Gamification and serious games in depression care: A systematic mapping study

Gamification in marketing: Insights on current and future research directions based on a bibliometric and theories, contexts, characteristics and methodologies analysis

Gamification involves using game design elements in non-game contexts. It is an emerging strategy that, being able to motivate consumer engagement with brands, has been increasingly used by companies in marketing activities. Recently, the application of gamification to marketing has become increasingly popular, with an increasing amount of research outputs. However, a clear overview of the field, a theoretical orientation or an agenda for research are still missing, which justifies the analysis of the existing literature joining these two fields of research. The motivation for conducting this review was twofold: Firstly, it is helpful to attain a broad overview of this developing field, synthesizing the existing knowledge in a structured way, understanding how gamification research in marketing has progressed and what type of knowledge has been acquired; secondly, it allows us to provide valuable information that will guide future research. Thus, this study provides a hybrid review, which integrates a bibliometric and TCCM analysis, of gamification in marketing by analyzing 114 articles. The data was retrieved from the Scopus scientific database. The bibliometric analysis showed the existence of 8 clusters, mostly representing current areas of research. It was found that the focus of the literature, so far, has been on studying which game elements should be implemented in a gamification system, as well as examining the impact of gamification experiences on engagement and consumer's behaviors. The TCCM analysis revealed the major theories and methodological approaches explored in published articles. The use of self-determination theory and quantitative methodology, based on primary data using online surveys, stands out. These complementary analyzes allowed to provide future research directions to scholars and practitioners working in this domain, promoting the advancement of scientific knowledge, contextual relevance and methodological rigor. Moreover, this review also helps marketers make more informed strategic decisions and supports successful gamification design.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Gamifying Cognitive Behavioral Therapy Techniques on Smartphones for Bangkok's Millennials With Depressive Symptoms: Interdisciplinary Game Development

BACKGROUND

There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand.

OBJECTIVE

This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok's millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones.

METHODS

First, this paper follows each development step of solidifying BlueLine's game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player's interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions.

RESULTS

With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions.

CONCLUSIONS

This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine's game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism.

A smartphone-based serious game for depressive symptoms: Protocol for a pilot randomized controlled trial

Background

Depression is the most prevalent mental disorder, with detrimental effects on the patient's well-being, high disability, and a huge associated societal and economic cost. There are evidence-based treatments, but it is difficult to reach all people in need. Internet-based interventions, and more recently smartphone-based interventions, were explored to overcome barriers to access. Evidence shows them to be effective alternatives to traditional treatments. This paper presents the protocol of a pilot study whose primary aim is to investigate the efficacy of a smartphone-based serious game intervention for patients with mild to moderate depressive symptoms.

Methods

This randomized controlled pilot trial protocol foresees two arms design: 1/ smartphone- based serious game intervention (based on Cognitive Behavior Therapy with particular emphasis on Behavioral Activation and Physical Activity), 2/ waiting list control group. The study is expected to recruit 40 participants (18+), which will be randomly assigned to one of the experimental conditions. The duration of the intervention is two months. The primary outcome measure will be depressive symptomatology. Secondary outcomes will include other variables such as physical activity, resilience, anxiety, depression impairment, and positive and negative affect. Treatment expectation, satisfaction, usability, and game playability will also be measured. The data will be analyzed based on the intention-to-treat and per protocol analyses.

Discussion

The study aims to establish initial evidence for the efficacy of a smartphone-based serious game intervention, to serve as input for a larger-scale randomized control trial. The intervention exploits advanced smartphone capabilities, such as the use of a serious game as delivery mode, with the potential benefit of engagement and treatment adherence, and motion sensors to monitor and stimulate physical activity. As a secondary objective, the study aims to gather initial evidence on the user's expectations, satisfaction, usability and playability of the serious game as a treatment.

