Mental Health on the Go: Effects of a Gamified Attention Bias Modification Mobile Application in Trait Anxious Adults

Computer-Mediated Communication (CMC) and Anxiety in Adolescence: Preference for CMC, Social Media Burden, and Attention Bias to Threat

Despite societal and empirical interest in the impact of computer-mediated communication (CMC) on anxiety in adolescents, little is known about the associations between specific aspects of CMC use and anxiety severity and the role of individual vulnerability factors. In this study, we examined the links between two contexts of CMC, preference for CMC over face-to-face interactions and perceived social media social media burden, along with an anxiety-related cognitive vulnerability factor and attention bias to threat. Participants were mildly to severely anxious 12- to 14-year-olds (N = 78, M age = 12.89, 55% female). They self-reported on CMC preferences and social media burden and on anxiety symptoms in two domains (generalized anxiety disorder (GAD) and social anxiety) and completed an eye-tracking assessment of attention bias. We tested the hypothesis that preferring CMC over face-to-face communications and perceiving greater social media burden would predict more severe anxiety symptoms, particularly among those with greater attention bias to threat. As predicted, greater feelings of social media burden predicted more severe anxiety symptom severity (GAD only) but only among those with greater attention bias to threat. The potential role of attention bias in associations between CMC and adolescent anxiety and the specificity of effects on GAD symptom severity is discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42761-024-00253-1.

Gamification in Mobile Apps for Children With Disabilities: Scoping Review

BACKGROUND

Children with disabilities face numerous challenges in accessing health services. Mobile health is an emerging field that could significantly reduce health inequities by providing more accessible services. Many mobile apps incorporate gamification elements such as feedback, points, and stories to increase engagement and motivation; however, little is known about how gamification has been incorporated in mobile apps for children with disabilities.

OBJECTIVE

This scoping review aims to identify and synthesize the existing research evidence on the use of gamification in mobile apps for children with disabilities. Specifically, the objectives were to (1) identify the categories of these mobile apps (eg, treatment and educational) (2), describe the health-related outcomes they target, (3) assess the types and levels of gamification elements used within these apps, and (4) determine the reasons for incorporating gamification elements into mobile apps.

METHODS

We searched MEDLINE, PsycINFO, CINAHL, Embase, the ACM Digital Library, and IEEE Xplore databases to identify papers published between 2008 and 2023. Original empirical research studies reporting on gamified mobile apps for children with disabilities that implemented at least 1 gamification strategy or tactic were included. Studies investigating serious games or full-fledged games were excluded.

RESULTS

A total of 38 studies reporting on 32 unique gamified mobile apps were included. Findings showed that gamified apps focus on communication skills and oral health in children with autism spectrum disorder while also addressing self-management and academic skills for other disability groups. Gamified mobile apps have demonstrated potential benefits across different populations and conditions; however, there were mixed results regarding their impact. The gamification strategies included fun and playfulness (23/32, 72%), feedback on performance (17/32, 53%), and reinforcement (17/32, 53%) in more than half of apps, whereas social connectivity was used as a gamification strategy in only 4 (12%) mobile apps. There were 2 main reasons for integrating gamification elements into mobile apps described in 16 (42%) studies: increasing user engagement and motivation and enhancing intervention effects.

CONCLUSIONS

This scoping review offers researchers a comprehensive review of the gamification elements currently used in mobile apps for the purposes of treatment, education, symptom management, and assessment for children with disabilities. In addition, it indicates that studies on certain disability groups and examinations of health-related outcomes have been neglected, highlighting the need for further investigations in these areas. Furthermore, research is needed to investigate the effectiveness of mobile-based gamification elements on health and health behavior outcomes, as well as the healthy development of children with disabilities.

Smartphone-Delivered Attentional Bias Modification Training for Mental Health: Systematic Review and Meta-Analysis

BACKGROUND

Smartphone-delivered attentional bias modification training (ABMT) intervention has gained popularity as a remote solution for alleviating symptoms of mental health problems. However, the existing literature presents mixed results indicating both significant and insignificant effects of smartphone-delivered interventions.

OBJECTIVE

This systematic review and meta-analysis aims to assess the impact of smartphone-delivered ABMT on attentional bias and symptoms of mental health problems. Specifically, we examined different design approaches and methods of administration, focusing on common mental health issues, such as anxiety and depression, and design elements, including gamification and stimulus types.

METHODS

Our search spanned from 2014 to 2023 and encompassed 4 major databases: MEDLINE, PsycINFO, PubMed, and Scopus. Study selection, data extraction, and critical appraisal were performed independently by 3 authors using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. When necessary, we pooled the standardized mean difference with a 95% CI. In addition, we conducted sensitivity, subgroup, and meta-regression analyses to explore moderator variables of active and placebo ABMT interventions on reducing symptoms of mental health problems and attentional bias.

RESULTS

Our review included 12 papers, involving a total of 24,503 participants, and we were able to conduct a meta-analysis on 20 different study samples from 11 papers. Active ABMT exhibited an effect size (Hedges g) of -0.18 (P=.03) in reducing symptoms of mental health problems, while the overall effect remained significant. Similarly, placebo ABMT showed an effect size of -0.38 (P=.008) in reducing symptoms of mental health problems. In addition, active ABMT (Hedges g -0.17; P=.004) had significant effects on reducing attentional bias, while placebo ABMT did not significantly alter attentional bias (Hedges g -0.04; P=.66).

CONCLUSIONS

Our understanding of smartphone-delivered ABMT's potential highlights the value of both active and placebo interventions in mental health care. The insights from the moderator analysis also showed that tailoring smartphone-delivered ABMT interventions to specific threat stimuli and considering exposure duration are crucial for optimizing their efficacy. This research underscores the need for personalized approaches in ABMT to effectively reduce attentional bias and symptoms of mental health problems.

TRIAL REGISTRATION

PROSPERO CRD42023460749; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=460749.

