Abstract
Digital mental health applications have emerged as a promising solution to address the global treatment gap in mental healthcare. This dissertation examines whether these technologies widen access to mental health support or deepen existing inequalities. Through a comprehensive literature synthesis, this study analyses the dual potential of digital therapies to simultaneously reduce traditional barriers whilst creating new forms of exclusion. The findings reveal that digital mental health interventions can effectively reduce classic obstacles including geographical distance, stigma, clinician shortages, and lengthy waiting times, particularly benefiting young people, rural populations, and culturally adapted programmes for ethnic minorities. However, the evidence also demonstrates significant risks of exacerbating inequalities through the digital divide, culturally insensitive design, low digital literacy among older adults, and inadequate regulatory oversight. The analysis indicates that equity outcomes depend substantially upon deliberate design choices, affordability considerations, and policy frameworks. This dissertation concludes that digital mental health apps are neither inherently equalising nor inherently exclusionary; rather, their impact on health equity is contingent upon intentional, equity-focused implementation strategies. Future research must prioritise inclusive design principles and longitudinal equity assessments to ensure these technologies fulfil their democratising potential.
Introduction
Mental health disorders represent one of the most significant public health challenges of the twenty-first century, affecting approximately one billion people globally and contributing substantially to disability-adjusted life years worldwide (World Health Organization, 2022). Despite this considerable burden, a profound treatment gap persists, with estimates suggesting that between 76% and 85% of individuals with mental health conditions in low- and middle-income countries receive no treatment, whilst treatment gaps of 35% to 50% persist even in high-income nations (Patel et al., 2018). Traditional barriers to mental healthcare access include geographical distance from services, lengthy waiting times, workforce shortages, prohibitive costs, and pervasive stigma surrounding mental illness.
Against this backdrop, digital mental health applications have proliferated rapidly, with over 10,000 mental health apps now available in major application stores (Torous et al., 2021). These technologies promise to democratise mental healthcare by delivering evidence-based interventions directly to users’ smartphones, bypassing traditional barriers and potentially reaching underserved populations. Governments in several high-income countries, including Germany, the United Kingdom, and Australia, have integrated digital therapeutics into public healthcare systems, reflecting growing institutional confidence in these tools (Lattie, Stiles-Shields and Graham, 2022).
However, this optimistic narrative warrants critical scrutiny. The same structural inequalities that limit access to traditional mental healthcare may manifest differently in digital contexts, potentially creating new forms of exclusion. The digital divide—encompassing disparities in device ownership, internet connectivity, digital literacy, and data affordability—threatens to concentrate the benefits of digital mental health tools among already-advantaged populations. Furthermore, concerns regarding algorithmic bias, privacy vulnerabilities, cultural insensitivity, and inadequate regulatory oversight raise questions about whether these technologies may inadvertently harm the very populations they purport to serve (Robinson et al., 2024).
This dissertation addresses a question of considerable academic and societal importance: do digital mental health applications widen access to care or deepen existing inequalities? Understanding this dynamic is essential for policymakers, healthcare providers, technology developers, and researchers seeking to harness digital innovation for equitable health outcomes. The analysis contributes to broader debates concerning health equity, digital inclusion, and the social determinants of mental health in an increasingly technologically mediated society.
Aim and objectives
Aim
The primary aim of this dissertation is to critically evaluate whether digital mental health applications widen access to mental health support or deepen existing inequalities across different population groups.
Objectives
To achieve this aim, the following specific objectives guide the investigation:
1. To identify and synthesise evidence regarding the mechanisms through which digital mental health applications reduce traditional barriers to mental healthcare access.
2. To examine the key drivers of inequality risks associated with digital mental health interventions, including the digital divide, design limitations, digital literacy barriers, and regulatory gaps.
3. To analyse the differential impacts of digital mental health tools across specific equity dimensions, including socioeconomic status, race and ethnicity, geographical location, and age.
