Gamified Cognitive Control Training for Remitted Depressed Individuals: User Requirements Analysis

The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: Large-Scale Randomized Controlled Trial

BACKGROUND

With many digital mental health interventions failing to engage clients for enough time to demonstrate substantive changes to their well-being and with only 2% of all digital solutions on app stores having undergone randomized controlled trials, the rising demand for mental health prevention and early intervention care is not being met. Young adults in particular struggle to find digital well-being apps that suit their needs.

OBJECTIVE

This study explored the effects of eQuoo, an evidence-based mental health game that teaches psychological skills through gamification, on resilience, depression, anxiety, and attrition in a student population.

METHODS

In total, 1165 students from 180 universities in the United Kingdom participated in a 5-week, 3-armed randomized controlled trial. Participants were randomly allocated into 1 of 3 groups: eQuoo users, users of a treatment-as-usual evidence-based cognitive behavioral health app called Sanvello, and a no-intervention waitlist. The Rugged Resilience Scale, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-8 were administered to all participants at baseline and every 7 days until completion.

RESULTS

A repeated measures-ANOVA revealed statistically significant increases in resilience scores in the test group (P<.001) compared with both control groups (Sanvello: P=.10 and waitlist: P=.82) over 5 weeks. The app also significantly decreased anxiety and depression scores (both P<.001). With 64.5% (251/389) adherence, the eQuoo group retained 42% more participants than the control groups.

CONCLUSIONS

Digital health interventions such as eQuoo are effective, scalable, and low-cost solutions for supporting young adults and are available on all leading mobile platforms. Further investigation could clarify the extent to which specific elements of the eQuoo app (including gamification) led to better outcomes.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00027638; https://drks.de/search/en/trial/DRKS00027638.

Gamification improves antidepressant effects of cognitive control training-A pilot trial

OBJECTIVE

Computerised cognitive trainings have been put forward to improve control over negatively biased information processing and associated depressive symptomatology. Yet, disease-related impairments of motivation and endurance, as well as insufficient accessibility hinder use of this promising therapeutic opportunity. Here, we developed an app (de:)press^© ) that utilizes a cognitive control training (paced auditory serial addition task) enriched with gamification and information elements. We compared a six-week training with de:)press^© to a non-gamified version (active control group).

METHODS

Thirty-two depressed participants were included. Each received either de:)press^© or the non-gamified version and was instructed to train three times per week for two weeks. Afterwards (four weeks) they were free to train at their own discretion. Depression severity was assessed during training and two follow-up sessions. Primary endpoint was defined as difference between groups [change of Montgomery-Åsberg Depression Rating Scale (MADRS)] four weeks after end of training.

RESULTS

Depression severity decreased in both groups. At primary endpoint, MADRS scores were significantly lower in the de:)press^© -group compared to the control group. No differences were observed at three months' follow-up. Intervention usability was consistently rated positively. Participants who had trained with de:)press^© maintained the recommended training frequency without further prompting. Besides transient fatigue or frustration, no adverse effects were observed.

CONCLUSION

This pilot demonstrates that gamification and information elements can substantially increase cognitive control training efficacy in alleviating depressive symptoms. Moreover, it provides first evidence for the feasibility and efficacy of de:)press^© as an add-on intervention to treat depression.

CLINICAL TRIAL REGISTRATION

The study is registered under ClinicalTrials.gov, identifier: NCT04400162.

Is the combination of behavioral activation and attention training technique effective to reduce depressive symptomatology? A multiple case study

Background

This study tested whether the combination of BATD and Attention Training Technique (ATT) is effective to reduce depressive symptomatology and investigate the mechanisms of action underlying the effectiveness of treatment with a multiple N-of-1 trials.

Methods

Nine adults with depressive symptoms were randomly included in three different combinations of BATD and ATT, concurrent in Condition 1 and sequential in Conditions 2 and 3 (ATT followed by BATD and BATD followed by ATT, respectively). The sequential components allow investigating the specific changes that occur during the two distinct treatment phases. Multiple self-report and pre–post-assessments were conducted on generic mental health measures (depressive symptoms, life functioning, mood, and well-being) and intervention-specific measures (behavioral activation, behavioral avoidance, self-focused attention, cognitive control and rumination), with two-week and three-month follow-up assessments. We also measured treatment adherence with treatment attendance, homework compliance and a clinical interview.