Did Usage of Mental Health Apps Change during COVID-19? A Comparative Study Based on an Objective Recording of Usage Data and Demographics

This paper aims to objectively compare the use of mental health apps between the pre-COVID-19 and during COVID-19 periods and to study differences amongst the users of these apps based on age and gender. The study utilizes a dataset collected through a smartphone app that objectively records the users' sessions. The dataset was analyzed to identify users of mental health apps (38 users of mental health apps pre-COVID-19 and 81 users during COVID-19) and to calculate the following usage metrics; the daily average use time, the average session time, the average number of launches, and the number of usage days. The mental health apps were classified into two categories: guidance-based and tracking-based apps. The results include the increased number of users of mental health apps during the COVID-19 period as compared to pre-COVID-19. Adults (aged 24 and above), compared to emerging adults (aged 15-24 years), were found to have a higher usage of overall mental health apps and guidance-based mental health apps. Furthermore, during the COVID-19 pandemic, males were found to be more likely to launch overall mental health apps and guidance-based mental health apps compared to females. The findings from this paper suggest that despite the increased usage of mental health apps amongst males and adults, user engagement with mental health apps remained minimal. This suggests the need for these apps to work towards improved user engagement and retention.

The Effect of Mental Health App Customization on Depressive Symptoms in College Students: Randomized Controlled Trial

BACKGROUND

Mental health apps have shown promise in improving mental health symptoms, including depressive symptoms. However, limited research has been aimed at understanding how specific app features and designs can optimize the therapeutic benefits and adherence to such mental health apps.

OBJECTIVE

The primary purpose of this study is to investigate the effect of avatar customization on depressive symptoms and adherence to use a novel cognitive behavioral therapy (CBT)-based mental health app. The secondary aim is to examine whether specific app features, including journaling, mood tracking, and reminders, affect the usability of the mental health app.

METHODS

College students were recruited from a university study recruitment pool website and via flyer advertisements throughout campus. A total of 94 participants completed a randomized controlled trial in which they were randomized to either customization or no customization version of the app. Customization involved personalizing a virtual avatar and a travel vehicle to one's own preferences and use of one's name throughout the app. Participants completed a 14-day trial using a novel CBT-based mental health app called AirHeart. Self-report scores for depressive symptoms, anxiety, and stress were measured at baseline and after the intervention. Postintervention survey measures also included usability and avatar identification questionnaires.

RESULTS

Of the 94 enrolled participants, 83 (88%) completed the intervention and postintervention assessments. AirHeart app use significantly reduced symptoms of depression (P=.006) from baseline to the end of the 2-week intervention period for all participants, regardless of the customization condition. However, no differences in depressive symptoms (P=.17) or adherence (P=.80) were observed between the customization (39/83, 47%) and no customization (44/83, 53%) conditions. The frequency of journaling, usefulness of mood tracking, and helpfulness of reminders were not associated with changes in depressive symptoms or adherence (P>.05). Exploratory analyses showed that there were 3 moderate positive correlations between avatar identification and depressive symptoms (identification: r=-0.312, P=.02; connection: r=-0.305, P=.02; and lack of relatability: r=0.338, P=.01).

CONCLUSIONS

These results indicate that CBT mental health apps, such as AirHeart, have the potential to reduce depressive symptoms over a short intervention period. The randomized controlled trial results demonstrated that customization of app features, such as avatars, does not further reduce depressive symptoms over and above the CBT modules and standard app features, including journal, reminders, and mood tracking. However, further research elucidating the relationship between virtual avatar identification and mental health systems is needed as society becomes increasingly more digitized. These findings have potential implications for improving the optimization of mental health app designs.

TRIAL REGISTRATION

Open Science Framework t28gm; https://osf.io/t28gm.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low-quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (P=.70) and no intervention (P=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (P=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (P=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine "Google Scholar," and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969.

Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review

BACKGROUND

Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities.

OBJECTIVE

This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines.

METHODS

The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents.

RESULTS

A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play.

CONCLUSIONS

The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology.