4. To evaluate the conditions under which digital mental health applications may promote equity versus those under which they may exacerbate disparities.
5. To develop evidence-based recommendations for equity-focused design, implementation, and policy approaches to digital mental health.
Methodology
This dissertation employs a literature synthesis methodology, drawing upon peer-reviewed research, systematic reviews, meta-analyses, and authoritative policy documents to examine the equity implications of digital mental health applications. This approach is appropriate given the study’s aim of synthesising diverse evidence streams to address a complex, multidimensional research question.
Search strategy and source selection
The primary evidence base comprises peer-reviewed publications identified through systematic database searches, supplemented by targeted searches of government publications, international organisation reports, and academic institutional resources. Priority was given to systematic reviews and meta-analyses where available, given their capacity to synthesise evidence across multiple studies and contexts. Individual empirical studies were included to illustrate specific findings or address gaps in review-level evidence.
Sources were selected according to explicit quality criteria including publication in peer-reviewed journals indexed in recognised databases, methodological rigour as assessed by transparent reporting of methods and limitations, relevance to the research question concerning equity and access in digital mental health, and recency, with preference for publications from 2017 onwards to reflect the rapidly evolving digital health landscape.
Analytical approach
The synthesis proceeded through several iterative stages. Initial reading and categorisation involved reviewing selected sources to identify major themes and findings relevant to the research objectives. Thematic organisation grouped evidence according to key equity dimensions (socioeconomic status, race/ethnicity, geography, and age) and according to mechanisms (access-enhancing versus inequality-deepening). Critical analysis involved evaluating the strength, consistency, and generalisability of findings across studies and contexts. Integration and interpretation synthesised findings to address the overarching research question and develop coherent conclusions.
Limitations
Several methodological limitations warrant acknowledgement. As a literature synthesis, this study relies upon the quality and comprehensiveness of existing research, which exhibits notable gaps regarding certain populations and contexts. The rapid pace of technological development means that some findings may have limited temporal validity. Additionally, publication bias may result in overrepresentation of positive findings in the accessible literature.
Literature review
The global mental health treatment gap
The imperative driving digital mental health innovation stems from the substantial global treatment gap. The World Health Organization has consistently documented that the majority of individuals with mental health conditions worldwide receive no treatment, with particularly acute shortfalls in low- and middle-income countries (World Health Organization, 2022). This gap reflects multiple intersecting barriers: insufficient mental health workforce capacity, with many countries having fewer than one mental health professional per 100,000 population; geographical concentration of services in urban centres; financial barriers including direct costs and opportunity costs; and pervasive stigma that deters help-seeking (Patel et al., 2018).
Traditional service delivery models have proven inadequate to close this gap, prompting interest in scalable alternatives. Task-shifting approaches that train non-specialist providers to deliver basic mental health interventions have shown promise in low-resource settings (Mudiyanselage et al., 2024). Digital technologies represent a logical extension of this principle, potentially enabling service delivery at scale without proportional increases in specialist workforce requirements.
Mechanisms through which digital apps widen access
A substantial body of evidence documents the access-enhancing potential of digital mental health applications. These tools reduce classic barriers by offering remote, low-intensity, often on-demand care that does not require physical travel to healthcare facilities or synchronous appointments with clinicians (Lattie, Stiles-Shields and Graham, 2022; Torous et al., 2021; Philippe et al., 2021; Graham, Weissman and Mohr, 2021).
Several specific mechanisms merit elaboration. First, digital interventions overcome geographical barriers by delivering services wherever users have internet connectivity. For individuals in rural and remote areas, where mental health services are frequently scarce or entirely absent, this represents a potentially transformative capability. Graham, Weissman and Mohr (2021) highlight rising adoption of digital mental health tools in rural communities, where they address both physical distance and the intensified stigma that characterises close-knit communities where seeking mental healthcare may be socially visible.