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Beyond the modified dot-probe task: A meta-analysis of the efficacy of alternate attention bias modification tasks across domains

Attention biases towards disease-relevant cues have been implicated in numerous disorders and health conditions, such as anxiety, cancer, drug-use disorders, and chronic pain. Attention bias modification (ABM) has shown that changing attention biases can change related emotional processes. ABM most commonly uses a modified dot-probe task, which has received increasing criticism regarding its reliability and inconsistent findings. The purpose of the present review was thus to systematically review and meta-analyse alternative tasks used in ABM research. We sought to examine whether alternative tasks significantly changed attention biases and emotional outcomes, and critically examined whether relevant sample, task and intervention characteristics moderated each of these effect sizes. Seventy-four (completer n = 15,294) study level comparisons were included in the meta-analysis. Overall, alternative ABM designs had a medium effect on changing biases (g = 0.488), and a small, but significant effect on improving clinical outcomes (g = 0.117). We found this effect to be significantly larger for studies which successfully changed biases compared to those that did not. Across all tasks, it appeared that targeting engagement biases results in the largest change to attention biases. Importantly, we found tasks incorporating gaze-contingency - encouraging engagement with non-biased stimuli - show the most promise for improving emotional outcomes.

Reliability (or lack thereof) of smartphone ecological momentary assessment of visual dot probe attention bias toward threat indices

BACKGROUND AND OBJECTIVES

Cognitive bias theories posit that generalized anxiety disorder (GAD) and social anxiety disorder (SAD) are entwined with attention bias toward threats, commonly indexed by faster response time (RT) on threat-congruent (vs. threat-incongruent) trials on the visual dot probe. Moreover, although smartphone ecological momentary assessment (EMA) of the visual dot probe has been developed, their psychometric properties are understudied. This study thus aimed to assess the reliability of 8 smartphone-delivered visual dot probe attention bias and related indices in persons with and without GAD and SAD.

METHODS

Community-dwelling adults (n = 819; GAD: 64%; SAD: 49%; Mixed GAD and SAD: 37%; Non-GAD/SAD Controls: 24%) completed a five-trial smartphone-delivered visual dot probe for a median of 60 trials (12 sessions x 5 trials/session) and an average of 100 trials (20 sessions x 5 trials/session).

RESULTS

As hypothesized, Global Attention Bias Index, Disengagement Effect, and Facilitation Bias had low-reliability estimates. However, retest-reliability and internal reliability were good for Trial-Level Bias Scores (TLBS) (Bias Toward Treat: intra-class correlation coefficients (ICCs) = 0.626-0.644; split-half r = 0.640-0.670; Attention Bias Variability: ICCs = 0.507-0.567; split-half r = 0.520-0.580) and (In)congruent RTs. Poor retest-reliability and internal reliability estimates were consistently observed for all traditional attention bias and related indices but not TLBS.

LIMITATIONS

Our visual dot probe EMA should have administered ≥320 trials to match best-practice guidelines based on similar laboratory studies.

CONCLUSIONS

Future research should strive to examine attention bias paradigms beyond the dot-probe task that evidenced meaningful test-retest reliability properties in laboratory and real-world naturalistic settings.

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.

Pilot study of attentional retraining for postpartum smoking relapse

Introduction

Tobacco smoking is a leading cause of preventable death worldwide. The perinatal period provides a unique opportunity for intervention, as many smokers quit smoking during pregnancy but relapse postpartum. Novel relapse prevention interventions that reduce the burden of treatment attendance in this population are needed. Attentional retraining (AR) has been shown to reduce attentional biases toward smoking-related stimuli, a cognitive process implicated in smoking, AR has not been applied to perinatal smokers, and the effect of AR on craving and smoking is not clear. The goal of this study was to evaluate the delivery of AR for smoking cues in perinatal smokers utilizing a mobile intervention.

Methods

This pilot study utilized Ecological Momentary Assessment (EMA) methodology delivered on a mobile device to examine the relapse process and evaluate the utility of AR in former smokers attempting to remain abstinent postpartum. AR (or Control Training) was administered to abstinent smokers (N = 17) for up to 2 weeks both before and after delivery.

Results

All 17 participants completed the study. There was evidence that AR reduced attentional bias in the AR group (vs. Controls). There was no evidence that AR reduced craving. An exploratory analysis revealed that there was no evidence that AR reduced smoking during the study period.

Discussion

AR using EMA methodology via a mobile device is feasible in perinatal smokers. Further research using larger samples is required to evaluate the utility of mobile AR in reducing craving and smoking.

Attentional biases for sad faces in offspring of mothers with a history of major depression: trajectories of change from childhood to adolescence

BACKGROUND

Theorists have proposed that the way children process social-emotional information may serve as a mechanism of risk for the intergenerational transmission of depression. There is growing evidence that infants and children of mothers with a history of major depressive disorder (MDD) during the child's life exhibit attentional avoidance of sad faces, which has been proposed as an early emerging emotion regulation strategy. In contrast, there is clear evidence that at-risk and depressed adolescents and adults exhibit difficulty disengaging attention from sad faces.

METHODS

Seeking to link these two literatures, the current U.S.-based study used eye tracking within the context of an accelerated longitudinal design to assess attentional biases in 8-14-year-old offspring of mothers with a history MDD during the child's life (n = 123) or no history of MDD (n = 119) every six months for two years, allowing us to map trajectories of attention from age 8 to 16.

RESULTS

Mother MDD history moderated age-based changes in children's gaze duration to sad (t[240] = 2.44, p = .02), but not happy (t[240] = 0.11, p = .91) or angry (t[240] = 0.67, p = .50), faces. Consistent our hypotheses, offspring of mothers with MDD exhibited significantly less attention to sad faces than offspring of never depressed mothers before age 8.5 but significantly more attention to sad faces after age 14.5, which was due to an increase in gaze duration to sad faces from childhood to adolescence among offspring of mothers with MDD (t[122] = 5.44, p < .001) but not among offspring of never depressed mothers (t[118] = 1.49, p = .14).

CONCLUSIONS

It appears that the form, and perhaps function, of attentional bias may shift across development in at-risk youth. To the extent that this is true, it has significant implications not only for theories of the intergenerational transmission of depression risk but also for prevention and early intervention efforts designed to reduce this risk.

Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study

BACKGROUND

Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring.

OBJECTIVE

In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm.

METHODS

We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged.

RESULTS

We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users.

CONCLUSIONS

These games may help improve the effectiveness and engagement levels of computerized interventions for depression.

Effects of attention bias modification for anxiety: Neurophysiological indices and moderation by symptom severity

OBJECTIVE

Attention bias modification (ABM) aims to decrease anxiety symptom severity through the reduction of threat-related attention bias (AB). Individual differences in treatment response and poor measurement reliability of AB have called its clinical promise into question. The current study examined whether individual differences in anxiety severity at baseline moderated treatment response, and employed both behavioral and neurophysiological metrics of AB.