Competitive Debate as Innovation in Gamification and Training for Adult Learners: A Conceptual Analysis

Adult learners demand teaching innovations that are ever more rapid and attractive. As a response to these demands and the challenges of skills training, this article presents a conceptual analysis that introduces competitive debate as an impact training model. The aim is to learn whether debate can be considered to fall within the frame of gamification, so that the full potential of debate as gamification can be exploited. There is a significant research gap regarding competitive debate as a game, with the training mechanics for adult learners remaining practically unexplored. Through a conceptual analysis of game, game experience, and gamification, and their respective characteristics, we conclude that competitive debate is an ideal instrument for gamification.

Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis

BACKGROUND

Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification.

OBJECTIVE

The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements.

METHODS

A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis.

RESULTS

A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40).

CONCLUSIONS

The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.

Smart Homes as Enablers for Depression Pre-Diagnosis Using PHQ-9 on HMI through Fuzzy Logic Decision System

Depression is a common mental illness characterized by sadness, lack of interest, or pleasure. According to the DSM-5, there are nine symptoms, from which an individual must present 4 or 5 in the last two weeks to fulfill the diagnosis criteria of depression. Nevertheless, the common methods that health care professionals use to assess and monitor depression symptoms are face-to-face questionnaires leading to time-consuming or expensive methods. On the other hand, smart homes can monitor householders’ health through smart devices such as smartphones, wearables, cameras, or voice assistants connected to the home. Although the depression disorders at smart homes are commonly oriented to the senior sector, depression affects all of us. Therefore, even though an expert needs to diagnose the depression disorder, questionnaires as the PHQ-9 help spot any depressive symptomatology as a pre-diagnosis. Thus, this paper proposes a three-step framework; the first step assesses the nine questions to the end-user through ALEXA or a gamified HMI. Then, a fuzzy logic decision system considers three actions based on the nine responses. Finally, the last step considers these three actions: continue monitoring through Alexa and the HMI, suggest specialist referral, and mandatory specialist referral.

Machine Learning and IoT Applied to Cardiovascular Diseases Identification through Heart Sounds: A Literature Review

This article presents a systematic mapping study dedicated to conduct a literature review on machine learning and IoT applied in the identification of diseases through heart sounds. This research was conducted between January 2010 and July 2021, considering IEEE Xplore, PubMed Central, ACM Digital Library, JMIR—Journal of Medical Internet Research, Springer Library, and Science Direct. The initial search resulted in 4372 papers, and after applying the inclusion and exclusion criteria, 58 papers were selected for full reading to answer the research questions. The main results are: of the 58 articles selected, 46 (79.31%) mention heart rate observation methods with wearable sensors and digital stethoscopes, and 34 (58.62%) mention care with machine learning algorithms. The analysis of the studies based on the bibliometric network generated by the VOSviewer showed in 13 studies (22.41%) a trend related to the use of intelligent services in the prediction of diagnoses related to cardiovascular disorders.

Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial

Background

Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another.

Objective

The aim of our study is to test whether 3 enhancements—facilitator contact (FC), an online discussion board, and virtual badges (VB)—alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence.

Methods

Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions—the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed.

Results

A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline.

Conclusions

The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence.

Trial Registration

ClinicalTrials.gov NCT02861755; http://clinicaltrials.gov/ct2/show/NCT02861755

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.29137]

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low–quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (<i>P</i>=.70) and no intervention (<i>P</i>=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (<i>P</i>=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (<i>P</i>=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.32331]

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (<i>P</i>=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (<i>P</i>=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (<i>P</i>=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

CLINICALTRIAL

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969

Ambient Intelligence Based on IoT for Assisting People with Alzheimer’s Disease Through Context Histories