Second, digital tools bypass capacity constraints in traditional services. Waiting times for psychological therapies in public healthcare systems frequently extend to months, during which symptoms may worsen and motivation for treatment may diminish. Self-guided digital interventions offer immediate access, potentially preventing deterioration and providing support during waiting periods. The integration of prescribed digital therapeutics into public systems in Germany, the United Kingdom, and Australia reflects recognition of this capacity-extending function (Lattie, Stiles-Shields and Graham, 2022).
Third, digital delivery may reduce stigma barriers for individuals reluctant to access face-to-face mental healthcare. The privacy of smartphone-based interventions enables engagement without the social risks associated with visiting mental health facilities or disclosing conditions to employers when attending appointments.
Effectiveness of digital mental health interventions
The access-enhancing potential of digital mental health tools would be moot if these interventions lacked effectiveness. The evidence base, whilst acknowledging important heterogeneity, generally supports the clinical utility of well-designed digital interventions for common mental health conditions.
Philippe et al. (2021), in a comprehensive meta-review of digital health interventions for mental healthcare delivery, found consistent evidence of effectiveness for interventions targeting depression and anxiety, particularly those based on cognitive behavioural therapy principles and incorporating some degree of human support. Purely self-guided interventions demonstrate smaller effect sizes but remain superior to waitlist controls, suggesting clinical utility even in the absence of clinician involvement.
For adolescents and young people, digital interventions appear particularly promising. Lehtimaki et al. (2020) conducted a systematic overview of evidence on digital mental health interventions for this population, concluding that internet-delivered cognitive behavioural therapy with some human support demonstrates effectiveness and may prove especially valuable where traditional services are scarce. This finding has particular equity relevance given that mental health conditions frequently onset during adolescence and that young people face specific barriers to accessing traditional services.
Culturally adapted digital programmes for racial and ethnic minorities demonstrate particularly encouraging results. Ellis, Draheim and Anderson (2022) conducted a systematic review and meta-analysis of culturally adapted digital mental health interventions, finding large effect sizes (g≈0.9) and good acceptability. This suggests that when digital interventions are intentionally designed to reflect the cultural contexts, values, and needs of specific communities, they may achieve equity gains that elude generic approaches.
The digital divide as a driver of inequality
Notwithstanding the access-enhancing potential documented above, digital mental health tools risk deepening inequalities when their benefits accrue disproportionately to already-advantaged populations. The digital divide—encompassing disparities in device ownership, internet connectivity, data affordability, and digital literacy—represents the most fundamental barrier.
Globally, significant populations lack the technological infrastructure necessary to access digital mental health tools. Whilst smartphone penetration has increased rapidly, ownership remains stratified by income, age, and geography. Even where devices are available, data costs may render bandwidth-intensive applications prohibitively expensive for low-income users. Lattie, Stiles-Shields and Graham (2022) emphasise that costs of data, devices, and subscriptions, combined with poor Wi-Fi connectivity, create substantial barriers for socioeconomically disadvantaged populations.
Rural and remote populations face particular connectivity challenges. Whilst digital tools theoretically overcome geographical distance, the rural digital divide means that precisely those populations most distant from traditional services may also lack reliable internet access. Power supply inconsistencies compound these challenges in some contexts (Mudiyanselage et al., 2024; Graham, Weissman and Mohr, 2021).
In low- and middle-income countries, where the mental health treatment gap is most acute, digital infrastructure limitations are correspondingly more severe. Adjei-Boateng and Ikoh (2025) note that whilst digital mental health interventions offer promise for adolescents and young people in these settings, realising this potential requires addressing fundamental connectivity barriers that current interventions frequently assume away.
Design biases and cultural limitations
Beyond infrastructure, the design characteristics of dominant digital mental health tools create additional barriers. Torous et al. (2025) observe that mainstream apps often lack cultural tailoring and are dominated by a few popular products, many of which were developed primarily for English-speaking, Western, and relatively advantaged user populations. Evidence-based tools frequently achieve minimal reach, whilst widely downloaded applications may lack empirical support (Wasil et al., 2020).
