Globally mental health disorders have been increasing more so since the advent of the COVID-19 pandemic (Rajkumar, 2020; Zhou et al., 2020). Recent studies have shown an increase in psychological symptoms of distress amongst the general population across the world, with a particular increase in anxiety and depression rates (Rajkumar, 2020; Salari et al., 2020). South Africa evidences similar mental health trends amongst the population. According to the South African Stress and Health (SASH) study, 30.3% of South Africans are likely to suffer from a mental disorder in their lifetime (Herman et al., 2009). At the time of the SASH study, South Africa reported a 12-month prevalence of 16.5% for mental disorders (Williams et al., 2008). Despite the burden of mental illness, mental health facilities in South Africa are often under resourced with general hospitals providing 2.8 beds per 100,000 population, community facilities accommodating 3.6 beds per 100,000 and mental health hospitals accommodating 18 beds per 100,000. In addition, these facilities are also under staffed resulting in the underdiagnosis and treatment of mental health disorders (Lund et al., 2010, 2012; Burns, 2011; Matsea et al., 2018). There is an urgent need for resources to aid with screening, diagnosis and intervention for mental health difficulties in the population.

Cortelyou-Ward et al. (2018) amongst others recommended using technology to assist with access to appropriate mental health care. “Telehealth” is the term given to encompass all healthcare including mental health care provided through the use of various technologies, which are inclusive but not necessarily limited to the internet (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013; Zhou et al., 2020). These activities include: screening, assessment, diagnosis, intervention, psychoeducation and support amongst others and can involve purely virtual input (no direct contact with a person) or face to face input using virtual conferencing or similar engagement (Zhou et al., 2020). The use of telepsychology in the South African context is fairly limited. Goldschmidt et al. (2021) argue that this could be a result of the high data costs in the country as well as the lack of training on the use of telepsychology. However, the context of the pandemic has ensured a rapid switch to telepsychology with very few guidelines for practitioners on utilising psychotherapy and psychological assessment in this space. August and Mashegoane (2021) reported that telepsychology guidelines emanating from African organisations such as the Health Professions Council of South Africa (Health Professions Council of South Africa, 2020) and international guidelines from the British Psychological Society (British Psychological Society, 2021) and the American Psychological Association (American Psychological Association, 2020) have been generic, presenting overarching factors that practitioners should consider when conducting assessments. Additionally in the South African context, Evans (2018) and Chipise et al. (2019) also provide brief guidelines for telepsychology. Psychological assessment is briefly mentioned in each of these documents, but the focus is more on guidelines for practitioners using tests online. There are currently no psychometrically validated, online screening instruments for mental health developed in South Africa with the exception of an online, open access screening tool for depression (see Hassem, 2021). Using psychological assessment in the online space introduces a myriad of ethical concerns from issues around confidentiality through to risk and data security necessitating ethical guidelines.

Ethics typically refers to “a set of certain, aspirational moral values and principles that are intended to guide ethical conduct” (Walsh, 2015, p. 69). In the field of psychology the need for ethical guidelines can be traced back to the World Wars and the tests used with soldiers as well as the many soldiers returning from war with mental health difficulties. Indeed this led to ethical standards in the health sciences more broadly. The American Psychological Association (APA) developed its first formal ethical code in 1953. This code was revised thrice and currently speaks to Beneficence and Non-maleficence, Fidelity and Responsibility, Integrity, Justice, and Respect for People’s Rights and Dignity (Walsh, 2015).

In South Africa, it was clear as early as the 1920’s that gross ethical violations were occurring within psychology particularly within psychological assessment (Fick, 1929). Systematic discrimination on the basis of skin colour was the norm in South Africa prior to 1994. Individuals of European origin (White) people were privileged over Black (indigenous populations living in South Africa as well as all immigrants not of European descent) people. Hence tests developed in Europe and the United States were used with Black people (Fick, 1939). When Black people performed poorly, it was concluded that this was due to genetically lowered ability. Such gross misconduct led to a huge distrust in psychological assessment until South Africa became a democracy in 1994 (Laher and Cockcroft, 2014). In 2006, the Professional Board for Psychology at the Health Professions Council of South Africa promulgated its ethical code for psychologists (Government Gazette, 2006). Chapter 5 of the code addresses ethical issues linked to psychological assessment.