New Internet of Things (IoT) applications are enabling the development of projects that help with monitoring people with different diseases in their daily lives. Alzheimer’s is a disease that affects neurological functions and needs support to maintain maximum independence and security of patients during this stage of life, as the cure and reversal of symptoms have not yet been discovered. The IoT-based monitoring system provides the caregivers’ support in monitoring people with Alzheimer’s disease (AD). This paper presents an ontology-based computational model that receives physiological data from external IoT applications, allowing identification of potentially dangerous behaviors for patients with AD. The main scientific contribution of this work is the specification of a model focusing on Alzheimer’s disease using the analysis of context histories and context prediction, which, considering the state of the art, is the only one that uses analysis of context histories to perform predictions. In this research, we also propose a simulator to generate activities of the daily life of patients, allowing the creation of data sets. These data sets were used to evaluate the contributions of the model and were generated according to the standardization of the ontology. The simulator generated 1026 scenarios applied to guide the predictions, which achieved average accurary of 97.44%. The experiments also allowed the learning of 20 relevant lessons on technological, medical, and methodological aspects that are recorded in this article.

A computational model for adaptive recording of vital signs through context histories

Wearable devices emerged from the advancement of communication technology and the miniaturization of electronic components. These devices periodically monitor the user's vital signs and generally have a short battery life. This work introduces ODIN, a model for optimized vital signs collection based on adaptive rules. Analyzing vital sign values requires preciseness, so the adaption of these collected data allows a personalized analysis of the user's health condition. The comparison with related works indicates that ODIN is the only model that presents context-aware-adaptive vital signs collection. The implementation of a prototype allowed to perform three evaluations of ODIN. The first evaluation used simulations in different scenarios, with the adaptive approach increasing battery life by 119% through the analysis of input data compared to data collection without adaptivity. The second evaluation applied the prototype to a database of real physiologic data, which allowed reduced data collection when the user has regular vital signs. This reduction optimized battery consumption by 66% compared to collection without adaptivity. Finally, the third evaluation applied ODIN through an Arduino and a heart rate monitor (Polar H7). The average power saved across mobile devices was 21%. Consequently, the adaptive strategy presented in this work allows the optimization of computational resources during the collection and analysis of vital signs. This optimization occurs because of the reduction in energy expenditure and the reduction in the amount of data that needs to be collected and stored.

A Survey on Gamification for Health Rehabilitation Care: Applications, Opportunities, and Open Challenges

Research trends in gamification have shown a significant diversity in various areas of e-health, particularly in addressing the issues of rehabilitation and physical activity. Rehabilitation requires better engaging tools that help to increase the patient’s motivation and engagement in particular forms of rehabilitation training. Adopting gamification in rehabilitation offers different treatment and care environments when implementing rehabilitation training. As gamification is increasingly being explored in rehabilitation, one might not realize that using various techniques in gamified applications yields a different effect on gameplay. To date, varied gamification techniques have been utilized to provide useful experiences from the perspective of health applications. However, a limited number of surveys have investigated the gamification of rehabilitation and the use of suitable game techniques for rehabilitation in the literature. The objective of this paper is to examine and analyze the existing gamification techniques for rehabilitation applications. A classification of rehabilitation gamification is developed based on the rehabilitation gamifying requirements and the gamification characteristics that are commonly applied in rehabilitation applications. This classification is the main contribution of this paper. It provides insight for researchers and practitioners into suitable techniques to design and apply gamification with increased motivation and sustainable engagement for rehabilitation treatment and care. In addition, different game elements, selection blocks, and gamification techniques are identified for application in rehabilitation. In conclusion, several challenges and research opportunities are discussed to improve gamification deployment in rehabilitation in the future.

Role of a Digital Return-To-Work Solution for Individuals With Common Mental Disorders: Qualitative Study of the Perspectives of Three Stakeholder Groups

Background

Although effective return-to-work (RTW) interventions are not widely available for individuals with common mental disorders on sick leave, there is potential for transforming such interventions into a digital solution in an effort to make them more widely available. However, little is currently known about the viewpoints of different stakeholder groups, which are critical for successful development and implementation of a digital RTW intervention in health care services.

Objective

The aim of this study was to examine stakeholder groups’ perspectives on the role and legitimacy of a digital RTW solution called mWorks for individuals with common mental disorders who are on sick leave.

