%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e60937 %T Effectiveness of Serious Games as Digital Therapeutics for Enhancing the Abilities of Children With Attention-Deficit/Hyperactivity Disorder (ADHD): Systematic Literature Review %A Lin,Jing %A Chang,Woo-Rin %+ Department of Digital Contents, College of Art and Design, Kyung Hee University, 1732 Deogyeong-daero, Giheung-gu, Yongin-si, 17104, Republic of Korea, 82 01088818489, lastanimator01@gmail.com %K serious games %K ADHD %K attention deficit disorder with hyperactivity %K neurodevelopmental disorders %K digital therapeutics %K DTx %K systematic review %K pediatric %K children %D 2025 %7 6.5.2025 %9 Review %J JMIR Serious Games %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often begins in childhood and requires long-term treatment and management. Given the potential adverse effects of pharmacological interventions in children, interest in alternative treatments has increased. Among alternative therapies, serious games have emerged as a promising digital therapeutic approach and are increasingly recognized as an important intervention for children with ADHD. Objective: This systematic review aims to evaluate the effectiveness of serious games as digital therapeutics for children with ADHD. It focuses on assessing therapeutic outcomes, including improvements in attention, hyperactivity-impulsivity, social skills, motor skills, executive functions, and enjoyment. Methods: The review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive literature search was performed across 5 databases: PubMed, Web of Science, Scopus, IEEE Xplore, and ACM Digital Library, covering English studies published from January 2010 to January 2024. Eligibility criteria were established based on the PICOS (Participants, Intervention, Comparison, Outcomes, Study design) framework, with digital therapeutics guidelines pragmatically applied to inform inclusion criteria, exclusion criteria, and quality assessment. Standardized tools including the Cochrane Risk of Bias Tool for randomized controlled trials, the Cochrane Risk of Bias Tool for Non-Randomized Studies of Interventions (ROBINS-I) for nonrandomized controlled trial studies, and the Critical Appraisal Skills Program checklists were used to evaluate risk of bias. Data on study design, targeted abilities, game software and hardware, and intervention parameters (duration, frequency, and length) were extracted and synthesized descriptively. Results: Of the 35 studies identified (1408 participants), gender data were available for 22 studies (888 participants), comprising 660 male and 228 female participants. Analysis revealed multiple abilities focused across many studies: 80% (28/35) assessed attention, 29% (10/35) addressed hyperactivity-impulsivity, 17% (6/35) explored improvements in social skills, 20% (7/35) evaluated motor skills, and 43% (15/35) investigated executive functions. Furthermore, in 89% (31/35) of the trials, children exhibited a positive attitude toward game interventions. Evidence suggests that serious games may contribute to improvements in attention, hyperactivity-impulsivity, social skills, and executive functions in children with ADHD. Although findings on motor skills were inconclusive, interventions incorporating somatosensory inputs demonstrated benefits for hand-eye coordination. Conclusions: The findings support the potential of serious games as a digital therapeutic modality for children with ADHD, offering benefits in core symptoms and associated impairments while promoting engagement. Trial Registration: PROSPERO CRD420250509693; https://www.crd.york.ac.uk/PROSPERO/view/CRD420250509693 %M 40327858 %R 10.2196/60937 %U https://games.jmir.org/2025/1/e60937 %U https://doi.org/10.2196/60937 %U http://www.ncbi.nlm.nih.gov/pubmed/40327858 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e67418 %T Game Design, Effectiveness, and Implementation of Serious Games Promoting Aspects of Mental Health Literacy Among Children and Adolescents: Systematic Review %A Zeiler,Michael %A Vögl,Sandra %A Prinz,Ursula %A Werner,Nino %A Wagner,Gudrun %A Karwautz,Andreas %A Zeller,Natalie %A Ackermann,Lorenz %A Waldherr,Karin %+ Medical University of Vienna, Department for Child and Adolescent Psychiatry, Waehringer Guertel 18-20, Vienna, 1090, Austria, 43 14040021270, michael.zeiler@meduniwien.ac.at %K serious games %K gamification %K mental health literacy %K game design %K children %K adolescents %K systematic review %K artificial intelligence %D 2025 %7 5.5.2025 %9 Review %J JMIR Ment Health %G English %X Background: The effects of traditional health-promoting and preventive interventions in mental health and mental health literacy are often attenuated by low adherence and user engagement. Gamified approaches such as serious games (SGs) may be useful to reach and engage youth for mental health prevention and promotion. Objective: This study aims to systematically review the literature on SGs designed to promote aspects of mental health literacy among adolescents aged 10 to 14 years, focusing on game design characteristics and the evaluation of user engagement, as well as efficacy, effectiveness, and implementation-related factors. Methods: We searched PubMed, Scopus, and PsycINFO for original studies, intervention development studies, and study protocols that described the development, characteristics, and evaluation of SG interventions promoting aspects of mental health literacy among adolescents aged 10 to 14 years. We included SGs developed for both universal and selected prevention. Using the co.LAB framework, which considers aspects of learning design, game mechanics, and game design, we coded the design elements of the SGs described in the studies. We coded the characteristics of the evaluation studies; indicators of