METHODS

Participants (N = 99) were randomly assigned to four weeks of ABM or placebo control training (PT). Self-reported anxiety symptom severity, and AB metrics and ERPs generated during the dot probe task were collected at baseline (Time 1), one-week post-intervention (Time 5), and at a three-month follow-up (Time 6).

RESULTS

ABM, relative to PT, reduced ERPs indexing attention discrimination (N170) and increased ERPs indexing salience tracking (P3). Increases in P3 were associated with ABM-related reductions in anxiety. Anxiety severity was reduced following ABM, but only among those with higher baseline anxiety symptom severity.

CONCLUSIONS

ABM effectively reduced symptom severity among those with higher levels of anxiety, and modulated neurophysiological indices of AB.

SIGNIFICANCE

Results provide evidence for attention-relevant ERPs as outcomes of ABM treatment responsivity and suggest that ABM may be most beneficial for those with more severe anxiety symptoms.

Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms

This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I² = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I² = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.

Efficacy of attention bias modification via smartphones in a large population sample

Negative affective biases are a key feature of anxiety and depression that uphold and promote negative mood. Bias modification aims to reduce these biases using computerized training, but shows mixed success and has not been tested at scale. The aim was to determine whether bias modification delivered via smartphones can improve mood in a large sample. In total, 153 385 self-referring participants were randomly assigned to modification or sham bias training on a dot-probe or visual-search task. The primary outcome of interest was balance of mood, assessed on the Positive and Negative Affect Schedule. In total, 22 933 participants who provided at least two mood ratings were included in analyses. There was a large amount of participant attrition. In the remaining smaller sample, results supported the prediction that visual-search modification would result in improved mood (95%CI [0.10, 0.82]; p = 0.01, d = 0.05, N = 2588 after two ratings; 95%CI [1.75,6.54]; p = 0.001, d = 0.32, N = 118 after six ratings), which was not seen for the sham version (N = 4818 after two ratings; N = 138 after six ratings). Dot-probe modification was not associated with mood improvements (p = 0.52). Visual-search, but not dot-probe, bias modification slightly but significantly improved mood. Although this effect size is very small and subject to large participant drop-off, it might be worth considering an adjunct to current treatments.

Efficacy of attention bias modification via smartphones in a large population sample

Negative affective biases are a key feature of anxiety and depression that uphold and promote negative mood. Bias modification aims to reduce these biases using computerized training, but shows mixed success and has not been tested at scale. The aim was to determine whether bias modification delivered via smartphones can improve mood in a large sample. In total, 153 385 self-referring participants were randomly assigned to modification or sham bias training on a dot-probe or visual-search task. The primary outcome of interest was balance of mood, assessed on the Positive and Negative Affect Schedule. In total, 22 933 participants who provided at least two mood ratings were included in analyses. There was a large amount of participant attrition. In the remaining smaller sample, results supported the prediction that visual-search modification would result in improved mood (95%CI [0.10, 0.82]; p = 0.01, d = 0.05, N = 2588 after two ratings; 95%CI [1.75,6.54]; p = 0.001, d = 0.32, N = 118 after six ratings), which was not seen for the sham version (N = 4818 after two ratings; N = 138 after six ratings). Dot-probe modification was not associated with mood improvements (p = 0.52). Visual-search, but not dot-probe, bias modification slightly but significantly improved mood. Although this effect size is very small and subject to large participant drop-off, it might be worth considering an adjunct to current treatments.

Attentional biases toward real images and drawings of negative faces

The allocation of attention is affected by internal emotional states, such as anxiety and depression. The attention captured by real images of negative faces can be quantified by emotional probe tasks. The present study investigated whether attentional bias toward drawings of negative faces (line drawings and cartoon faces) differs from that of real faces. Non-clinical university students indicated their levels of anxiety and depression via self-report questionnaires, and completed a probe discrimination task under three face image conditions in a between-participants design. Significant correlations were found between bias scores and scores on the self-reported BDI-II under the real face condition. However, two types of face drawings were only weakly correlated with self-report scores. In our probe task to investigate attentional bias to facial stimuli in nonclinical adults, the strength of the relationship between depression and attentional bias to negative face was stronger for real faces than for face drawings.

Socially-Oriented Persuasive Game to Promote Disease Awareness and Prevention

Persuasive games are widely implemented in the health domain to promote desirable behaviour change. Previous research shows that using persuasive games employing various strategies results in increased motivation and awareness that led to a positive change in behaviour. This paper investigates the efficacy of a competition-based persuasive game at creating awareness and motivating people to adhere to COVID-19 precautionary measures. To achieve this goal, we developed and evaluated a competition-based persuasive game to promote the awareness and adoption of COVID-19 precautionary measures. The results of our pretest and posttest study ( $N=67$ ) followed by a semistructured interview of 18 participants show the efficacy of the game with respect to promoting a positive change in attitude, intention, self-efficacy, knowledge, and promoting motivation and positive player experience among participants. The qualitative results provide insight into how and why persuasive games promote desirable behaviour. The paper contributes to the knowledge of how emerging technologies in the form of persuasive games can be designed and used to contribute to solving problems in our society.

Gamified Challenges in Online Weight-Loss Communities

Gamified challenges, one of the most popular features of online weight-loss communities, enable users to set weight-loss goals and compete with other challenge participants via leaderboards. Using the data from a leading online weight-loss community, we study the effect of gamified challenges on the weight-loss outcome. Our findings indicate that participation in gamified challenges has a positive and significant effect on weight loss. We found that, on average, the participants achieved a weight loss of 0.742 kg by participating in at least one challenge a month. We found that effective challenges do not include a numeric weight goal (e.g., lose 5 kg), focus on exercise-only behavioral goals, and have a large active group size. Further, the results show that the absence (presence) of a numeric weight goal benefits users in exercise (diet) challenges. Moreover, a small active group size can help (hurt) users in exercise (diet) challenges. Our results suggest that gamification elements that induce competition should be used with caution in goal-setting environments, especially when gamifying dietary goals. Online weight-loss communities can recommend a useful combination of numeric weight goals, behavioral goals, and an optimal number of participants in each challenge to induce an encouraging level of social comparison.

