Second Mind: Ethical and Legal Considerations on Digital Mental Health in the Portuguese Context

Authors

DOI:

https://doi.org/10.51338/rppsm.332

Keywords:

Big Data, Internet of Things, Mental Health/ethics, Mental Health/legislation & jurisprudence, Mental Health Services, Psychiatry, Telemedicine

Abstract

With the emergence of eHealth and mHealth, information technologies and mobile devices are now part of the clinical reality and its future prospects. Within this scope, given its own characteristics, its use in mental health has been focused as especially opportune for advancing in the fight against inequalities in access to quality healthcare. However, this area also appears to be particularly sensitive, and its digital transition deserves a careful analysis from an ethical‐legal point of view. This article aims to review some technologies currently applied in psychiatry and their ethical and legalimplications, namely: 1) issues of access and effectiveness of these technologies; 2) artificial intelligence in psychiatry and its clinical, legal and ethical implications; 3) surveillance systems with geolocation and digital tablets; 4) digital phenotyping and use of big data in mental health. We conclude that, despite contributing evident benefits to mental health, the implementation of these technologies is not innocuous. Their development requires both a legal strengthening of the protection of the patient and a broadening of the ethical debate in an anticipatory perspective, as well as keeping up with the speed of their implementation.

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References

World Health Organization. eHealth at WHO. WHO. [Accessed February 16, 2021]. Available from: http://www.who.int/ehealth/about/en/

WHO Global Observatory for eHealth, World Health Organization. MHealth: New Horizons for Health through Mobile Technologies. World Health Organization; 2011. [Accessed February 16, 2021]. Available from: http://www.who.int/goe/publications/goe_mhealth_web.pdf

Seventy‐First World Health Assembly, Agenda Item 12.4, Digital Health. WHO; 2018.

EHealth Action Plan 2012‐2020 ‐ Innovative Healthcare for the 21st Century. Brussels: Comissão Europeia; 2012.

Resolução Do Conselho de Ministros n.o 67/2016.

SPMS, CNTS. Plano Estratégico Nacional para a Telessaúde 2019‐2022. Published online 2019.

Q4 and Annual 2020 Healthcare IT/Digital Health Funding and M&A Report Download. Mercom Capital Group. Accessed February 16, 2021. http://mercomcapital.com/q4‐and‐annual‐2020‐healthcare‐it‐digital‐health‐funding‐and‐ma‐report‐download/

Q3 2020: A new annual record for digital health (already). Rock Health. [Accessed February 16, 2021]. Available from: https://rockhealth.com/reports/q3‐2020‐digital‐health‐funding‐already‐sets‐a‐new‐annual‐record/

República Portuguesa. Plano de Recuperação e Resiliência. Recuperar Portugal 2021‐2026 ‐ Plano Preliminar 2020. [Accessed February 28, 2020]. Available from: https://www.portugal.gov.pt/pt/gc22/comunicacao/documento?i=plano‐de‐recuperacao‐e‐resiliencia‐recuperar‐portugal‐2021‐2026‐plano‐preliminar‐

Faria PL de, Cordeiro J. Public health: current and emergent legal and ethical issues in a nutshell. In: Routledge Handbook of Medical Law and Ethics.

London: Routledge Handbooks; 2014.

European Commission. Summary Report on the Public Consultation on the Green Paper on Mobile Health. Brussels: EC; 2015.

Winnike AN, Iii BJ. Rewiring Mental Health: Legal and Regulatory Solutions for the Effective Implementation of Telepsychiatry and Telemental Health Care. Houston J Health Law Policy. 2017; 83.

Gooding P. Mapping the rise of digital mental health technologies: Emerging issues for law and society. Int J Law Psychiatry. 2019;67:101498. doi:10.1016/j.ijlp.2019.101498

Torous J, Roberts LW. The Ethical Use of Mobile Health Technology in Clinical Psychiatry. J Nerv Ment Dis. 2017;205:4‐8. doi:10.1097/NMD.0000000000000596

Mental Health Action Plan 2013‐2020. Geneva: World Health Organization; 2013.

World Health Assembly‎. Fourth report of Committee A. Geneva: World Health Organization :1975.

Bhugra D, Tasman A, Pathare S, Priebe S, Smith S, Torous J, Arbuckle MR, et al. The WPA‐Lancet Psychiatry Commission on the Future of Psychiatry. Lancet Psychiatry. 2017;4:775‐818. doi: 10.1016/S2215‐0366(17)30333‐4

C Wittson, R Dutton. A new tool in psychiatric education. Ment Hosp. 1956;7.

