The first section of the focus group discussions revolved around identifying which behavioral changes signaled an improvement in, or worsening of, mood to our participants. Two main themes were identified: behaviors that people engage in, which have an impact on mood, named here as promoters of change, and behaviors that manifest because of a change in mood, termed as markers of change. These themes were further subdivided into either external changes (referring to changes in their behaviors and could, in principle, be measured objectively) or internal changes (referring to changes in thoughts or feelings rather than actions). Figure 1 summarizes the markers and promoters of change discussed in the groups with example quotes.

Under the first theme of technology-related factors, we identified the subthemes of accessibility, usability and convenience, personalization of experience and modularity, reliability, and discreetness or stigma. Most participants were concerned about the price of the technology and the surrounding infrastructure, including access to reliable Wi-Fi. Participants also agreed that technology and software would need to be simple to use and convenient; for example, requiring regular charging or software updates that took time and technological literacy would affect their engagement. Participants valued the option to personalize their experience and adapt the software to their needs by deciding what to measure and manipulating the screen display. Clinicians agreed that modularity within the software would also be useful for them.

Concerns arose regarding the reliability of the technology, especially devices with physiological readings, and how making health decisions based on unreliable sensors could potentially be harmful. Discretion was also important, as wearable devices should not identify people with psychiatric disorders. Participants preferred mobile phone apps to wearable devices; however, commercially available fitness devices or smartwatches would avoid these concerns.

Data and information management emerged among the three focus groups and revolved around five main topics: security, privacy, control over data collection, feedback, and clinician data management and workload. Compared with patients, clinicians verbalized more data considerations.

Within the subtheme of security, participants were mainly concerned about sensitive information being leaked or picked up through digital sensors and going out to third parties and private corporations. Privacy concerns were related to who could gain access to the data and what choice patients would have over their access. In addition, patients wanted control over data collection and the option to engage with this technology or opt out rather than being a prerequisite for treatment. Therefore, many participants preferred the idea of a wearable device over a smartphone app for health or research purposes, as having a separate device gave participants a sense of awareness and control over when data collection took place.

Patients generally wished to review their progress, and thus, receiving feedback from RMTs would be valuable but should be tailored according to personal preferences and in a way that promotes positive reinforcement.

For clinicians, themes emerged related to managing big data, training, and clinical workloads. They were concerned about receiving adequate training, which would affect the effectiveness of the tool and their overall workload, and discussed the necessity of software to help sift through large amounts of information to generate actionable insights. Clinicians raised further concerns about whether RMT data would be used to evaluate risk and whether this would add to their workload.

Attitudes toward whether RMTs could provide an additional source of emotional support during treatment went in 2 opposite directions. On the positive end of the spectrum, participants believed that digital tools could complement human interaction by creating another channel of communication, which was thought to help with in-treatment discussions. Both clinicians and patients discussed how RMTs could accommodate the provision of lower-intensity extra support after treatment, for example, by having posttreatment check-ins. This technology was also thought to provide an opportunity to create a community by sharing achievements and involving others in their goals, thus providing an additional source of support.

Conversely, 2 further subthemes revolved around the fear of overreliance on technology and a decline in human interaction. Clinicians believed that relying on a wearable device during treatment could affect relapse rates if patients became reliant on these tools and they were then taken away after treatment. Patients echoed this sentiment and added that this overreliance may detract from a feeling of autonomy.

Any replacement of human interactions was almost universally considered detrimental to the therapeutic alliance. Participants believed that no longer feeling accountable to a therapist would detract from their motivation to engage with treatment or homework.

The positive motivational impact of automated messages or notifications being delivered to people via smartphones was discussed in all groups. Participants thought positively of RMTs as tools for memory aids in several ways, including helping manage practicalities such as taking medication and keeping track of what improves their mood. Clinicians believed that using RMTs as memory aids could improve adherence to homework or medication. Another way in which it was perceived as a complement to treatment was through planning and goal setting.

Subthemes within self-awareness revolved around having a reflexive tool to identify triggers and boosters of well-being, assess treatment trajectory, positive or negative reinforcements, and the potential to worsen rumination and health anxiety. Keeping a continuous log of these reflections was thought to help identify changes in symptom trajectories in an ecological context, such that it could provide guidance on what improves people’s mood and identify negative triggers.

Clinicians discussed the benefits of potentially identifying treatment trajectories, such that they may adjust strategies depending on changes in behavior. A subtheme of positive reinforcement emerged in the groups, in which people believed that being shown progress could prove motivating. Others advised caution, as being presented with failure to achieve goals could lead to feelings of self-defeat. Being forewarned of a possible dip in mood gave some people a sense of foreboding, which they felt could create a self-fulfilling prophecy.

A prevalent concern was whether monitoring health would lead to increased anxiety as people obsess over data, which could, in turn, worsen existing symptoms such as lack of sleep. Indeed, some people disliked the idea of having a regular request to reflect on their mental state and, therefore, constant reminders of their ill mental health. Clinicians highlighted the risks to those with health anxiety if they were exposed to constant health monitoring and feedback.