efficacy, effectiveness, and user engagement; and factors potentially fostering or hindering the reach, efficacy and effectiveness, organizational adoption, implementation, and maintenance of the SGs. Results: We retrieved 1454 records through database searches and other sources. Of these, 36 (2.48%) studies describing 17 distinct SGs were included in the review. Most of the SGs (14/17, 82%) were targeted to a universal population of youth, with learning objectives mainly focusing on how to obtain and maintain good mental health and on enhancing help-seeking efficacy. All SGs were single-player games, and many (7/17, 41%) were embedded within a wider pedagogical scenario. Diverse game mechanics and game elements (eg, minigames and quizzes) were used to foster user engagement. Most of the SGs (12/17, 71%) featured an overarching storyline resembling real-world scenarios, fictional scenarios, or a combination of both. The evaluation studies provided evidence for the short-term efficacy and effectiveness of SGs in improving aspects of mental health literacy as well as their feasibility. However, the evidence was mostly based on small samples, and user adherence was sometimes low. Conclusions: The results of this review may inform the future development and implementation of SGs for adolescents. Intervention co-design, the involvement of facilitators (eg, teachers), and the use of diverse game mechanics and customization to meet the needs of diverse users are examples of elements that may promote intervention success. Although there is promising evidence for the efficacy and effectiveness of SGs for promoting mental health literacy in youth, there is a need for more rigorously planned studies, including randomized controlled trials and real-world evaluations, that involve follow-up measures and the assessment of in-game performance alongside self-reports. %M 40324175 %R 10.2196/67418 %U https://mental.jmir.org/2025/1/e67418 %U https://doi.org/10.2196/67418 %U http://www.ncbi.nlm.nih.gov/pubmed/40324175 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65103 %T Testing the Effectiveness of a Gamified Emotional Cognitive Bias Modification Task as an Intervention for Low Mood: Randomized Controlled Trial %A Kuruoğlu,Rumeysa %A Attwood,Angela %A Penton-Voak,Ian %K low mood %K mood %K depression %K depressive %K mental health %K cognitive bias modification %K perceptions %K gamification %K emotion recognition bias %K emotional facial expressions %K emotions %K facial %K expression %K biases %K mental health %D 2025 %7 1.5.2025 %9 %J JMIR Serious Games %G English %X Background: Emotion recognition bias in depression is well-documented and is proposed to play a causal role in depression. A cognitive bias modification (CBM) intervention targeting the bias in emotional expression perception was developed, but despite robust training effects on emotion perception, the effect on mood was unreliable and weak. We propose a new gamified cognitive bias modification (GCBM) to address potential limitations that may attenuate therapeutic effects. Objective: This study aimed to investigate the effectiveness of a single session of GCBM on emotion perception and to assess whether the gamified version of the task would produce the same robust training effects on the interpretation of emotional expressions as the original CBM. The second aim was to compare the effectiveness of a single session of CBM training, CBM control (no training), and GCBM training on immediate mood. Methods: We report a between-subjects fully automated and web-based experimental study that recruited participants via the web from the general population (N=916). We tested the effectiveness of GCBM in changing participants’ responses to ambiguous facial expressions. The primary outcome was emotion recognition bias, measured as the increased identification of happy faces. We also compared the effects of a single session of GCBM training (n=397), CBM training (n=400), and CBM control (n=119) conditions on immediate mood, measured using the Immediate Mood Scaler. Results: Results showed that participants in the GCBM intervention condition classified more ambiguous faces as “happy” after the training compared with controls, indicating an increased perception of happiness in ambiguous faces (B=1.57, P<.001). There was also evidence that GCBM training produced more positive changes in immediate mood compared with the CBM control condition (B=−3.64, P=.003) and compared with the CBM training condition (B=1.69, P=.048). Conclusions: GCBM demonstrated promising results in changing participants’ emotion recognition bias to ambiguous facial expressions and enhance the immediate mood compared with both CBM and control conditions. These results suggest that GCBM holds promise to be a better alternative to CBM for addressing mood-related cognitive biases. Further exploration of GCBM’s long-term effects on mood and its clinical application is needed. %R 10.2196/65103 %U https://games.jmir.org/2025/1/e65103 %U https://doi.org/10.2196/65103 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e67298 %T Relationship Between Within-Session Digital Motor Skill Acquisition and Alzheimer Disease Risk Factors Among the MindCrowd Cohort: Cross-Sectional Descriptive Study %A Hooyman,Andrew %A Huentelman,Matt J %A De Both,Matt %A Ryan,Lee %A Duff,Kevin %A Schaefer,Sydney Y %K digital health technology %K web-based assessment %K aging %K APOE %K motor skills %K sensitivity %K risk factors %K adults %K older adults %D 2025 %7 24.4.2025 %9 %J JMIR Aging %G English %X Background: Previous research has shown that in-lab motor skill acquisition (supervised by an experimenter) is sensitive to biomarkers of Alzheimer disease (AD). However, remote unsupervised screening of AD risk through a skill-based task via the web has the potential to sample