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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:[email protected]
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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