[Mobile health technologies in cardiology]

Digital medicine is becoming an essential part of the healthcare system. The intense development of mobile technologies, the global coverage of mobile networks, and the growing attachment in the society to mobile devices have prompted the creation of mobile healthcare (mHealth). At present, mobile healthcare technologies have been tested in various cardiovascular diseases. Among the main tasks set for telemedicine, it is necessary to note improvements of general medical care, monitoring of patients' condition, accuracy of clinical diagnoses, timely correction of therapy, and improvement of emergency care. Clinical studies are performed in parallel with active work in the field of informational technologies to provide safety of data storage and intellectual processing. Finally, despite the broad public support for the development of this area of medicine, the search continues for methods to improve patients' compliance with the prescribed therapy. This article presents current information about the use of mHealth in cardiology, study results, prospects of mobile healthcare, and major difficulties in implementing projects in this area.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial

Background

To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits.

Objective

The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

Methods

A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement.

Results

The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively.

Conclusions

This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx

International Registered Report Identifier (IRRID)

PRR1-10.2196/32359

The effectiveness of gaming interventions for depression and anxiety in young people: systematic review and meta-analysis

BACKGROUND

Recent research has investigated the use of serious games as a form of therapeutic intervention for depression and anxiety in young people.

AIMS

To conduct a systematic review and meta-analysis into the effectiveness of gaming interventions for treating either depression or anxiety in individuals aged 12-25 years.

METHOD

An electronic search was conducted on the 30 March 2020, using PsycINFO, ISI Web of Science Core Collection, Medline and EMBASE databases. Standardised effect sizes (Hedge's g) were calculated for between-participant comparisons between experimental (therapeutic intervention) and control conditions, and within-participant comparisons between pre- and post-intervention time points for repeated measures designs.

RESULTS

Twelve studies (seven randomised controlled trials (RCTs) and five non-randomised studies) were included. For RCTs, there was a statistically significant and robust effect (g = -0.54, 95% CI -1.00 to -0.08) favouring the therapeutic intervention when treating youth depression. For non-RCTs, using a repeated measures design, the overall effect was also strong (g = -0.75, 95% CI -1.64 to 0.14) favouring therapeutic intervention, but this was not statistically significant. Interestingly, we found no statistically significant effect for treating youth anxiety.

CONCLUSIONS

There is preliminary evidence to suggest that gaming interventions are an effective treatment for youth depression, but not anxiety. Further research is warranted to establish the utility, acceptability and effectiveness of gaming interventions in treating mental health problems in young people.

Exploring the human factors for mindfulness in mHealth service usage: An Elaboration Likelihood Model

MHealth service is widely accepted as a good path towards healthcare promotion. However, patients’ low-level usage restricted its effectiveness. This work draws upon the elaboration likelihood model and mindfulness theory to investigate the mindfulness mechanism in mHealth service usage, which highlights: First, both perceived information quality and mindfulness positively affect mHealth service usage. Also, perceived information quality is observed to affect the establishment of mindfulness positively. These findings stress that both perceived information quality and mindfulness are essential for mHealth service usage. Second, peer patient influence and physicians’ recommendations positively affect the establishment of mindfulness. These findings stress that human factors are essential for consumers’ establishment of mindfulness. Third, mindfulness mediates the relationship between human factors and mHealth service usage. This phenomenon indicates that when consumers adopt a mHealth service, both peer patient influence and physicians’ recommendations have a positive impact on mHealth service usage indirectly. Fourth, the effects of both peer patient influence and physicians’ recommendations on mindfulness depend on patients’ perceived eHealth literacy levels. This finding illustrates that while peer patient influence is especially crucial for improving mindfulness in a cohort with a high-level perceived eHealth literacy, physicians’ recommendations are especially crucial for improving mindfulness in a cohort with low-level perceived eHealth literacy.

Commercial Off-The-Shelf Video Games for Reducing Stress and Anxiety: Systematic Review

BACKGROUND

Using commercial off-the-shelf video games rather than custom-made computer games could have several advantages for reducing stress and anxiety, including their low cost, advanced graphics, and the possibility to reach millions of individuals worldwide. However, it is important to emphasize that not all commercial video games are equal, and their effects strongly depend on specific characteristics of the games.

OBJECTIVE

The aim of this systematic review was to describe the literature on the use of commercial off-the-shelf video games for diminishing stress and anxiety, examining the research outcomes along with critical variables related to computer game characteristics (ie, genre, platform, time of play).

METHODS

A systematic search of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The search databases were PsycINFO, Web of Science, Medline, IEEExplore, and the Cochrane Library. The search string was: [("video game*") OR ("computer game*")] AND [("stress") OR ("anxiety") OR ("relaxation")] AND [("study") OR ("trial") OR ("training")].

RESULTS

A total of 28 studies met the inclusion criteria for the publication period 2006-2021. The findings demonstrate the benefit of commercial off-the-shelf video games for reducing stress in children, adults, and older adults. The majority of the retrieved studies recruited young adults, and fewer studies have involved children, middle-aged adults, and older adults. In addition to exergames and casual video games, other genres of commercial off-the-shelf games helped to reduce stress and anxiety.

CONCLUSIONS

Efficacy in reducing stress and anxiety has been demonstrated not only for exergames and casual video games but also for other genres such as action games, action-adventure games, and augmented reality games. Various gaming platforms, including consoles, PCs, smartphones, mobile consoles, and virtual reality systems, have been used with positive results. Finally, even single and short sessions of play had benefits in reducing stress and anxiety.

TRIAL REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202130081; https://inplasy.com/?s=INPLASY202130081.

Mobile Attention Bias Modification Training Is a Digital Health Solution for Managing Distress in Multiple Sclerosis: A Pilot Study in Pediatric Onset

Introduction: Emotional health is important dimension of care for patients living with pediatric onset multiple sclerosis (POMS), but few options are available for stress and anxiety reduction. The high burden of interventions requiring regular in person and onsite visits for treatment are less feasible. Attention bias modification training (ABMT) is effective for anxiety reduction in adult and adolescent populations. We tested the feasibility and preliminary efficacy of ABMT delivered through a mobile gamified version as a digital emotional health tool for patients with POMS.

Methods: Participants with POMS were consecutively recruited from the NYU Langone Pediatric MS Care Center and enrolled to complete a 1-month intervention with use of the Personal Zen ABMT app on their mobile personal device. Feasibility was evaluated by use of the 1-month intervention and efficacy was measured by changes in depression, anxiety, and affect.