Wootton R, Yellowlees P, McLaren P. Telepsychiatry and E‐Mental Health. Cambridge: Cambridge University Press; 2003.

World Health Organization, ed. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on EHealth. Geneva: World Health Organization; 2010

Consultas Em Telemedicina. Ministério da Saúde, Governo de Portugal [Accessed February 28, 2020]. Available from: https://www.sns.gov.pt/monitorizacao‐do‐sns/consultas‐em‐telemedicina/

Dimitrov DV. Medical Internet of Things and Big Data in Healthcare. Healthc Inform Res. 2016;22:156‐63. doi:10.4258/hir.2016.22.3.156

Carlo AD, Hosseini Ghomi R, Renn BN, Areán PA. By the numbers: ratings and utilization of behavioral health mobile applications. Npj Digit Med. 2019;2:1‐8. doi: 10.1038/s41746‐019‐0129‐6

Neary M, Schueller SM. State of the Field of Mental Health Apps. Cogn Behav Pract. 2018;25(4):531‐537. doi: 10.1016/j.cbpra.2018.01.002

Open Notes. Reading mental health notes can be a powerful tool in therapy. [Accessed February 23, 2021]. Available from: https://www.opennotes.org/mental‐health‐patients/

Orpwood R, Gibbs C, Adlam T, Faulkner R, Meegahawatte D. The Gloucester Smart House for People with Dementia — User‐Interface Aspects. In: Keates S, Clarkson J, Langdon P, Robinson P, eds. Designing a More Inclusive World. Springer; 2004:237‐45. doi:10.1007/978‐0‐85729‐372‐5_24

Thorpe JR, Forchhammer BH, Maier AM. Development of a Sensor‐Based Behavioral Monitoring Solution to Support Dementia Care. JMIR MHealth UHealth. 2019;7:e12013. doi:10.2196/12013

Bhugra D. Bill of Rights for Persons with Mental Illness. Int Rev Psychiatry. 2016;28:335‐5. doi:10.1080/09540261.2016.1210580

Bouchard S, Paquin B, Payeur R. Delivering cognitive‐behavior therapy for panic disorder with agoraphobia in videoconference. Telemed J E Health. 2004;10:13‐25. doi: 10.1089/153056204773644535

Langabeer JR, Gonzalez M, Alqusairi D, Champagne‐Langabeer T, Jackson A, Mikhail J, et al. Telehealth‐Enabled Emergency Medical Services Program Reduces Ambulance Transport to Urban Emergency Departments. West J Emerg Med. 2016;17:713‐20. doi: 10.5811/westjem.2016.8.30660

Moore RC, Depp CA, Wetherell JL, Lenze EJ. Ecological momentary assessment versus standard assessment instruments for measuring mindfulness, depressed mood, and anxiety among older adults. J Psychiatr Res. 2016;75:116‐23. doi:10.1016/j.jpsychires.2016.01.011

Freeman D, Bradley J, Antley A, Bourke E, DeWeever N, Evans N, et al. Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. Br J Psychiatry. 2016;209:62‐7. doi: 10.1192/bjp. bp.115.176438

Emmelkamp PMG, Meyerbröker K. Virtual Reality Therapy in Mental Health. Annu Rev Clin Psychol. 2021 May 7;17:495‐519. doi: 10.1146/ annurev‐clinpsy‐081219‐115923.

Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM. The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemed J E Health. 2016;22:87‐113. doi:10.1089/tmj.2015.0206

Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;2015. doi:10.1002/14651858. CD002098.pub2

Frittgen EM, Haltaufderheide J. ‘Can you hear me?’: communication, relationship and ethics in video‐based telepsychiatric consultations. J Med Ethics. 2022;48:22‐30. doi:10.1136/medethics‐2021‐107434

Ustun B, Adler LA, Rudin C, Faraone SV, Spencer TJ, Berglund P, et al. The World Health Organization Adult Attention‐Deficit/Hyperactivity Disorder Self‐Report Screening Scale for DSM‐5. JAMA Psychiatry. 2017;74:520‐6. doi:10.1001/ jamapsychiatry.2017.0298

Virtual counsellor steps in to help out on suicide hotline | PBA. Bono Aust. [Accessed February 24, 2021]. Available from: https://probonoaustralia.com.au/news/2019/04/virtual‐counsellor‐steps‐in‐to‐help‐out‐on‐suicide‐hotline/