Generic applications that fail to account for cultural diversity in mental health conceptualisation, symptom expression, and therapeutic preferences may be less acceptable and effective for users from minority ethnic backgrounds. Torous et al. (2025) document that generic apps are underused by Black users, whilst significant evidence gaps persist regarding effectiveness for Black and Indigenous populations. This pattern suggests that the current digital mental health ecosystem may preferentially serve majority populations whose cultural frameworks informed application design.
The potential of culturally adapted interventions, as documented by Ellis, Draheim and Anderson (2022) and Schueller et al. (2019), remains largely unrealised in the commercial application marketplace. Mehrotra et al. (2025), evaluating mental health apps available to Indian users, found substantial quality variation and limited cultural relevance, illustrating how market dynamics may fail to generate appropriately tailored products for diverse populations.
Age-related disparities in digital mental health access
Whilst young people may be particularly well-suited to digital mental health interventions, older adults face systematic barriers that risk their exclusion. Philippe et al. (2021) identify low digital literacy and design that fails to accommodate the needs of older users as key barriers. Seifert, Reinwand and Schlomann (2019), focusing specifically on designing digital mental health interventions for older adults, emphasise the need to account for digital inequality in this population.
Barriers facing older adults include lower rates of smartphone ownership and internet use, reduced familiarity with application interfaces, sensory and motor limitations that standard designs may not accommodate, and different preferences regarding human interaction in healthcare. Without deliberate age-inclusive design, digital mental health tools may exacerbate age-related disparities in mental healthcare access whilst simultaneously serving younger populations who already face fewer barriers.
Paradoxically, older adults may have substantial unmet mental health needs that digital tools could potentially address. Social isolation, bereavement, chronic illness, and late-life transitions create mental health challenges, whilst mobility limitations may impede access to traditional services. The failure to develop age-appropriate digital mental health solutions represents a missed equity opportunity.
Regulatory gaps and privacy concerns
The rapid proliferation of mental health apps has outpaced regulatory frameworks, creating risks that may disproportionately affect vulnerable users. Torous and Roberts (2017) identified transparency and trust as crucial deficits in the digital mental health marketplace, noting inadequate disclosure of evidence bases, business models, and data practices. Subsequent developments have only partially addressed these concerns.
Robinson et al. (2024) highlight how weak oversight, poor transparency, and algorithmic bias can disproportionately harm vulnerable users. Privacy concerns are particularly salient given the sensitive nature of mental health data and the potential for breaches to cause significant harm. Balcombe and De Leo (2020) identify data security and privacy as ongoing challenges in the digital mental health space.
Catania et al. (2024), evaluating digital mental health technologies in the United States, found substantial variation in quality and insufficient mechanisms for users to distinguish evidence-based interventions from ineffective or potentially harmful alternatives. The burden of quality assessment falls upon individual users, who may lack the expertise to make informed selections—a burden likely to fall most heavily on users with lower health literacy or educational attainment.
Algorithmic bias represents an emerging concern as artificial intelligence becomes increasingly integrated into digital mental health tools. If training data underrepresent certain populations, resulting algorithms may perform differentially across groups, potentially providing less effective or inappropriate support to minority users.
Equity dimensions: a comparative analysis
Synthesising across equity dimensions reveals a consistent pattern: digital mental health tools simultaneously create opportunities for access improvement and risks of inequality exacerbation, with outcomes depending substantially on design and implementation choices.
Regarding socioeconomic status, remote and low-cost care options, including SMS-based interventions that minimise data requirements, can reduce financial barriers to mental healthcare. However, costs of devices, data, and premium subscriptions may exclude the poorest potential users (Lattie, Stiles-Shields and Graham, 2022; Mudiyanselage et al., 2024; Philippe et al., 2021; Catania et al., 2024).