Results: A total n = 35 patients with POMS were enrolled in the study (M_age = 17.7, SD = 2.2 years, range 14–23). Feasibility criteria were met with 74% completing the full intervention time, and 100% of the sample completing at least 50% of targeted intervention use. Initial efficacy was found for a reduction in negative affect from baseline to intervention end [M = 22.88, SD = 9.95 vs. M = 19.56, SD = 7.37; t₍₃₃₎ = 2.47, p = 0.019]. Anxiety also significantly decreased from pre to post-intervention in adults [M = 11.82, SD = 9.90 vs. M = 7.29, SD = 7.17; t₍₁₆₎ = 3.88, p = 0.001] and youth [M = 51.14, SD = 19.66 vs. M = 40.86, SD = 27.48; t₍₁₃₎ = 3.17, p = 0.007].

Conclusion: Mobile ABMT with the Personal Zen app is a feasible and accessible digital emotional health tool for patients with POMS and may have broader application for managing distress across chronic neurological conditions.

Transcranial Direct Current Stimulation (tDCS) Augments the Effects of Gamified, Mobile Attention Bias Modification

Anxiety-related attention bias (AB) is the preferential processing of threat observed in clinical and sub-clinical anxiety. Attention bias modification training (ABMT) is a computerized cognitive training technique designed to systematically direct attention away from threat and ameliorate AB, but mixed and null findings have highlighted gaps in our understanding of mechanisms underlying ABMT and how to design the most effective delivery systems. One neuromodulation technique, transcranial direct current stimulation (tDCS) across the pre-frontal cortex (PFC) may augment the effects of ABMT by strengthening top-down cognitive control processes, but the evidence base is limited and has not been generalized to current approaches in digital therapeutics, such as mobile applications. The present study was a single-blind randomized sham-controlled design. We tested whether tDCS across the PFC, vs. sham stimulation, effectively augments the beneficial effects of a gamified ABMT mobile app. Thirty-eight adults (Mage = 23.92, SD = 4.75; 18 females) evidencing low-to-moderate anxiety symptoms were randomly assigned to active or sham tDCS for 30-min while receiving ABMT via a mobile app. Participants reported on potential moderators of ABMT, including life stress and trait anxiety. ECG was recorded during a subsequent stressor to generate respiratory sinus arrhythmia (RSA) suppression as a metric of stress resilience. ABMT delivered via the app combined with tDCS (compared to sham) reduced AB and boosted stress resilience measured via RSA suppression, particularly for those reporting low life stress. Our results integrating tDCS with ABMT provide insight into the mechanisms of AB modulation and support ongoing evaluations of enhanced ABMT reliability and effectiveness via tDCS.

Low working memory load facilitates attention bias modification training

Implementations of attention bias modification training (ABMT) attempt to retrain attention away from rather than towards threat, thereby disrupting the anxiety-related attentional bias (AB). Yet, results of ABMT studies have been mixed due to limitations in knowledge of mechanisms underlying ABMT efficacy. Dual-process models of anxiety posit that ABMT works primarily through strengthening of the top-down cognitive control of attention to threat. If this is the case, introducing a working memory load (WML) during ABMT should reduce training efficacy. However, prior studies employing this method show mixed results (Booth, Mackintosh, Mobini, Oztop, & Nunn, 2014; Clarke et al., 2017) and fail to directly compare low and high WML with no WML or to account for individual differences in anxiety and working memory capacity (WMC). The present study (N = 306) assessed trait anxiety and WMC in neurotypical adults who were then randomly assigned to ABMT that trained attention toward or away from threat, with either no, low, or high WML, for a total of six training groups. Attentional bias was assessed before and after training. Results showed ABMT successfully trained attention under low WML, but not under high or no WML, suggesting that ABMT is facilitated by engaging but not overtaxing WML.

Tablet therapy as an assistive technology-based treatment for anxiety in pediatric oncology

The painful interventions and invasive procedures associated with pediatric cancer treatment can result in anxiety. Anxiety can be reduced or better controlled through distraction and thought retraining. Although art therapy, non-electronic play therapy, music therapy, and traditional counseling are often used to alleviate stress and anxiety, new technology innovations are proving to be additional options to decrease stress and anxiety through distraction and attention shifting. Tablet-based interventions are emerging as an easily available and effective means of reducing stress and fear prior to operations, and have potential applications to reduce anxiety for patients before receiving chemotherapy, during time spent in hospital rooms, and while experiencing distressing physiological symptoms. This paper reviews the research on tablet therapy and discusses the application of assistive technologies in clinical oncology settings to reduce pediatric anxiety throughout the treatment process.

The impact of online brain training exercises on experiences of depression, anxiety and emotional wellbeing in a twin sample

This study assessed the effectiveness of cognitive and emotional brain training and transfer effects to wellbeing and depression and anxiety symptoms. 352 healthy adult twins were randomised to a training group where they were asked to play brain training games over a 30-day period, or a waitlist control group. This study focused on the impact of the brain training on explicit and implicit emotional cognition, and analysed effects using both Intention-To-Treat (ITT) and Per-Protocol (PP) approaches. Both analyses revealed significant training effects for improvement in the explicit identification of fear expressions (ITT: p < 0.001, d = 0.33; PP training 3 h+: p < 0.001, d = 0.55), and a reduction in implicit bias for anger expressions amongst males (ITT: p < 0.001, d = 0.94; PP training 3 h+: p = 0.04, d = 0.90). Female participants also showed improvements in implicit bias for happy expressions (ITT: p = 0.003, d = 0.34; PP training 3 h+: p = 0.03, d = 0.47). Improvements resulting from training in emotional cognition did not directly improve wellbeing, depression or anxiety symptoms. Regression modelling also suggested training improvements in emotional cognition yielded no indirect transfer effects for the mental health and wellbeing measures. The results suggest brain training in healthy populations has potential for improving emotional cognition, but the subsequent impact on improving wellbeing and mental health symptoms is still equivocal.

Recommendations for Implementing Gamification for Mental Health and Wellbeing

Gamification is increasingly being proposed as a strategy to increase engagement for mental health and wellbeing technologies. However, its implementation has been criticized as atheoretical, particularly in relation to behavior change theory and game studies theories. Definitions of the term “gamification” vary, sometimes widely, between and within academic fields and the effectiveness of gamification is yet to be empirically established. Despite this, enthusiasm for developing gamified mental health technologies, such as interventions, continues to grow. There is a need to examine how best to implement gamification in mental health and wellbeing technologies in a way that takes quick production cycles into account while still emphasizing empirical investigation and building a rigorous evidence base. With reference to game studies and the medical (eHealth/mHealth) literature, this article interrogates gamification for mental health and wellbeing by examining core properties of the game form. It then explores how gamification can best be conceptualized and implemented for mental health and wellbeing goals from conceptualization through to iterative co-development and evaluation that accommodates software development schedules. Finally, it summarizes its conceptual analysis into recommendations for researchers and designers looking to do so. These recommendations are: (1) assess suitability, (2) implement to support, (3) assess acceptability, (4) evaluate impact, and (5) document comprehensively. These recommendations aim to encourage clear language, unified terminology, the application and evaluation of theory, comprehensive and constant documentation, and transparent evaluation of outcomes.

