Research roundup: Ensuring that digital mental health benefits everyone

Willis, H. A., et al., Journal of Clinical and Adolescent Psychology, Vol. 51, No. 6, 2022.

Telepsychology and mobile health (TPmH) services include the integration of telecommunication technologies with psychological practice (APA, 2024). The use of these TPmH (Clough & Casey, 2015) has increased since the onset of the Covid-19 pandemic. TPmH services offer promising solutions for reaching young people and families that are not able to use traditional face-to-face services. However, the rapid transition to TPmH has occurred with limited guidance concerning cultural adaptation and integration.

The article explores the literature on TPmH services for racial-ethnic minoritized (REM) youth, culturally responsive evidence-based treatment or interventions (EBTIs), and the intersection of TPmH services and EBTIs to propose a framework of equity-centered recommendations for the future use of TPmH within the research, practice, and policy spaces.

Recommended research priorities to note include:

Empirically evaluate the effectiveness of TPmH interventions for REM children and adolescents.

This recommendation encourages research on differences in outcomes for REM youth who engage with TPmH compared to in-person interventions. Other ways to evaluate the effectiveness of TPmH interventions include researching differential effectiveness for the REM youth population based on setting and examining how outcomes can be improved when incorporating changes to TPmH services.

Increasing research on psychological assessment using TPmH. This recommendation encourages researchers to examine whether TPmH is culturally adapted in ways that can be effectively delivered to REM youth. This may include using machine learning methods that are trained and tested on culturally representative data, which reduce misclassification and measurement error.

Practice and policy recommendations to note include:

• Developing evidence-informed guidance on how to integrate a variety of culturally responsive technological approaches for intervention. Subject matter experts are encouraged to collaborate on ways to use technology that improves accessibility and efficacy for REM youth.
• Providing training and support in culturally responsive TPmH for trainees in health service psychology. Authors recommend conducting research that identifies concerns clinicians may have about using TPmH interventions, as well as potential strategies for supporting clinicians. It may also be important for graduate programs to provide training in interdisciplinary research methods and in collaborating with application developers.

Digital mental health tools, ranging from telehealth service platforms to mobile applications and prescription digital therapeutics, have rapidly expanded in recent years. These innovations are beginning to bridge the gaps in care for those who may not have easy access to traditional face-to-face services. As digital mental health tools evolve, they promise to address mental health needs on a global scale by offering greater flexibility, scalability, and cost-effectiveness. However, even with the rapid expansion of digital mental health, there is still a concern that these innovations may not address the needs of the most vulnerable people and could inadvertently widen existing disparities in access, adoption, and efficacy for underserved communities.

Factors such as digital literacy, socioeconomic barriers, cultural sensitivity in treatment, and access to reliable internet are critical issues. Individuals from low-income and rural areas may struggle to access or navigate digital mental health tools, while certain marginalized groups may find that these tools do not adequately address their specific needs. For example, digital tools may lack cultural adaptations such as using culturally specific metaphors or culturally relevant names, based on the target group for treatment (Spanhel, K., et al., 2021). As research and implementation in this field continue to grow, it’s clear that there is a pressing need for ethical and equity-centered frameworks and recommendations that ensure these innovations do not reinforce inequities but instead deliver on their goals.

Building frameworks around equitable research, practice, and policy in digital mental health requires intentional action from developers, researchers, policymakers, and clinicians. Specifically, psychologists play a key role in advocating for ethical standards that prioritize inclusivity, cultural competence, and accessibility. As digital mental health tools become a more prominent part of care delivery, frameworks and recommendations will help guide the field of psychology toward solutions that genuinely reduce disparities and promote equitable access for all people.

In this installment of Research Roundup, we explore existing frameworks and recommendations for researchers and clinicians who use digital mental health tools with patients. The first article explores equitable and culturally responsive recommendations for use of telepsychology and mobile health services (mHealth) for marginalized youth. The second provides recommendations for behavioral and social science researchers in promoting digital health equity. The third presents an equity framework for researchers as they develop, implement, and test behavioral digital health interventions to ensure that they consistently prioritize equity.

This is just a brief snapshot of the available research on these topics. Psychologists and other mental health professionals are encouraged to dive deeper and explore scholarly literature to determine what may be useful to them in practice, particularly as it relates to patients’ values, culture, and preferences.

Jaworski, B. K., et al., Translational Behavioral Medicineopens in new window, Vol. 13, No. 3, 2023

Given the digital health expansion and the need to promote digital health equity, behavioral and social science researchers offered recommendations to help advance the practice, policy, and research of digital health tools to improve population health.