Regarding race, ethnicity, and culture, culturally adapted digital interventions demonstrate large effects and good acceptability, confirming the potential for equity gains when tailoring is prioritised. However, the predominance of generic, culturally homogeneous applications in the marketplace means this potential remains largely unrealised (Torous et al., 2025; Ellis, Draheim and Anderson, 2022; Schueller et al., 2019; Lehtimaki et al., 2020).
Regarding geography, digital tools can overcome distance and stigma, with evidence of rising adoption in rural areas. However, the rural digital divide, including connectivity and power supply issues, creates access barriers for precisely those populations most distant from traditional services (Mudiyanselage et al., 2024; Wang and Li, 2025; Graham, Weissman and Mohr, 2021).
Regarding age, youth-centric platforms and school or peer-supported models offer effective approaches for young people. However, older adults may be excluded by low digital literacy and designs unsuited to their needs and preferences (Lehtimaki et al., 2020; Stanescu, 2025; Adjei-Boateng and Ikoh, 2025; Philippe et al., 2021; Seifert, Reinwand and Schlomann, 2019).
Discussion
Reconciling the access and inequality narratives
The evidence synthesised in this dissertation does not support a simple answer to whether digital mental health apps widen access or deepen inequality. Rather, the evidence demonstrates that both outcomes occur simultaneously across different population groups and contexts, with the balance determined by design choices, implementation strategies, and policy frameworks.
This finding has important implications for how stakeholders should approach digital mental health innovation. Uncritical enthusiasm that assumes digital tools will automatically democratise mental healthcare ignores substantial evidence of barriers and risks. Equally, blanket scepticism that dismisses digital mental health as inherently exclusionary overlooks genuine access improvements for populations previously unable to receive any care.
A more productive framing recognises digital mental health tools as technologies with dual potential, whose equity impacts are neither predetermined nor inevitable. This framing shifts attention from whether to adopt digital mental health approaches toward how to design, implement, and regulate them in ways that maximise access gains whilst minimising inequality risks.
The conditionality of equity outcomes
Several conditions appear to distinguish equity-enhancing from inequality-deepening implementations. Affordability emerges as a fundamental requirement: tools that require expensive devices, substantial data consumption, or premium subscriptions will systematically exclude low-income users. Design approaches such as SMS-based interventions, offline functionality, and free or subsidised access through public healthcare systems can address this barrier.
Cultural adaptation represents another critical condition. The strong evidence for effectiveness of culturally tailored interventions, contrasted with evidence of underuse of generic tools by minority populations, indicates that inclusive design is not merely desirable but essential for equitable outcomes. This requires meaningful involvement of diverse communities in design processes rather than superficial translation of culturally specific content.
Age-inclusive design presents similar requirements. Interfaces that assume familiarity with contemporary smartphone conventions, feature small text and low-contrast elements, or provide inadequate guidance will exclude older users regardless of device availability. Deliberate design for diverse age groups, informed by user research with older populations, can address these barriers.
Connectivity solutions may enable access for populations currently excluded by digital infrastructure limitations. Approaches may include offline-capable applications, low-bandwidth designs, integration with community resources such as libraries or community centres, and advocacy for improved digital infrastructure as a social determinant of health.
The role of policy and regulation
Individual design choices, whilst important, occur within policy contexts that shape incentives and establish minimum standards. Current regulatory frameworks have proven inadequate to ensure quality, transparency, and equity in the digital mental health marketplace.
Several policy directions merit consideration. Quality standards and certification could help users and healthcare providers identify evidence-based interventions, reducing the current burden of individual quality assessment. Transparency requirements regarding evidence bases, data practices, and business models would enable informed decision-making. Equity impact assessments could require developers to demonstrate consideration of diverse user populations before market entry or integration into public systems.