The relations among worry, meta-worry, intolerance of uncertainty and attentional bias for threat in men at high risk for generalized anxiety disorder: a network analysis

BACKGROUND

Improving the psychotherapies for generalized anxiety disorder (GAD) is dependent on a deeper understanding of the relations between GAD and its associated cognitive factors. In the present study, we investigate how the core feature of GAD (i.e., worry) and its associated cognitive factors, such as meta-worry, intolerance of uncertainty, and attention bias towards threat, relate to each other in men at high risk for GAD.

METHODS

We used network analysis to explore the relations among these variables in a cross-sectional sample of 122 men at high risk for generalized anxiety disorder. Specifically, we computed the expected influence and predictability of each variable.

RESULTS

In the final network, we found that worry and meta-worry had the highest expected influence and predictability. In contrast, attention bias towards threat showed the lowest expected influence and predictability. The estimates of the expected influence of the nodes were stable (correlation stability coefficient = 0.52).

CONCLUSIONS

The present study is the first to investigate the relations among worry, meta-worry, intolerance of uncertainty, and attention bias towards threat in men at high risk for generalized anxiety disorder. These findings indicate that worry and meta-worry may play important roles in the present network. The implications for clinical interventions and future studies are discussed.

PuzzleWalk: A theory-driven iterative design inquiry of a mobile game for promoting physical activity in adults with autism spectrum disorder

Primary symptoms of adults with autism spectrum disorder (ASD), such as pervasive social deficits in social interaction and communication, cause adults with ASD to adopt a sedentary lifestyle. Meanwhile, gamified and behavioral theory-based interventions have been shown to improve physical activity in a fun and unobtrusive way. In this paper, we describe the iterative design inquiry process of PuzzleWalk, a gamified, physical activity-promoting mobile app designed for adults with ASD. We report the design rationales and lessons learned across four user-centered design phases with ASD experts and adults with ASD, including user requirement gathering, iterative participatory design, usability evaluation, and field deployment. The design insights generated from this work could inform future research focusing on designing sociotechnical systems, games, and interventions for people with ASD.

Age Moderates Link Between Training Effects and Treatment Response to Attention Bias Modification Treatment for Social Anxiety Disorder

Attention bias modification treatment (ABMT) aims to reduce anxiety symptoms via practice on computerized attention training tasks. Despite evidence of efficacy, clinical effects appear heterogeneous. More research on ABMT mechanisms and moderators of treatment response is needed. Age is one potentially important moderator, as developmental differences in training effects may impact response. We examined developmental links between ABMT training effects and response in social anxiety disorder (SAD). We pooled data from two randomized controlled trials in treatment-seeking youths and adults with SAD (N = 99) that used identical ABMT methods. We first characterized learning effects associated with the eight-session ABMT training protocol. We then tested whether learning magnitude predicted the clinical (change in SAD symptoms) and cognitive (change in attention bias) responses to treatment. Finally, we tested whether age moderated the association between ABMT learning and treatment response. Results indicate that ABMT was associated with an incremental learning curve during the protocol, and that learning improved with age. Age further moderated the association between learning gains during the ABMT protocol and subsequent reduction in self-reported SAD symptoms, such that this association was stronger with age. These effects were not evident in bias scores or clinician ratings. Finally, pre-treatment SAD symptoms and bias scores predicted ABMT learning gains. This study highlights the links among age, learning processes, and clinical response to ABMT. These insights may inform attempts to increase the clinical efficacy of ABMT for anxiety.

The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis

Background

There has been a growing interest in the application of gamification (ie, the use of game elements) to computerized cognitive training. The introduction of targeted gamification features to such tasks may increase motivation and engagement as well as improve intervention effects. However, it is possible that game elements can also have adverse effects on cognitive training (eg, be a distraction), which can outweigh their potential motivational benefits. So far, little is known about the effectiveness of such applications.

Objective

This study aims to conduct a systematic review and meta-analysis to investigate the effect of gamification on process outcomes (eg, motivation) and on changes in the training domain (eg, cognition), as well as to explore the role of potential moderators.

Methods

We searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ProQuest Psychology, Web of Science, Scopus, PubMed, Science Direct, Excerpta Medica dataBASE, Institute of Electrical and Electronics Engineers Xplore, Association for Computing Machinery, and a range of gray-area literature databases. The searches included papers published between 2008 and 2018. Meta-analyses were performed using a random-effects model.

Results

The systematic review identified 49 studies, of which 9 randomized controlled trials were included in the meta-analysis. The results of the review indicated that research in this context is still developing and lacks well-controlled empirical studies. Gamification in cognitive training is applied to a large range of age groups and audiences and is mostly delivered at a research site through computers. Rewards and feedback continue to dominate the gamification landscape, whereas social-oriented features (eg, competition) are underused. The meta-analyses showed that gamified training tasks were more motivating/engaging (Hedges g=0.72) and more demanding/difficult (Hedges g=–0.52) than non- or less-gamified tasks, whereas no effects on the training domain were found. Furthermore, no variables moderated the impact of gamified training tasks. However, meta-analytic findings were limited due to a small number of studies.

Conclusions

Overall, this review provides an overview of the existing research in the domain and provides evidence for the effectiveness of gamification in improving motivation/engagement in the context of cognitive training. We discuss the shortcomings in the current literature and provide recommendations for future research.

Virtual Reality Games and the Role of Body Involvement in Enhancing Positive Emotions and Decreasing Anxiety: Within-Subjects Pilot Study

Background

In the last few years, the introduction of immersive technologies, especially virtual reality, into the gaming market has dramatically altered the traditional concept of video games. Given the unique features of virtual reality in terms of interaction and its ability to completely immerse the individual into the game, this technology should increase the propensity for video games to effectively elicit positive emotions and decrease negative emotions and anxiety in the players. However, to date, few studies have investigated the ability of virtual reality games to induce positive emotions, and the possible effect of this new type of video game in diminishing negative emotions and anxiety has not yet been tested. Furthermore, given the critical role of body movement in individuals’ well-being and in emotional responses to video games, it seems critical to investigate how body involvement can be exploited to modulate the psychological benefits of virtual reality games in terms of enhancing players’ positive emotions and decreasing negative emotions and anxiety.