Aside from South Africa and the United States, various ethical documents have been developed detailing the specific ethical criteria which need to be adhered to by the professionals involved in online psychological consulting (Fisher and Fried, 2003; International Test Commission, 2005; Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013; Luxton et al., 2016; Evans, 2018). However, these are primarily focussed on therapeutic interventions and provide minimal information with regards to the ethical concerns that might be necessary for online mental health screening Therefore, while a strong need exists for online tools that can aid screening or diagnosis of mental health, there are no clear guidelines with regards to the ethical considerations for such an undertaking (see Hassem and Laher, 2020). Using the recommendations provided by Hassem and Laher (2020), a draft guidelines document was developed as a supplementary document to various international best practice guidelines documents like the International Test Commission (ITC) Guidelines for Translating and Adapting Tests – Second Edition (International Test Commission, 2017), the ITC Guidelines on Test Use (International Test Commission, 2013), and the ITC Guidelines on Computer-Based and Internet Delivered Testing (International Test Commission, 2013). The stages involved in the development of the ethical guidelines for online screening instruments are represented in Figure 1.

The draft ethical guidelines document aims to provide guidelines regarding the ethical considerations for all stakeholders involved in the development and placement of mental health screening tools on a digital platform. The document specifically addresses ethical concerns regarding open mode tests with regards to purpose and scope, modes of testing, psychometric properties, informed consent, ensuring minimal risk to participants, feedback as well as data security. Table 1 provides a brief overview of the sections in the guidelines document.

Within the digital space, documents like the ethical guidelines can contribute to ensuring individual wellbeing and empowering individuals to be proactive in ensuring their own mental health. Documents like these serve to facilitate the creation of online wellness spaces in the current climate where online mental health is fast becoming a norm. Additionally, the guidelines serve to support professionals working in the field as a point of reference for designing as well as assessing the quality of online screening instruments. This is more so for contexts like South Africa where access to mental health resources are lacking but also where assessment tools are not always applicable to the majority of the population. For us the development of guidelines was paramount as we had embarked on a project to develop an open access online screening tool for depression for use with the South African population (Hassem, 2021). Whilst doing this we were unable to find a comprehensive document that spoke to the ethics of online screening of mental health. Hence the systematic review of literature and the development of the draft guidelines for the online screening of mental health instruments (Hassem and Laher, 2020).

This study aimed to explore the efficacy of the draft guidelines by consulting with experts in the field with the objective of producing an open access ethics guidelines document for use in developing and adapting online screening tools for mental health.

This study utilised a qualitative research design where two samples of experts in the field of psychology and psychiatry were invited to review each section of the draft ethical guidelines for online mental health screening. After feedback was received from Sample 1, the draft guidelines were updated based on the expert feedback received and a second group of experts were asked to comment on the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (Brouwers et al., 2010). Hence the approach with sample 1 was inductive where the themes extracted were data driven whilst the approach with sample 2 was deductive with themes reported as per the AGREE domains (Braun and Clarke, 2006). The design and reporting of the study conforms with the reporting standards for qualitative research as proposed by Levitt et al. (2018).

A purposive sample of 50 international and South African experts in the field of psychology or cognate disciplines like psychiatry and who had experience in psychometrics, test development and/or ethics were invited to participate in the study. We identified experts to approach via their publications or presentations at local and international conferences. A total of 15 experts responded to the invitation. Of the 15 experts, eight identified as psychologists, six as psychiatrists, and one as a mental health activist. Majority of the sample (n = 8) were male and South African (n = 12). Only twelve experts stated their age, with the majority falling in the 50–60 years age category, while one expert was in the 60+ category. Majority of the sample (n = 5) were practising in the field between 11 and 20 years, while two experts were practising between 30 and 40 years.

A purposive sample of 31 international and South African experts in the field of assessment were approached to participate in the study. Nine experts responded to the call. Majority of sample were female (n = 8) and from South Africa (n = 8). All participants identified as being psychologists, with the majority identifying as research psychologists. It is important to note that in South Africa test development falls under the scope of practice of the research psychologist with those registering in other categories like clinical, counselling or educational psychology receiving little or no training in this area. Hence experts would largely hold a research psychology and/or psychometry registration. Majority of the experts were in the 45–65 years age range. Five experts were practicing in excess of 25 years, 2 experts in excess of 10 years and 2 experts were practicing between 2 and 5 years.

This study set out to revise the draft of ethical guidelines on the online screening of mental health as developed from the results of a systematic review by Hassem and Laher (2020). The study used two samples of experts to review the draft guidelines. After the feedback from the first sample, the guidelines were revised and presented to a second sample of experts who rated the guidelines according to the AGREE tool – a measure that was developed to objectively assess the quality of guidelines in health fields. The results from the AGREE tool were encouraging with majority of the experts supporting the use and dissemination of the guidelines. However, under each of the 6 domains of the AGREE tool, experts provided suggestions for improving the clarity of the guidelines. Based on the feedback provided the guidelines were revised to include a section on objectives, more explicit information on the target population as well as target users, explicit statements on updating the guidelines, independence from funding bodies and a declaration of no competing interests. These amended guidelines are provided in Supplementary Appendix A.