Methods

A purposeful snowball sampling method was utilized to recruit respondents. Semistructured individual and focus group interviews were conducted for stakeholder groups of service users, RTW professionals, and influential managers regarding their experiences, needs, and preferences for mWorks. Content analysis generated themes and categories that constituted the main findings.

Results

The legitimacy of a digital RTW solution was high among all stakeholder groups since such a tool was perceived to enable service users to take control over their RTW process. This was mainly a product of accessible support and promotion of service user decision making, which had the potential to empower service users. All respondents stressed the importance of fostering a positive user experience with usability and emphasis on service user resources and strengths, as opposed to various limitations and shortcomings. Stakeholder groups highlighted critical content to facilitate RTW, such as the need to clarify a back-to-work plan, accompanied by an accessible RTW network and strategies for handling mental health problems. Implementation challenges primarily involved influential managers’ concern of legislation incompatibility with innovative technology, and RTW professionals’ concern of the possibility that digital solutions may replace them to a certain extent.

Conclusions

This formative research emphasizes the importance of shifting power from RTW professionals to service users. mWorks can play a role in mediating service user control over the RTW process, and thereby increase their empowerment. A digital RTW solution may facilitate the circumvention of implementation barriers associated with introducing evidence-based RTW interventions in a traditional RTW context.

Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial

Forty percent of all general-practitioner appointments are related to mental illness, although less than 35% of individuals have access to therapy and psychological care, indicating a pressing need for accessible and affordable therapy tools. The ubiquity of smartphones offers a delivery platform for such tools. Previous research suggests that gamification-turning intervention content into a game format-could increase engagement with prevention and early-stage mobile interventions. This study aimed to explore the effects of a gamified mobile mental health intervention on improvements in resilience, in comparison with active and inactive control conditions. Differences between conditions on changes in personal growth, anxiety and psychological wellbeing, as well as differences in attrition rates, were also assessed. The eQuoo app was developed and published on all leading mobile platforms. The app educates users about psychological concepts including emotional bids, generalization, and reciprocity through psychoeducation, storytelling, and gamification. In total, 358 participants completed in a 5-week, 3-armed (eQuoo, "treatment as usual" cognitive behavioral therapy journal app, no-intervention waitlist) randomized controlled trial. Relevant scales were administered to all participants on days 1, 17, and 35. Repeated-measures ANOVA revealed statistically significant increases in resilience in the test group compared with both control groups over 5 weeks. The app also significantly increased personal growth, positive relations with others, and anxiety. With 90% adherence, eQuoo retained 21% more participants than the control or waitlist groups. Intervention delivered via eQuoo significantly raised mental well-being and decreased self-reported anxiety while enhancing adherence in comparison with the control conditions. Mobile apps using gamification can be a valuable and effective platform for well-being and mental health interventions and may enhance motivation and reduce attrition. Future research should measure eQuoo's effect on anxiety with a more sensitive tool and examine the impact of eQuoo on a clinical population.

A Serious Game on the First-Aid Procedure in Choking Scenarios: Design and Evaluation Study

Background

Choking is one of the causes of unintentional injury death. Gaining the knowledge of the first-aid procedure that has to be applied in case of choking can increase the chances of survival of persons with choking. Serious games can be a good channel for educating people about choking scenarios and the actions to be taken to save the persons with choking.

Objective

The objective of this study is to present and evaluate the effectiveness of a serious game designed to prevent choking and to promote the first-aid procedure that needs to be applied in case of choking.

Methods

In this study, we present a serious game as a set of minigames that reproduces the main steps of the protocol for the first-aid performed in choking. In the proposed game, the player acquires the role of a helper who has to save the person in a choking emergency by applying the main steps of the protocol. Time and score restrictions are imposed to pass each minigame. To test this game, we performed a pilot study with 48 high school students. Different tests were performed to assess the students’ preferences and their knowledge on choking before and after playing the proposed game. The obtained results were analyzed using Mann-Whitney U test when a grade variable was involved and by using Fisher exact test when 2 categorical variables were involved.