Objective

This within-subjects study aimed to explore the ability of commercial virtual reality games to induce positive emotions and diminish negative emotions and state anxiety of the players, investigating the effects of the level of body involvement requested by the game (ie, high vs low).

Methods

A total of 36 young adults played a low body-involvement (ie, Fruit Ninja VR) and a high body-involvement (ie, Audioshield) video game in virtual reality. The Visual Analogue Scale (VAS) and the State-Trait Anxiety Inventory, Form-Y1 (STAI-Y1) were used to assess positive and negative emotions and state anxiety.

Results

Results of the generalized linear model (GLM) for repeated-measures multivariate analysis of variance (MANOVA) revealed a statistically significant increase in the intensity of happiness (P<.001) and surprise (P=.003) and, in parallel, a significant decrease in fear (P=.01) and sadness (P<.001) reported by the users. Regarding the ability to improve anxiety in the players, the results showed a significant decrease in perceived state anxiety after game play, assessed with both the STAI-Y1 (P=.003) and the VAS-anxiety (P=.002). Finally, the results of the GLM MANOVA showed a greater efficacy of the high body-involvement game (ie, Audioshield) compared to the low body-involvement game (ie, Fruit Ninja VR), both for eliciting positive emotions (happiness, P<.001; and surprise, P=.01) and in reducing negative emotions (fear, P=.05; and sadness, P=.05) and state anxiety, as measured by the STAI-Y1 (P=.05).

Conclusions

The two main principal findings of this study are as follows: (1) virtual reality video games appear to be effective tools to elicit positive emotions and to decrease negative emotions and state anxiety in individuals and (2) the level of body involvement of the virtual video game has an important effect in determining the ability of the game to improve positive emotions and decrease negative emotions and state anxiety of the players.

The altered early components and the decisive later process underlying attention bias modification in social anxiety: evidence from event-related potentials

Attention bias modification (ABM) is a potential intervention in relieving social anxiety symptoms, while its underlying neural mechanisms are not yet understood. The current study included 63 college students with social anxiety. Participants were assigned to the attention modification program (AMP, n = 20), the attention control condition (ACC, n = 20) and the passive waiting group (PW, n = 23). Questionnaires and the emotional Stroop task with EEG recordings were used to assess whether and how the 4-week ABM period affected emotional symptoms and specific emotional processing. Results showed that the two training groups (AMP and ACC) produced comparable emotional improvements and both showed a decrease in negative bias compared with the PW group. The ERP results indicated that despite no significant ERP changes in the PW group, the ACC group exhibited a greater N1, whereas the AMP group exhibited a reduced VPP at the post-test stage compared to the pre-test stage. Besides, both training groups showed a similar late positive potential (LPP) reduction. Notably, the reduction in LPP was positively correlated with behavioral and symptom improvement. Thus, manipulations unique to ABM (face-target contingency) primarily modulate the early attention distribution of material-related stimuli. However, the clinical benefits of attention training may be due to later cognitive-affective mechanisms.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

The Effects of Casual Videogames on Anxiety, Depression, Stress, and Low Mood: A Systematic Review

Background: Despite the variety of available treatments for mental health symptoms, many individuals do not engage with treatment and among those who do, dropout rates are often high. Therefore, providing alternative opportunities to access treatment is imperative. Research interest in the therapeutic effects of digital mental health initiatives and serious games has grown in recent years, but the potential of simple, easy-to-use casual videogames (CVGs) that can be played in short bursts of time has seldom been considered. Objective: The objective of the present study is to provide a systematic review of the literature examining the effects of CVGs on treating anxiety, depression, stress, and low mood. Method: A systematic search was conducted, using the terms (casual gam* or casual videogam* or mini gam* or minigam* or mini-gam* or gamif*) and (mental health or anx* or depress* or stress or mood) and (study or trial or treatment or prescribed or prevention) as "Title," "Abstracts," "Keywords," or "Topic" words across all years. A Google search was also completed to check for articles that may have been missed. Results: N = 13 studies met inclusion criteria (no studies were added via the Google search). These studies reported findings for nine different CVGs, with six studies aimed at reducing anxiety, two examining effects for depression, and four investigating the effects of CVGs on treating stress or low mood. Promising effects were identified. Conclusion: CVGs may have promise for treating anxiety, depression, stress, and low mood.

The effectiveness of touchscreen-based attentional bias modification to thin body stimuli on state rumination

Ruminative thinking is considered a vulnerability factor for eating disorder symptomatology. Research suggests that attentional bias to body shape stimuli may serve to underpin this maladaptive form of emotion regulation. The current study aimed to determine the direct effect of attentional bias to thin-ideal bodies on state depressive rumination. Additionally, this study sought to evaluate the efficacy of attentional bias modification (ABM) utilising a touchscreen device. A well-established ABM protocol, the modified dot probe task, was used for both attentional assessment and training. Female undergraduate students (N = 110) completed an ABM session where attention was trained either towards, or away from, thin-ideal body images. Pre- and post-attentional training, participants completed the dot probe task, as well as a state measure of depressive rumination. Results revealed that the ABM training induced a greater attentional bias to thin-ideal bodies in the attend-thin training condition than in the avoid-thin training condition. Furthermore, induced attentional avoidance of thin-ideal bodies led to a significant reduction in state depressive rumination. The current findings suggest that touchscreen-based ABM is effective in modifying patterns of attentional bias and state depressive rumination.

Attentional Bias Modification in Virtual Reality - A VR-Based Dot-Probe Task With 2D and 3D Stimuli

Background

Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias toward threatening information. The current study incorporated virtual reality (VR) technology and three-dimensional stimuli with a dot-probe task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

Methods

A total of 100 participants were randomized to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-months follow-up.

Results

Change in anxiety did not correlate with change in bias (p = 0.24). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM (p = 0.144), or between groups (p = 0.976). For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment (p < 0.001). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 9% of participants were classified as ‘recovered’ at 3-months follow-up.

Conclusion

A single session of VR-based ABM did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.

Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

BACKGROUND

There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators.