Researchers used their expertise in diverse methods, measures, and applications within the field of digital health and the existing literature on digital health equity to guide their recommendations about using digital tools in the behavioral health space. Researchers also described the important role of ethical implementation science and its impact on real-world outcomes. They made these five recommendations:

• Center equity in research teams and theoretical approaches. Researchers emphasized the value of multidisciplinary research teams that can address digital health inequities from a variety of theoretical frameworks. Subject matter experts in behavioral health science are encouraged to collaborate with technology developers to investigate psychological constructs that reinforce health disparities and examine approaches to promoting equity.
• Focus on issues of digital health literacy and engagement. Researchers are encouraged to focus on patient engagement with digital interventions such as mobile apps and to understand the impact that literacy and engagement can have on disparities in digital health access, especially among marginalized groups. Research is also needed to explore the ways that mental health-focused organizations can use strategies and digital tools to best meet the needs of the populations they serve.
• Use methods that elevate the perspectives and needs of underserved populations. It is recommended that researchers use mixed-methods approaches to gain real-world, contextual understandings of relevant constructs. For example, qualitative research allows researchers to explore how, why, and under what conditions digital health tools can be used and to identify barriers to that use.
• Ensure ethical approaches for collecting and using digital health data, understanding limitations, and mitigating biases. It is important for researchers to identify gaps in data representation and how identifying these gaps can be used to help build better digital health tools. For example, language in informed consent around participant awareness and power relations helps make sure participants are not left vulnerable.
• Develop strategies for widespread adoption and use of digital health tools within and across systems and settings. It is recommended that researchers consider dissemination and implementation science frameworks to enhance the equitable use of digital health tools. An example of a dissemination and implementation science model is the Consolidated Framework for Implementation Research, which considers characteristics of the organization and individuals within the implementation process.

Miller, S. J., et al., Translational Behavioral Medicineopens in new window, Vol. 13, No. 6, 2023

Behavioral digital health interventions (e.g., mobile apps, wearable devices) have the potential to improve access to health-enhancing resources. However, there are disparities such as the digital divideopens in new window where marginalized groups face obstacles in accessing technology. Additionally, biases can be embedded within digital health interventions themselves and can impact the dissemination of these interventions. For example, clinicians who hold negative attitudes about age and technology might fail to recommend digital interventions to older patients who could benefit from them.

Using the literature on behavioral digital health interventions and associated risks, a working group of behavioral scientists from the Society of Behavioral Medicine’s Health Equity Special Interest Group put together the PIDAR framework (Partner, Identify, Demonstrate, Access, Report). This framework is intended to help behavioral health researchers develop, implement, and test digital health interventions to ensure health equity and to mitigate risks associated with digital mental health among marginalized groups. The group proposed the following recommendations to avoid health disparities in behavioral digital health work:

• Partner with key stakeholders who are potential end-users. The working group emphasized the need for diverse perspectives within partnerships to ensure that digital health interventions are unbiased and inclusive. This includes partnering across all stages of the research and implementation process. Helpful techniques for designing such interventions include human-centered design and community-based participatory research.
• Identify the potential impact of digital health interventions on health inequities. It is recommended that research teams brainstorm potential positive and negative impacts of the digital health interventions on marginalized communities. Sample questions to use when identifying the potential impact of interventions include, “Do all end users have equitable access to the technology needed to use the intervention? If not, what national and regional resources are available to help the end user gain access?” and “Does any subgroup of intended end users stand to benefit less or more from the intervention?”
• Demonstrate how to use digital health interventions. Researchers are encouraged to provide end users with resources to help support and improve their digital literacy. An example is partnering with preexisting programs that are designed to improve people’s ability to use technology. Researchers are also encouraged to provide training for and demonstrations of using the digital health interventions that are being studied.
• Improve access to technology. Researchers are encouraged to rethink the requirement of internet access that is sometimes needed for digital interventions, especially for those who cannot access the internet easily. For interventions that may need internet access, researchers are encouraged to work with existing institutions that provide free internet access and/or free or low-cost devices such as public libraries, nonprofit organizations, and government programs. Another way that researchers can help improve access to technology is to develop infrastructures that clinics can use to easily integrate the interventions into existing workflows.
• Report the impact of the research on health equity. Proper and transparent reporting of unintended consequences by researchers is important for clarifying what needs to be worked on. The authors also recommend that national societies and associations host workshops focused on this topic to promote further discussion about unintended consequences and how to overcome them.

The rise of digital mental health presents both opportunities and challenges for mental health professionals. Clinically, it is essential for providers to be aware of how these tools can be integrated into practice to enhance care. However, without careful consideration of equity, digital tools may fall short in serving diverse populations and may exacerbate existing disparities, especially among marginalized communities.

In their research and implementation, mental health professionals must critically evaluate the accessibility, cultural relevance, and efficacy of digital health tools they recommend to ensure that they meet the needs of all patients. A central theme of these articles is the need to make sure that digital mental health truly becomes an opportunity that everyone can access, use, and benefit from.

Psychologists and other mental health professionals are in a unique position to advocate for and help develop digital health equity frameworks that prioritize inclusivity. This means engaging stakeholders in conversations about making these tools more accessible to people with varying levels of digital literacy, ensuring that equity is embedded in the design of interventions and addressing population health concerns. By advocating for these issues, psychologists and mental health professionals can help drive the development of digital mental health tools that are not only innovative but also equitable and ethical.