Results

The findings of our study showed that the players enjoyed the game. No statistical differences were detected when considering the gender of the player, their preferences for video games, or their previous experience in choking emergencies. By comparing the knowledge of these students before and after playing the game, we found that all the indicators of the knowledge about how to act in case of a choking emergency were improved through this serious game.

Conclusions

The findings of our study show that the proposed game is a good strategy for promoting and teaching first-aid procedures in choking emergencies to nonexperts in this field.

Development and testing of iAware model for ubiquitous care of patients with symptoms of stress, anxiety and depression

BACKGROUND AND OBJECTIVE

This work proposes a model for ubiquitous care of patients with anxiety, depression and stress disorders using gamification and biodata, called iAware. Depression and anxiety are the most prevalent mental disorders, reaching million people worldwide. As they share many characteristics these two disorders can manifest themselves together. In addition, stress is one of the related factors with both depression and anxiety, being relevant in the analysis of these disorders. This work was carried out through a study on depression, anxiety and stress disorders (DASD), their treatments and the use of gamification as a means of engagement.

METHODS

A/B tests evaluated with a clinical population the interaction engagement of the patient to the treatment provided by gamification. The iAware monitors and applies interventions for the patient at the most appropriate time, based on the patient's history. In order to evaluate iAware, six patients used a prototype with a smartband for two weeks. The patients also filled out a survey based on the Technology Acceptance Model (TAM). The survey was composed of 10 sentences and the results of each one are discussed.

RESULTS

Interactions with intervention stages were greater in patients who used iAware gamified. The patients who used iAware got more occurrences of anxiety at home and in the afternoon and night. TAM evaluation showed that patients considered the use of iAware useful in their anxiety treatment routine.

CONCLUSIONS

The results pointed out that biodata is a supplementary alternative for DASD monitoring. In addition, the research work showed that the use of iAware for the support of anxiety treatment is useful for patients. Patients who used iAware without gamification did not perform or score the treatment activities. The evaluation showed evidence that the game improved the engagement of patients in the iAware use.

Therapeutic and Preventive Use of Video Games in Child and Adolescent Psychiatry: A Systematic Review

BACKGROUND

Over the past decade, the use of commercial video games and serious games has developed in child and adolescent psychiatry. These games may become relevant alternatives or adjuncts to traditional psychotherapy, providing that their effectiveness is properly established. The purpose of this literature review was to evaluate the effectiveness of serious games and commercial video games in the treatment or prevention of psychiatric disorders in children and adolescents.

METHODS

Medline's database was used to search articles published between January 2012 and July 2019. The following keywords were used for this search: "Video games" OR "Active video game" OR "serious gaming" OR "Serious game" OR "Exergame" AND "Child mental disorder" OR "Adolescent" OR "Child" AND "Therapy" OR "Prevention". Only comparative studies which targeted interventions on children and adolescents suffering from psychiatric disorders were included.

RESULTS

Twenty-two studies, focusing on a wide range of psychiatric conditions, met our inclusion criteria's: 14 evaluated serious games and 8 commercial games. All studies were randomized controlled trials but only two studies compared the intervention game to psychotherapeutic gold standard; other studies used a no-intervention control group or an alternative game as the control group. Eighteen studies reported significant improvements on the symptoms and test scores targeted.

CONCLUSION

Serious games and commercially available video games can be an effective trajectory for psychotherapy in child and adolescent psychiatry. However, there is a lack of longitudinal studies which assess the sustained effects of these games, and standards for proper evaluation of their effectiveness are missing.