The theme of clinical utility emerged in relation to how, and to what extent, digital tools could complement treatment. The identified subthemes were related to improving the clinical experience, objective symptom measurement, outcome definitions, treatment effectiveness or concerns over the evidence base, and targeting physical health.

RMTs were thought to improve the clinical experience by replacing questionnaires, offering an electronic alternative to paper, and gamifying data collection. Both patient groups expressed a strong dislike for repeated symptom measurement questionnaires, and automatic data collection was considered a pleasing alternative. For aspects of therapy that cannot be fully automated, such as homework, participants still expressed a stronger disposition to engage with electronic methods.

Clinicians discussed the utility of more objective behavioral or physiological symptom measures that could help contextualize a patient’s symptoms. At the same time, they warned that objective benchmarks for outcome definitions would vary drastically across patients, such that symptom improvement may manifest with opposite digital signatures across different conditions.

Both patient groups discussed the issue of trust and whether technology was as effective as human-based treatments in the context of treatment. It was important for all groups that any recommendations based on digital tool readings be evidence based or accredited by the NHS to ensure their reliability.

An additional discussed benefit of using these devices in a clinical population was that they encourage improvement in physical health and sleep, which are items reportedly targeted in treatment.

The implementation of digital health tools in health care services requires insights into barriers and facilitators from stakeholders. In the second section of our focus group discussions, we identified six main themes: technology-related factors, information and data, emotional support, cognitive support, increased self-awareness, and clinical utility. The implications and impact of these themes on implementation within treatment with regard to treatment effectiveness, service provision, and patient and clinician experiences are discussed in the following sections.

One of the necessary drivers of implementation is that these tools are perceived as improving treatment outcomes. The perception that RMTs could provide better communication and increased self-awareness are 2 routes through which this could be achieved. The third route is through supporting homework [25]. Being able to follow patient trajectories more closely would aid the development of prediction models for recovery and relapse [15] and help clinicians make prompt and better-informed decisions [26]. In addition, integrating a treatment platform where patient-clinician communication is enhanced with physical health tracking, psychoeducation, and memory and motivational aids that are specifically tailored to patient symptoms and treatment schedules could boost effectiveness and move toward a more holistic and personalized approach to treatment.

The patient-clinician therapeutic relationship was one of the most prominent themes, where concerns that it may replace human-delivered treatment can feel dismissive and indeed hinder treatment effectiveness, despite finding value in the extra low-intensity support technology provided. Despite the dearth of research on the effect of digital health on therapeutic relationships [27], a recent narrative review suggests that an alliance within digital mental health can be cultivated, although it may take a different form [28]. Given that a therapeutic alliance is a highly predictive factor for treatment response [28], such concerns should be carefully considered in implementation strategies [29].

Importantly, RMT capabilities in terms of feedback schedules need to be tailored to individual needs so as not to exacerbate symptoms. Generally, feedback was appreciated; however, close monitoring was strongly discouraged for those with health anxiety. Indeed, case studies from the physical health field have found that wearables worsen mental health in such cases [30].

Service provision could be negatively affected by the broadening of the digital divide—the gap between those who benefit from the digital age and those who do not. This study found that technology-related factors such as accessibility, usability, and complexity could affect the breadth of service provision by increasing the digital divide in three main ways: those with lower technology experience and literacy are less likely to benefit from technologies with more complex designs [31], people with severe depression are more likely to be unemployed and therefore have lower purchasing power for devices or stable internet [32], and reduced cognitive abilities could affect the capacity to effectively interact with the devices.

Despite research linking remote monitoring to increased overall access to health care [33] and an overall increase in the capacity for service provision, inequalities may still appear if those with less access, experience, or capacity are less likely to benefit from this technology.

The main potential for improvement in patient experience is by replacing recurring symptom questionnaires, which were almost unanimously disliked by patients, who disliked the repetition and negative phrasing of their symptoms. This is supported by previous research showing that patients with depression would value measures of wellness and illness [34]. Digital active data collection methods could allow for different ways of capturing symptoms, such as visual or animated scales. Their use could also be reduced altogether by incorporating passive sensing.

Additional patient concerns revolved around data, specifically around having agency over data collection and access, a finding replicated elsewhere [11]. Therefore, patient-clinician discussions on which behaviors to monitor, and why, could improve attitudes toward RMT use in treatment. Privacy concerns could be reduced for some people if certain features, such as location-based data, were not deemed relevant to a patient’s treatment and, therefore, not recorded.

A key facilitator for clinicians was the utility of having objective behavioral measures to contextualize symptoms. They believed that this could be used to motivate and engage patients in their care. However, a major factor that could affect clinician buy-in was related to data management and interoperability, a concern also found in primary care settings [35]. Electronic medical record systems are already a source of excess data inputting for clinicians. Adding active and passive data generated from digital health tools is unlikely to improve care and may well overburden clinicians unless they are provided with adequate tools and training to manage and interpret data in actionable ways. Much of the research on acceptability revolves around patients; however, clinicians are end users who have been shown to express varying attitudes toward the implementation of new technologies, attitudes that can be improved through exposure to technology and training [36].