Along with its devastating impact on clinical treatment, COVID-19 also brings an outsized demand for mental health applications in ASEAN. While digital innovation is expected to solve the barriers of mental healthcare, the ethical aspect remains an unavoidable debate.
We are fortunate to live in an era where conversations about mental well-being have emerged as a significant issue globally. Based on exploratory studies, nowadays, people with mental illness tend to be more open in digital platforms to promote awareness and support others. In 2019, there were more than 10,000 wellness apps, targeting an estimated 970 million people worldwide with mental disorders. Mental health apps have become more popular as a solution to support the limitations of face-to-face treatment, especially during the pandemic. Yet the practice of such apps also questions several ethical principles.
Promising Apps as Digital Mental Health Solutions in ASEAN
It is interesting to see ASEAN taking on both roles of a market and developer for mental health apps. Some current leading apps in the region are Ooca (Thailand), Naluri (Malaysia), Riliv (Indonesia), Mosia (Vietnam), MindFi (Singapore), and Arooga Health (Philippines), which mostly cover lifestyle intervention features (exercise, sleep, nutrition, and meditation). But there are many more out there, including apps that strategically treat the most common mental illnesses in the ASEAN region (depression, bipolar disorder, schizophrenia, and dementia). Furthermore, there is also advanced technology like tele psychiatry, and computerized cognitive-behavioral therapy that can create data-driven diagnosis and e-therapy. Based on the Asia-Pacific Front Line of Healthcare Report 2019, 34% of physicians believe mental health service can be delivered digitally and 20% confidence it can be powered by machine learning in the next 5 years.
Apps become the major solution for the limited number of psychiatrists and the narrow access to clinical treatment in ASEAN. Indonesia, the Philippines, Thailand and Malaysia are reported to only have below 1.5 psychiatrists per 100,000 citizens, not to mention their uneven distribution between rural and urban areas. Unfortunately, Myanmar, Cambodia and Indonesia also assign mental health facilities to their ‘secondary healthcare’ systems, which means citizens cannot find mental health services in all public facilities but have to visit specialists. This has led to the huge opportunity for apps to fill the absence of mental health services, including providing wider access, lower prices, and more personalized features.
The other advantage is to counter the false prejudices against mental health. For example, some groups in several rural areas of Southeast Asia still believe mental health disorders are the result of demonic possession. Fandi Andrian, marketing Lead of Riliv Indonesia, notes that ‘Interestingly, 89% of our users reported never accessing therapy before, which motivates us to change the misconception of toxic masculinity when culture and societal gender norms expect adults especially men to bury emotions. Beyond apps, Riliv want to promote awareness through psychology-pop content, mainly for young people in social media and Tik Tok”.
COVID-19 Disturbs the Treatment, yet Boosts the App’s Demand
The COVID-10 pandemic is bringing forth a tsunami of disruption to mental health services in 93% of countries worldwide. Currently, Mental Health and Psychosocial Support (MHPSS) becomes the priority area of UNICEF East Asia and Pacific Regional Office because the pandemic harshly affects frontline workers, young people living with HIV, and existing psychological disorders, as well as delays 34% mental health medication and 47% psychosocial support based on UNICEF rapid survey in the Asia Pacific.
In contradiction, the outbreak increases the use of mental health apps because it triggers both digital adoption and consumer health trend. It is reported that 40 million people across 6 countries in Southeast Asia go online for the first time in 2020, adding to the total internet users of 400 million in the region. As the result of the pandemic, 69% of people in the global tend to more focus on their mental health and 39% of digital consumers in Southeast Asia prioritize wellness needs when doing online purchasing. It is also predicted that untreated mental health will contribute 13% of total global disease and lead to the cause of mortality and morbidity worldwide in 2030, giving the stronger reason why digital tools are expected to improve current and future mental healthcare.
The Ethical Challenges of Mental Health App
Even before the pandemic, there has been a series of discussions to ensure the user’s sensitive medical records are not repurposed to gain profit. Behavioral health information becomes a valuable commodity, especially because the apps are already being marketed for segmented disorders and can be used for commercial databases. Leaks of confidential data from 136 popular depression websites in France, German and UK in 2019, as well as the 2016 hacking incident in New York State Psychiatric Institute should be a reminder for developers to urge better security in apps development.
An app might not be effective for vulnerable groups: elderly patients, low socio-economic groups, people with disabilities. Some mental illnesses like Autism, addictive disorders, and relationship-based problems are reported to be less suitable for digital mental health treatment. Digital interface may also be less efficient in responding to users who have suicidal intention or destructive behavior, particularly in apps that don’t have a direct connection to the nearest hospital. Another point is how far advanced technology can project real empathy during online treatment. Some literature pointed out how chatbots and video limits clinicians to observe non-verbal cues, give basic eye contact and ensure intimacy because the virtual interactions may not fulfill the standard psychotherapy.
Apps might make users rely too much on their own observations and potentially lead to incorrect self-diagnosis and self-prescribing because patients prefer to use lifestyle apps rather than those that directly target their disorders. Another ethical challenge is to assure how digital phenotyping in mental health apps can deliver high accuracy of user’s mood and cognition information that is being collected through smartphone and wearable signals. Last, the future trend of gamification in mental health treatment might bring addiction and loss of concentration because of the quest and reward system like the real game.
The pandemic is not only the reason why there is a soaring demand for mental health apps, but also why there is an urgency to address existing and not yet predicted ethical implications. Technology intervention in mental health services needs to be reviewed across sectors, especially government, companies and healthcare workers, due to the fact that 40% of global digital health players are from outside the health industry. This includes how to promote technology and mental health literacy, as well as finding the best way to involve human support in digital treatment.