The Scottish Mental Health Arts and Film Festival has seen hundreds of arts, public and community groups coproduce over 300 events to over 25,000 audience members. Integral to this arts-based approach, in contrast to social marketing or public education models, is the notion that mental health is an essentially contested concept whereby meanings are negotiated and debate encouraged. With emerging evidence that the festival is an ef ective way of engaging people intellectually and emotionally, we explore ethical issues, challenges and (...) paradoxes that have emerged as the festival has developed. Consideration is given to issues of power, purpose, opportunity costs, reach, impact, programming risks, and participation from those with experience of mental ill-health. Throughout, we explore practical implications for funding, managing, programming, marketing and evaluation of this and similar endeavours. (shrink)