It should be noted that the items assessing the rigour of the document received the highest rating with majority of the experts indicating that the methods to develop the guidelines were rigorous and clear. Of further noting is that none of the experts in the second sample raised issues relating to the content of the guidelines. Some provided feedback on issues of language and grammar but there was consensus that the actual categories and recommended guidelines within each of the categories were relevant and useful.

This document comes at a time when individuals are highly prone to mental health disorders as a result of the COVID-19 pandemic, and mental health professionals are charting a relatively new landscape. This contribution of a formal ethical guideline document for online mental health screening makes a novel contribution to knowledge in the global and local space. It is to our knowledge the first document, both globally and locally, dedicated to addressing the ethical concerns of developing and placing an open mode psychological screening test in the online environment. The document provides practical implementation guidelines which can be used to foster positive ethical behaviour in the online environment by encouraging developers to consider issues relating to access, fairness, minimal harm and data protection. In so doing the guidelines also contribute to a social justice imperative.

Anecdotal evidence on the efficacy of the guidelines comes from Hassem (2021, 2022), where these guidelines were followed in creating an open access depression screening tool and subsequently placing the tool on a website for the online screening of depression¹. The guidelines informed the adaptation of the CESD-R tool² by providing some direction on items to include online given the unsupervised nature of online screening as well as considerations for the accessibility and fairness of the screening tool. For example, all items linked to suicide and suicidal ideation were removed from the tool. Given the limited resources and mental health infrastructure in South Africa, it would be unethical to assess suicide ideation when the country does not have designated resources available to contact the individuals who display suicide ideation tendencies. The inclusion of this domain can only happen once resources are available in South Africa that allow efficient and effective tracking of individuals who endorse these items during the online screening. In addition, in order to ensure accessibility and fairness, the language used excluded any form of psychological jargon and included South African idioms of distress. Whilst it may be argued from a clinical perspective that suicidal ideation is vital for depression screening and diagnosis, the nature of online unsupervised screening suggests a risk that would outweigh the benefits more so in light of the limited resources available for support in South Africa. The website design was also informed by the ethical guidelines to ensure accessibility (minimal images), fairness (simple, easy to understand English used, inclusive of local idioms of distress), minimal harm (contact details of various organisations are provided which are inclusive of toll-free numbers) and data protection (routine monitoring and updates of the site; see Hassem, 2021).

Whilst these guidelines have demonstrated utility based on feedback from two samples of experts as well as through a project on the online screening of depression in South Africa, more research is required to finalise the guidelines. Despite the useful data obtained from both samples, the samples were small with low response rates. No doubt the context of the pandemic in 2021 contributed to this as people locally and internationally had less time for this type of work. Going forward it is necessary to adopt a more quantitative, cross sectional approach and approach a larger, more diverse sample to rate the guidelines using the AGREE tool and to provide further commentary on refining and finalising the guidelines. In particular issues of beneficence and maleficence need to be addressed especially as they pertain to self-harm and risk. Excluding items on suicide or suicidal ideation, for example, is a major limitation but ensuring care post screening is also an ethical responsibility. The guidelines should provide more direction for negotiating such dilemmas. Additionally, it is necessary to compare these guidelines against the set of principles in the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Science, 2008). Anecdotally the guidelines conform to the principles but a more systematic exploration of this would be useful.

The online screening of mental health is often suggested as a means of ensuring access to healthcare services for those who may not be able to consult with a professional. However, it was clear from the literature that there were no ethical guidelines for the online screening of mental health. Hence a set of guidelines was developed based on the findings of Hassem and Laher (2020). This study used two sets of experts to evaluate these draft guidelines. The experts agreed that the guidelines are much needed in the field of online screening of mental health. Based on the feedback received, the draft guidelines were revised and are appended to this article (see Supplementary Material). It is hoped that these draft guidelines will assist others in ensuring that ethical and rigorous procedures are followed in the development, adaptation and use of online screening instruments for mental health. Going forward the aim is to finalise the guidelines for use internationally to ensure best practice in the online screening of mental health.

The original contributions presented in this study are available from the authors upon request.

Ethical clearance for this study was obtained from the Human Research Ethics Committee, Medical (HRECM) of the University of the Witwatersrand, Johannesburg (Ethics protocol number: M180402). The patients/participants provided their written informed consent to participate in this study.

Both authors involved in conceptualising the guidelines, and contributed to data collection, results, analysis, and write-up of the manuscript and guidelines.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.