyresources(e.g.,patientgroups,otherhealthserviceproviders).

Ifpotentialbenefitsareclearandpotentialrisksaredeemedmanageablewithinthetherapeutic

relationship,thenthepsychiatristshouldnextobtaininformedconsentfromthepatientforuseofthe

mobiletechnology.Thisstepisimportanttohelpinformandprotectvulnerablepatients.Ethical

elementsofinformedconsentincludethesharingofinformationwiththepatient,theassessmentof

decisionalcapacityofthepatient,andtheconsiderationofapatient’sauthenticityofchoice(i.e.,

voluntarism)(Roberts,2016).Theinformationsharingprocessshouldincludedisclosureofknownand

theoreticalbenefitsandharms,aswellasthelimitsoftheevidencebasegiventhenascentresearch

thusfarregardingclinicaleffectivenessofmobiletechnologies.Withrespecttovoluntarism,the

psychiatristshouldbeawareofpotentialcoercivepressuresonthepatienttoincorporatemobile

technologyintohisorhercare;examplesincludedirect-to-consumeradvertisingfromthemobile

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industry,orsocialpressurestoengagewithnewtechnology.Proactivediscussionofthesepotential

conflictsmaymitigateunanticipatedconsequencesofcoercion.

Next,theethicaltensioninconfidentialitybetweenpsychiatryandthemobileindustryneedsto

besharedpriortoinitiationofmobiletechnologyuse.Aninformeddiscussionaboutriskstopatient

confidentialitywithrespecttodatacollection,archival,sharing,andevensellingwithadditionalparties

shouldtakeplace,andpatientsshouldbeencouragedtoknowthetermsofcontractfortheirmobile

applicationpackage.Thisinformationshouldbelocatedonthetermsandconditionsorprivacypolicy

pageofanapp,althougharecentresearchstudyfoundthatonly30%ofthe600mostcommonlyused

healthappsactuallyhadaprivacypolicy(Sunyaevetal.,2015).Manypatientsmaybesurprisedtolearn

thatmanyappsmakenoguaranteesofprivacy,andinsteadmayactuallysellanypatientreporteddata

(Carrns,2013).Passivelyacquireddata,inparticular,presentsthepossibilitythatuserdatamaybe

acquiredwithoutthepatient’sdirectknowledge.Manycompaniesalsocontractwithcloudservices,

wheredataisuploadedtothirdpartyserversthatmayormaynothonortheirownprivacycontracts.

Additionally,patientsmayalsoneedtobeawareofotherindividualswithaccesstotheirmobiledevice

ormobiledata.Discussingpotentiallapsesinconfidentialitywillassistpatientsandpsychiatristsin

makinganinformeddecisionaboutmobiletechnologyuseintheircare.

Last,thepsychiatristisadvisedtobothinitiateandmaintainanongoingdialoguewiththe

patientaboutwhethermobiletechnologyusemutuallyalignswithtreatmentgoalsandexpectations.

Similartohowpharmacologicalagentsareevaluatedandre-evaluatedinthecontextofatreatment

plan,mobiletechnologiesshouldalsobeappraisedwithinthisframework.Forexample,whatarethe

goalsofcareimprovementbytechnologyuse,andhowcanefficacybeassessed?Atwhatpointcanthe

psychiatristandpatientagreethatthetechnologyiscausingmoreharmthanbenefit,orthatbenefitis

nolongerpresent?Bydefiningthepreciseaimsofmobiletechnologyuse,thepsychiatristcanhelpto

ensurethatthetechnologyisusedinamannerfaithfultothepatient’soverallgoalsofcare.

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Conclusion

Thereisrapidlygrowinginterestintheuseofmobiletechnologiestoadvancementalhealth.As

thesetechnologiesareembracedbypatientsandthepublicatlarge,psychiatristswillneedtobeableto

incorporatethesemethodologiesintoethicallysoundclinicalpractice.Aswithanyformofclinical

innovation,thereisthepotentialforbenefitandforrisk–and,inthiscase,therisksrelatetoclinical

considerations,aswellaschallengesinfulfillingethicalstandardsfundamentaltomedicalpractice.We

suggestthattheremaybeethicaltensionsintheuseofmobiletechnologiesinpsychiatriccarebecause

ofthedifferencesintheethicalbasisofthepsychiatrist-patientrelationshipandthemobileindustry-

consumercontract.Nevertheless,mobiletechnologiesformonitoringandtherapeuticpurposesmay

havegreatvalueiftheyareintegratedintothetherapeuticrelationshipandgoalsinpatientcare.Asan

adjuvanttoexistingtherapeuticmodalities,andwithcarefulsafeguards,thesenewtechnologiesmay

strengthenpatientcarepractices.

Mobiletechnologiesoccupyauniqueclinicalspacetoday–similartoatreatmenttoolwith

respecttotheneedforinformedconsent,confidentialitydiscussion,andtreatmentgoals,yetdifferent

withrespecttoalackofclinicalneedabovestandardofcarethatcouldinformaclearrisk-benefitratio.

Currently,itappearsthatmobiletechnologiesarerespondingtoastrongpreferenceamongpatientsfor

greaterautonomyandparticipationinhealthcaredecisions.Wethereforeproposethatbenefitsand

harmsofmobiletechnologyatthistimeshouldbeweighedintermsofimpactonthepsychiatrist-

patientrelationship,thesourceofautonomyinclinicaldecision-makingtoday(Siegler,1981).Inthe

future,mobilehealthcouldevolvetowardaclinicalfunction,especiallyastheclinicalevidencebase

develops,ortheFDAoccupiesanenhancedregulatoryrole,orprofessionalorganizationslikethe

AmericanPsychiatricAssociationdevelopstandards.Withadditionaldatainthefuture,thebenefitsand

harmsofmobiletechnologymaybecomemoresalientwithregardtoclinicaloutcomesratherthanthe

therapeuticrelationship,andappropriatesafeguardsformobiletechnologymayevolvetowardamore

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clinicallyorientedframeworkforincorporatinginnovativetoolsintopractice–muchlikehow

pharmacologicaltreatmentsareconceptualizedtoday(Hoopetal.,2009).Untilthen,psychiatristsare

advisedtoapplyadistinct,ethicallymotivatedframeworkforclinicaluseofmobiletechnologies.

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