Ethical implications of digital gaming interventions for mental health: Systematic review and critical appraisal

Background: In 2020, two digital game-based therapeutic interventions were clinically approved, raising ethical questions about ‘games on prescription’. Aims: This article systematically reviews the opportunities, concerns, and ethical considerations in literature around applied digital gaming interventions for mental health. Methods: The protocol was registered at INPLASY (202330035). Electronic databases Pubmed, PsycNet, EthxWeb, Scopus and journal 'Game Studies' were searched from 1993 to 2023, identifying 5,502 papers combining concepts around games, ethics, and mental health. 158 full texts were screened and 42 included in this review. Using custom rating categories, we identified 10 papers addressing ethical issues as a ‘core’ focus, with the remaining 32 papers mentioning ethics either ‘prominently’ or ‘tangentially’. Results: Opportunities at a public level included improved availability and accessibility of mental health interventions. Concerns included negative attitudes towards digital games and potential exclusion of certain groups due to required infrastructure and skills. For user communities, papers mentioned the potential for enhanced care due to increased social connection, autonomy, and control. However, concerns included harms arising from physical side effects, addiction, miscommunication, reality/fantasy confusion, poor clinical design, social/therapeutic isolation, and data privacy. At game product and policy level, the significant regulatory vacuum surrounding digital interventions was cause for concern, as were challenges arising from the complex process and financial cost of production. Conclusions: There is urgent need for more ethical reflection on gamifying mental health interventions. Most papers did not discuss socio-political perspectives, revealing opportunities for humanities scholarship and the need for interdisciplinary collaboration and stakeholder engagement.