FDA-authorized software as a medical device in mental health: a perspective on evidence, device lineage, and regulatory challenges

FDA approval is widely regarded as a benchmark of quality for medical devices. However, concerns persist regarding its regulatory framework for digital mental health devices. This perspective article examined FDA-authorized Software as a Medical Device (SaMD) in mental health, tracing the devices' regulatory lineage through the De Novo and 510(k)-clearance pathways while assessing the quality of evidence that led to their authorization. Many 510(k)-cleared devices lacked direct evidence of effectiveness, relying solely on equivalence to predicate devices. Furthermore, we identified four FDA-authorized SaMD whose pivotal randomized controlled trials tested prototypes delivered on different digital platforms than those of the final marketed products. Strengthening regulatory standards requires randomized controlled trials evaluating the final marketed product on its intended platform and the use of context-appropriate control conditions. Sham placebo controls may be considered feasible; however, evidence supporting fully inert and fully blinding sham controls for digital interventions remains limited at present. This should occur alongside consistent application of the FDA's discretionary authority to require new 510(k) submissions when substantial product changes occur.