Gamifying CBT to deliver emotional health treatment to young people on smartphones

mHealth interventions promise the economic delivery of evidence-based mental health treatments like cognitive behavioural therapy (CBT) to populations that struggle to access health services, such as adolescents and in New Zealand, Māori and Pasifika youth. Unfortunately engagement with digital therapies is poor; modularisation and gamification have potential to increase their appeal. Gamifying CBT involves selecting suitable interventions, adapting them to a digital format while applying gamification principles. We describe the design and development of Quest - Te Whitianga, an app that encourages the user to learn CBT skills via a series of activities and games. A variety of approaches including consultation with clinicians, reference to best-practice literature, focus groups and interactive workshops with youth were used to inform the co-design process. Clinicians worked iteratively with experienced game designers to co-create a youth CBT digital intervention. The Quest modular app is set on an ocean and the user travels between islands to learn six evidence-based skills. These include a relaxation/mindfulness activity, activity planning, a gratitude journal plus problem solving and communication skills training. We describe the theoretical and design aspects of each module detailing the gamified features that aim to increase user engagement. In the near future we will be testing the app and the principles discussed in this paper via a randomised-controlled trial.

Applied Computing to Education on Noncommunicable Chronic Diseases: A Systematic Mapping Study

Background: The number of deaths from noncommunicable chronic diseases (NCDs) has increased worldwide. These deaths would be partly avoidable if prevention and follow-up measures were applied to reduce risk factors. Computing can help educate individuals, improving their knowledge about NCDs. This article presents a systematic mapping of studies that apply computing to education on NCDs. The results allow a general view of the literature and the identification of research opportunities. Materials and Methods: The methodology followed three steps: (1) definition of search databases from computer science and health sciences, (2) selection of keywords for search string composition, and (3) application of inclusion and exclusion criteria to filter the results. The survey occurred from January 2008 to April 2018. Results: The initial search resulted in 19,675 papers, of which 38 were selected after applying the filter criteria. The use of mobile computing stood out in 25 papers. The education modalities were self-management and educational content for diabetes (10 papers), asthma (1), cardiovascular disease (1) and chronic diseases (1), self-management of diabetes and games (1), educational content (15), games (6), personalized content (2), and virtual community (1). The percentage of papers on diabetes was 65%. Most solutions (55%) do not use data from individuals to provide information considering their health condition. In addition, 19 papers produced outcome measures by means of experiments. Conclusions: Mobile computing was the most used technology in the papers. In addition, self-management, educational content, and games were the most used mechanisms. A research opportunity consists of personalized assistance. In this sense, ubiquitous learning can provide a continuous and contextualized education.

Explicit Mental Health Messaging Promotes Serious Video Game Selection in Youth With Elevated Mental Health Symptoms

Serious games aimed at promoting well-being in youth have promising effects and potential for far-reaching impact. Considering that most mental health disorders remain untreated in youth, therapeutic games may be most valuable when they are aimed at untreated youth with internalizing symptoms. However, when targeting youth outside of a clinical setting, the first impression of therapeutic video games may determine whether and how a game is played. Thus, understanding the influence of messaging used in the promotion of therapeutic games on game choice and experience is critical. The current study examined two alternatives in promoting mental health games: one included explicit mental health messaging (e.g., learn to manage stress) and the other was a stealth promotion that did not mention mental health but highlighted the entertainment value. Young adults with mild to severe internalizing mental health symptoms (i.e., depressive, anxiety, and stress symptoms) were shown two distinct trailer designs, with random assignment determining which design held which message. Participants (n = 129, M_age = 21.33, SD_age = 3.20), unaware that both trailers promoted the same commercial video game, were 3.71 times more likely to choose what they believed was the mental health game. Additionally, an unforeseen difference in the attractiveness of the two trailer designs resulted in participants being 5.65 times more likely to select the mental health game promoted in one trailer design over the other. Messaging did not influence game experience (i.e., gameplay duration, autonomy, competence, intrinsic motivation and affect). Exploratory analyses indicated that game experience, but not game choice, was influenced by symptom severity, symptom type and the interaction between symptom severity and messaging. The present study suggests that explicit mental health messages attract youth with mental health symptoms. Ultimately, youth may be empowered to seek out mental health games if they are promoted properly, allowing for far-reaching positive influences on well-being. Toward this aim, future research is needed on the game selection process, addressing underlying motivations, the balance between explicit health and entertainment messaging, and multiple interacting influences on game selection (e.g., promotion and peers).