OBJECTIVE

This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions.

METHODS

We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3.

RESULTS

The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers' justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention's intended effects.

CONCLUSIONS

Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

Heterogeneity of the Anxiety-Related Attention Bias: A Review and Working Model for Future Research

The anxiety-related attention bias (AB) has been studied for several decades as a clinically-relevant output of the dynamic and complex threat detection-response system. Despite research enthusiasm for the construct of AB, current theories and measurement approaches cannot adequately account for the growing body of mixed, contradictory, and null findings. Drawing on clinical, neuroscience, and animal models, we argue that the apparent complexity and contradictions in the empirical literature can be attributed to the field's failure to clearly conceptualize AB heterogeneity and the dearth of studies in AB that consider additional cognitive mechanisms in anxiety, particularly disruptions in threat-safety discrimination and cognitive control. We review existing research and propose a working model of AB heterogeneity positing that AB may be best conceptualized as multiple subtypes of dysregulated processing of and attention to threat anchored in individual differences in threat-safety discrimination and cognitive control. We review evidence for this working model and discuss how it can be used to advance knowledge of AB mechanisms and inform personalized prevention and intervention approaches.

Anxiety-Linked Attentional Bias: Is It Reliable?

There is substantial evidence that heightened anxiety vulnerability is characterized by increased selective attention to threatening information. The reliability of this anxiety-linked attentional bias has become the focus of considerable recent interest. We distinguish between the potential inconsistency of anxiety-linked attentional bias and inconsistency potentially reflecting the psychometric properties of the assessment approaches used to measure it. Though groups with heightened anxiety vulnerability often exhibit, on average, elevated attention to threat, the evidence suggests that individuals are unlikely to each display a stable, invariant attentional bias to threat. Moreover, although existing assessment approaches can differentiate between groups, they do not exhibit the internal consistency or test-retest reliability necessary to classify individuals in terms of their characteristic pattern of attentional responding to threat. We discuss the appropriate uses of existing attentional bias assessment tasks and propose strategies for enhancing classification of individuals in terms of their tendency to display an attentional bias to threat.

The Potential of Game-Based Digital Biomarkers for Modeling Mental Health

BACKGROUND

Assessment for mental health is performed by experts using interview techniques, questionnaires, and test batteries and following standardized manuals; however, there would be myriad benefits if behavioral correlates could predict mental health and be used for population screening or prevalence estimations. A variety of digital sources of data (eg, online search data and social media posts) have been previously proposed as candidates for digital biomarkers in the context of mental health. Playing games on computers, gaming consoles, or mobile devices (ie, digital gaming) has become a leading leisure activity of choice and yields rich data from a variety of sources.

OBJECTIVE

In this paper, we argue that game-based data from commercial off-the-shelf games have the potential to be used as a digital biomarker to assess and model mental health and health decline. Although there is great potential in games developed specifically for mental health assessment (eg, Sea Hero Quest), we focus on data gathered "in-the-wild" from playing commercial off-the-shelf games designed primarily for entertainment.

METHODS

We argue that the activity traces left behind by natural interactions with digital games can be modeled using computational approaches for big data. To support our argument, we present an investigation of existing data sources, a categorization of observable traits from game data, and examples of potentially useful game-based digital biomarkers derived from activity traces.

RESULTS

Our investigation reveals different types of data that are generated from play and the sources from which these data can be accessed. Based on these insights, we describe five categories of digital biomarkers that can be derived from game-based data, including behavior, cognitive performance, motor performance, social behavior, and affect. For each type of biomarker, we describe the data type, the game-based sources from which it can be derived, its importance for mental health modeling, and any existing statistical associations with mental health that have been demonstrated in prior work. We end with a discussion on the limitations and potential of data from commercial off-the-shelf games for use as a digital biomarker of mental health.

CONCLUSIONS

When people play commercial digital games, they produce significant volumes of high-resolution data that are not only related to play frequency, but also include performance data reflecting low-level cognitive and motor processing; text-based data that are indicative of the affective state; social data that reveal networks of relationships; content choice data that imply preferred genres; and contextual data that divulge where, when, and with whom the players are playing. These data provide a source for digital biomarkers that may indicate mental health. Produced by engaged human behavior, game data have the potential to be leveraged for population screening or prevalence estimations, leading to at-scale, nonintrusive assessment of mental health.

Home-delivered attention bias modification training via smartphone to improve attention control in sub-clinical generalized anxiety disorder: A randomized, controlled multi-session experiment

BACKGROUND

Mogg and Bradley (2016) proposed that attentional bias (to threat stimuli) among patients with generalized anxiety disorder (GAD) may be associated with the top-down attention control process. Additionally, some scholars (e.g., Enock & McNally, 2013) have designed mobile applications to enable patients to engage in home-delivered attentional bias modification (HD-ABM); however, many problems related to these training systems have not yet been addressed.

METHOD

A total of 82 participants (61 women, mean age = 21.47 y) who received GAD diagnoses were randomly assigned to an HD-ABM (n = 30), placebo training (n = 30), or waiting list (n = 22) group. Both the HD-ABM and placebo groups were trained with the attention training application (through Android phones three times a day for four weeks).

RESULTS

(1) All measures of participants' self-reported symptoms (except for trait anxiety) were significantly lower in Week 4 and in the follow-up. (2) Attentional network test (ANT) results demonstrated that all participants' alerting scores significantly increased by Week 4. (3) Participants in the HD-ABM and placebo groups demonstrated significant increases in their self-reported attention control scores, decreases in their attention bias index (ABI) scores, and progress in their executive control abilities.

LIMITATIONS

Self-report scales may have been insufficient for measuring effectiveness in the present study.

CONCLUSIONS

This study helps to elucidate the mechanism underlying changes in attention processes after HD-ABM training implemented through a mobile application in GAD.

ONYA—The Wellbeing Game: How to Use Gamification to Promote Wellbeing

The Wellbeing Game uses game design elements to promote wellbeing. Players document their daily activities in the game and categorize them to one or more of five wellbeing-related factors. The users join teams and can create team events to work together and improve their wellbeing status. The present study aims to review the application and the theoretical base of ‘The Wellbeing Game’, to adapt it to the German context, and to evaluate its health effects in different settings. Additional aims are to analyze the current state of research regarding the links between health, wellbeing, and gamification and to identify crucial game design elements that have to be implemented in the application in order to address the needs of competence, autonomy, and social relatedness according to the self-determination theory.