Results

Participants’ attendance, homework compliance and satisfaction were acceptable in the three conditions, with higher adherence in Condition 1 and Condition 3. Eight participants out of nine reported a reduction in depressive symptomatology and five an improvement in well-being. Most of their progress was maintained 2 weeks after the intervention but not 3 months later. Conditions 1 and 2 seemed to be associated with a higher response to generic mental health measures in comparison with Condition 3. The three conditions were not associated with consistent changes in intervention-specific measures, except for rumination with five participants out of nine reporting an improvement in rumination immediately after the intervention and eight participants 2 weeks after the intervention. The concurrent format was associated with a better improvement in rumination immediately after the intervention. No specific changes of self-focused attention and rumination characterized ATT, and no specific changes of behavioral activation, behavioral avoidance and rumination characterized BATD.

Conclusion

Our three interventions were judged acceptable and showed positive short-term benefit for generic mental health measures and rumination maintained 2 weeks later, but not 3 months later. Results suggest that five sessions of concurrent treatment could be a better option than sequential formats. However, our data did not support the specificity of ATT and BATD treatments.

Clinical Trial Registration: This trial was previously registered with the ClinicalTrials.gov NCT04595539 registration number and the title “Does Attention Training Technique Enhance the Effectiveness of Behavioral Activation Treatment for Depression: A Multiple Baseline Study.”

Individual differences associated with treatment adherence and transfer effects following gamified web-based cognitive control training for repetitive negative thinking

Recent research suggests beneficial effects of cognitive control training (CCT) on repetitive negative thinking (RNT), a key risk factor for internalizing symptomatology. However, relatively little is known regarding predictors of adherence to internet-delivered CCT as well as moderators of treatment effects for this intervention. Answering these questions could improve efficiency of clinical implementation of CCT as an eHealth intervention. The current pre-registered single-arm trial set-out to address these questions using a web-based gamified CCT procedure based on the adaptive Paced Auditory Serial Addition Task. Participants (N = 382) entered the internet-based study, where we observed considerable drop-out during the assessment phase and the first training sessions. Emotional stability and resilience emerged as predictors for deciding not to commence the intervention. Drop-out throughout the course of CCT was explained by age, emotion regulation-, and personality factors. We used latent profile analysis, a probabilistic modeling approach, to identify clusters of participants (User Profiles) based on indicators of baseline cognitive- and emotional functioning, training progress, and user experience. We obtained three User Profiles, reflecting low-, moderate-, and high-risk status. Effortful control, emotion regulation, internalizing symptomatology, resilience, and emotional stability played a central role in these User Profiles. Interestingly, User Profile predicted training related cognitive gains, as well as effects of CCT on anxiety- and stress symptoms, and reappraisal. Our findings suggest that CCT is most effective for the moderate- and high-risk groups. In addition, the high-risk group would likely benefit from a more intensive training procedure or repeated administration of the training procedure over time to foster long-term retention of training related gains.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Cognitive bias modification in problem and pathological gambling using a web-based approach-avoidance task: A pilot trial

There is evidence that training addicted participants to implicitly avoid disorder-related stimuli by using a training version of the Approach-Avoidance Task (AAT) results in reduced substance consumption (i.e., Approach Bias Modification [AppBM]). The aim of the present web-based study was to investigate the feasibility and effectiveness of AppBM in reducing gambling-related symptoms. A self-selected sample of participants with problem/pathological slot-machine gambling completed an online survey and received either AppBM or Sham training (final N = 131). Attrition during study participation was high (66%). In both conditions slot-machine related and neutral pictures were presented. Within the AppBM condition all slot-machine related pictures had to be pushed and all neutral pictures had to be pulled, whereas in the Sham condition the contingency was 50:50. Eight weeks after baseline, participants were re-assessed. Both groups showed a similar reduction in gambling-related symptoms. Findings are at odds with the hypothesis claiming that only contingency trainings yield beneficial effects. However, it cannot be ruled out that effects result from other factors unrelated to training such as expectancy effects. We think this study holds valuable information how to conduct larger trials in the future and may prove helpful to improve training and its delivery.