Man K, Damasio A. Homeostasis and soft robotics in the design of feeling machines. Nat Mach Intell. 2019;1:446‐52. doi:10.1038/s42256‐019‐0103‐7

Nebeker C, Lagare T, Takemoto M, Lewars B, Crist K, Bloss CS, et al. Engaging research participants to inform the ethical conduct of mobile imaging, pervasive sensing, and location tracking research. Transl Behav Med. 2016;6:577‐86. doi:10.1007/s13142‐016‐0426‐4

Apte A, Ingole V, Lele P, Marsh A, Bhattacharjee T, Hirve S, et al. Ethical considerations in the use of GPS‐based movement tracking in health research ‐ lessons from a care‐seeking study in rural west India. J Glob Health. 2019;9:010323. doi: 10.7189/ jogh.09.010323.42.

Seto E, Challa P, Ware P. Adoption of COVID‐19 Contact Tracing Apps: A Balance Between Privacy and Effectiveness. J Med Internet Res. 2021;23:e25726. doi:10.2196/25726

Regulamento Geral de Proteção de Dados. 2016. [Accessed February 23, 2021]. Available from: https://eur‐lex.europa.eu/legal‐content/PT/TXT/ HTML/?uri=CELEX:32016R0679

Miller S. The Use of Monitoring Conditions (GPS Tracking Devices)Re CMX [2014] QMHC 4. Psychiatry Psychol Law. 2015;22:321‐6. doi:10.1080/13218719.2015.1032875

Tully J, Cullen A, Hearn D, Fahy T. Service evaluation of electronic monitoring (GPS tracking) in a medium secure forensic psychiatry setting. J Forensic Psychiatry Psychol. 2015;27:1‐8. doi:10.1080/14789949.2015.1122823

Moulton D. Nova Scotia sets direction on GPS monitoring of patients. CMAJ Can Med Assoc J. 2015;187:E232‐E233. doi:10.1503/cmaj.109‐5024

Diário da República Eletrónico Lei de Saúde Mental ‐ Lei n.o 36/98, de 24 de julho. [Accessed February 23, 2021]. Available from: https://dre.pt/web/guest/legislacao‐consolidada/‐/lc/75115272/view?p_p_state=maximized

Brown MT, Bussell JK. Medication Adherence: WHO Cares? Mayo Clin Proc. 2011;86:304‐14. doi:10.4065/mcp.2010.0575

Subbaraman R, Mondesert L de, Musiimenta A, Pai M, Mayer KH, Thomas BE, et al. Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities. BMJ Glob Health. 2018;3:e001018. doi:10.1136/bmjgh‐2018‐001018

Browne SH, Umlauf A, Tucker AJ, Low J, Moser K, Gonzalez Garcia J, et al. Wirelessly observed therapy compared to directly observed therapy to confirm and support tuberculosis treatment adherence: A randomized controlled trial. PLoS Med. 2019;16. doi:10.1371/ journal.pmed.1002891

Lee DJ. NDA 207202 aripiprazole + MIND1 system (Abilify Mycite). Published online 2015:95. [Accessed May 10, 2022]. Available from:

Cosgrove L, Cristea IA, Shaughnessy AF, Mintzes B, Naudet F. Digital aripiprazole or digital evergreening? A systematic review of the evidence and its dissemination in the scientific literature and in the media. BMJ Evid‐Based Med. 2019;24:231‐8. doi:10.1136/bmjebm‐2019‐111204

Cosgrove L, Karter JM, McGinley M, Morrill Z. Digital Phenotyping and Digital Psychotropic Drugs: Men‐ tal Health Surveillance Tools That Threaten Human Rights. Health Hum Rights. 2020;22:33‐9.

Goold I. Digital tracking medication: big promise or Big Brother? Law Innov Technol. 2019;11:203‐30. doi:10.1080/17579961.2019.1665791

Legislação Consolidada ‐ Lei n.o 12/2005 ‐ Diário da República n.o 18/2005, Série I‐A de 2005‐01‐26 | DRE. [Accessed May 10, 2022]. Available from: https://dre.pt/dre/legislacao‐consolidada/lei/2005‐106603593

Pimentel M. Seguradoras violam lei sobre informação genética há 16 anos. Em Nome Lei. [Accessed May 29, 2021]. Available from: https://rr.sapo.pt/artigo/em‐nome‐da‐lei/2021/05/29/seguradoras‐violam‐lei‐sobre‐informacao‐genetica‐ha‐16‐anos/240563/