Public investment in digital mental health development and procurement could counterbalance market dynamics that favour commercially attractive over equitably accessible products. Integration of digital tools into public healthcare systems, as implemented in Germany, the United Kingdom, and Australia, represents one mechanism for ensuring access independent of ability to pay, though this requires careful attention to which tools are selected and how they reach underserved populations.
Limitations and gaps in the evidence base
This analysis must acknowledge significant limitations in the underlying evidence base. Most research on digital mental health originates from high-income, predominantly English-speaking countries, limiting generalisability to other contexts. Equity subgroup analyses are frequently absent from effectiveness studies, making it difficult to assess differential impacts across population groups. Longitudinal evidence on sustained engagement and outcomes remains limited, raising questions about whether initial access translates into meaningful benefit.
Certain populations remain particularly underresearched. Evidence regarding digital mental health for Indigenous populations, people with disabilities, individuals with severe mental illness, and users in low-income countries is notably sparse. This research gap itself reflects inequity in whose needs are prioritised in the research enterprise.
Meeting the research objectives
Returning to the stated objectives, this dissertation has achieved the following:
Regarding objective one, the analysis identified multiple mechanisms through which digital mental health apps reduce traditional barriers, including overcoming geographical distance, bypassing capacity constraints, reducing stigma exposure, and enabling immediate access.
Regarding objective two, key drivers of inequality risks were examined, including the digital divide in devices and connectivity, culturally insensitive design, digital literacy barriers particularly affecting older adults, and inadequate regulatory oversight.
Regarding objective three, differential impacts were analysed across socioeconomic status, race and ethnicity, geography, and age, revealing consistent patterns of simultaneous access enhancement and inequality risk.
Regarding objective four, the conditions distinguishing equity-promoting from inequality-deepening implementations were evaluated, including affordability, cultural adaptation, age-inclusive design, and connectivity solutions.
Regarding objective five, evidence-based recommendations were developed for equity-focused design and policy approaches, as elaborated above and further consolidated in the conclusions.
Conclusions
This dissertation set out to evaluate whether digital mental health applications widen access to mental health support or deepen existing inequalities. The synthesis of evidence leads to a nuanced conclusion: digital mental health apps can broaden reach and mitigate some mental health inequalities, but this is not automatic. Without deliberate attention to affordability, connectivity, cultural adaptation, age-friendly design, and regulation, they may preferentially benefit already-advantaged users and entrench gaps rather than close them.
This finding carries significant implications for multiple stakeholders. For technology developers, the evidence underscores the necessity of equity-focused design from the earliest stages, including diverse user research, cultural adaptation, accessibility features, and affordability considerations. For healthcare providers and commissioners, the findings caution against assuming that digital options will automatically reach underserved populations without deliberate strategies to address barriers. For policymakers, the analysis supports strengthened regulatory frameworks that establish quality standards, require transparency, and incentivise equitable design. For researchers, the evidence gaps identified herein indicate priorities for future investigation.
Several directions for future research emerge from this analysis. Longitudinal studies examining equity outcomes over extended periods would illuminate whether initial access translates into sustained benefit across diverse populations. Implementation research investigating what strategies most effectively reach underserved groups would inform practice. Comparative research across policy contexts would clarify the impact of different regulatory and financing approaches on equity outcomes. Participatory research meaningfully involving underserved communities in design and evaluation would ensure that future digital mental health tools reflect diverse needs and preferences.
The stakes of getting digital mental health implementation right are considerable. In a context of substantial global treatment gaps and limited prospects for rapid workforce expansion, digital tools represent a potentially valuable resource. However, if their benefits accrue primarily to already-advantaged populations, they may deepen rather than ameliorate health inequalities. The evidence reviewed in this dissertation suggests that equitable outcomes are achievable but require intentional effort. Digital mental health technologies are neither inherently democratising nor inherently exclusionary; their equity impact depends upon the choices made by those who design, implement, regulate, and procure them.
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