Diário da República Eletrónico. Legislação Consolidada ‐ Lei n.o 46/2006 ‐ Diário da República n.o 165/2006, Série I de 2006‐08‐28 | DRE. [Accessed May 10, 2022]. Available from: https://dre.pt/dre/legislacao‐consolidada/lei/2006‐156233888

Diário da República Eletrónico. Lei n.o 75/2021 | DRE. [Accessed May 10, 2022]. Available from: https://dre.pt/

Wyman O. Mindstrong Health Q&A: Advancing Mental Health with Smartphones. [Accessed February 28, 2021]. Available from: https://health.oliverwyman. com/2018/08/mindstrong‐health‐q‐a‐‐advancing‐mental‐health‐with‐smartphones.html

Didi‐Huberman G, Charcot JM. Invention of Hysteria: Charcot and the Photographic Iconography of the Salpêtrière. MIT Press; 2003.

Samaritans pulls “suicide watch” Radar app ‐ BBC News. [Accessed February 28, 2021]. Available from: https://www.bbc.com/news/technology‐29962199

Parecer 114/CNECV/2020 Sobre Questões Éticas Relacionadas Com “Big Data.”; 2020.

Resolução Do Parlamento Europeu, de 14 de Março de 2017, Sobre as Implicações Dos Grandes Volumes de Dados Nos Direitos Fundamentais: Privacidade, Proteção de Dados, Não Discriminação, Segurança e Aplicação Da Lei. Bruxelas: PE; 2017.

Disclosure of information about complainant’s attempted suicide to US Customs and Border Protection not authorized under the Privacy Act ‐ Office of the Privacy Commissioner of Canada. [Accessed February 28, 2021 ]. Available from: https://www.priv. gc.ca/en/opc‐actions‐and‐decisions/investigations/ investigations‐into‐federal‐institutions/2016‐17/pa_20170419_rcmp

Gerber N, Gerber P, Volkamer M. Explaining the privacy paradox: A systematic review of literature inves‐ tigating privacy attitude and behavior. Comput Secur. 2018;77:226‐61. doi:10.1016/j.cose.2018.04.002

Schermer BW, Custers B, van der Hof S. The Crisis of Consent: How Stronger Legal Protection May Lead to Weaker Consent in Data Protection. Geneva: Social Science Research Network; 2014. doi:10.2139/ ssrn.2412418

Muravyeva E, Janssen J, Specht M, Custers B. Exploring solutions to the privacy paradox in the context of e‐assessment: informed consent revisited. Ethics Inf Technol. 2020;22:223‐38. doi:10.1007/ s10676‐020‐09531‐5

Martinez‐Martin N, Greely HT, Cho MK. Ethical Development of Digital Phenotyping Tools for Mental Health Applications: Delphi Study. JMIR MHealth UHealth. 2021;9:e27343. doi:10.2196/27343

Tomičić A, Malešević A, Čartolovni A. Ethical, Legal and Social Issues of Digital Phenotyping as a Future Solution for Present‐Day Challenges: A Scoping Review. Sci Eng Ethics. 2021;28:1. doi:10.1007/ s11948‐021‐00354‐1

Brey PA. Anticipatory Ethics for Emerging Technologies. NanoEthics. 2012;6:1‐13. doi:10.1007/ s11569‐012‐0141‐7

“The goal is to automate us”: welcome to the age of surveillance capitalism | Technology | The Guardian. [Accessed February 28, 2021]. Available from: https:// www.theguardian.com/technology/2019/jan/20/ shoshana‐zuboff‐age‐of‐surveillance‐capitalism‐google‐facebook

Guta A, Voronka J, Gagnon M. Resisting the Digital Medicine Panopticon: Toward a Bioethics of the Oppressed. Am J Bioeth AJOB. 2018;18:62‐4. doi:10.108 0/15265161.2018.1498936

Ganascia JG. The New Ethical Trilemma: Security, Privacy and Transparency. Comptes Rendus Phys. 2011;12:684‐92. doi:10.1016/j.crhy.2011.07.002

Published

2022-06-24

How to Cite

Queiroz, G. (2022). Second Mind: Ethical and Legal Considerations on Digital Mental Health in the Portuguese Context. Revista Portuguesa De Psiquiatria E Saúde Mental, 8(3), 96–104. https://doi.org/10.51338/rppsm.332

Issue

Section

Narrative Review