a wider and more diverse pool of individuals at scale. Objective: The purpose of this study was to examine a web-based motor skill game (“Super G”) and its sensitivity to risk factors of AD (eg, age, sex, APOE ε4 carrier status, and verbal learning deficits). Methods: Emails were sent to 662 previous MindCrowd participants who had agreed to be contacted for future research and have their APOE ε4 carrier status recorded and those who were at least 45 years of age or older. Participants who chose to participate were redirected to the Super G site where they completed the Super G task using their personal computer remotely and unsupervised. Once completed, different Super G variables were derived. Linear and logistic multivariable regression was used to examine the relationship between available AD risk factors (age, sex, APOE ε4 carrier status, and verbal learning) and distinct Super G performance metrics. Results: Fifty-four participants (~8% response rate) from the MindCrowd web-based cohort (mean age of 62.39 years; 39 females; and 23 APOE ε4 carriers) completed 75 trials of Super G. Results show that Super G performance was significantly associated with each of the targeted risk factors. Specifically, slower Super G response time was associated with being an APOE ε4 carrier (odds ratio 0.12, 95% CI 0.02-0.44; P=.006), greater Super G time in target (TinT) was associated with being male (odds ratio 32.03, 95% CI 3.74-1192,61; P=.01), and lower Super G TinT was associated with greater age (β −3.97, 95% CI −6.64 to −1.30; P=.005). Furthermore, a sex-by-TinT interaction demonstrated a differential relationship between Super G TinT and verbal learning depending on sex (βmale:TinT 6.77, 95% CI 0.34-13.19; P=.04). Conclusions: This experiment demonstrated that this web-based game, Super G, has the potential to be a skill-based digital biomarker for screening of AD risk on a large scale with relatively limited resources. %R 10.2196/67298 %U https://aging.jmir.org/2025/1/e67298 %U https://doi.org/10.2196/67298 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66167 %T Digital Ergonomics of NavegApp, a Novel Serious Game for Spatial Cognition Assessment: Content Validity and Usability Study %A Sanchez-Escudero,Juan Pablo %A Aguillon,David %A Valencia,Stella %A Garcia-Barrera,Mauricio A %A Aguirre-Acevedo,Daniel Camilo %A Trujillo,Natalia %+ Group of Epidemiology, Universidad de Antioquia, Calle 70 No. 52-21, Medellín, Colombia, 57 6042198332, juanp.sanchez@udea.edu.co %K serious games %K spatial cognition %K digital neuropsychology %K Alzheimer disease %K content validity %K usability %D 2025 %7 2.4.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Alzheimer disease (AD) is the leading cause of dementia worldwide. With aging populations and limited access to effective treatments, there is an urgent need for innovative markers to support timely preventive interventions. Emerging evidence highlights spatial cognition (SC) as a valuable source of cognitive markers for AD. This study presents NavegApp, a serious game (SG) designed to assess 3 key components of SC, which show potential as cognitive markers for the early detection of AD. Objective: This study aimed to determine the content validity and usability perception of NavegApp across multiple groups of interest. Methods: A multistep process integrating methodologies from software engineering, psychometrics, and health measurement was implemented to validate the software. Our approach was structured into 3 stages, guided by the software life cycle for health and the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations for evaluating the psychometric quality of health instruments. To assess content validity, a panel of 8 experts evaluated the relevance and representativeness of tasks included in the app. In addition, 212 participants, categorized into 5 groups based on their clinical status and risk level for AD, were recruited to evaluate the app’s digital ergonomics and usability at various stages of development. Complementary analyses were performed to identify group differences and to explore the association between task difficulty and user agreeableness. Results: NavegApp was validated as a highly usable tool by both experts and users. The expert panel confirmed that the tasks included in the game were representative (Aiken V=0.96-1.00) and relevant (Aiken V=0.96-1.00) for measuring SC components. Both experts and nonexperts rated NavegApp’s digital ergonomics positively, with minimal differences between groups (rrb 0.08-0.29). Differences in usability perceptions were observed among participants with sporadic mild cognitive impairment compared to cognitively healthy individuals (rrb 0.26-0.29). A moderate association was also identified between task difficulty and user agreeableness (Cramér V=0.37, 95% CI 0.28-0.54). Conclusions: NavegApp is a valid and user-friendly SG designed for SC assessment, developed by integrating software engineering and psychometric evaluation methodologies. While the results are promising, further studies are warranted to evaluate its diagnostic accuracy and construct validity. This work outlines a comprehensive framework for SG development in cognitive assessment, emphasizing the importance of incorporating psychometric validity measures from the outset of the design process. %M 40173437 %R 10.2196/66167 %U https://games.jmir.org/2025/1/e66167 %U https://doi.org/10.2196/66167 %U http://www.ncbi.nlm.nih.gov/pubmed/40173437 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e64068 %T Escape Game to Promote Students’ Mental Health Outcomes in the Aftermaths of COVID-19 Pandemic: Protocol for a Mixed Methods Study Evaluating a Cocreated Intervention %A Labrosse,David %A Vié,Clara %A Harb,Mireille %A Montagni,Ilaria %+ Bordeaux Population Health U1219, Inserm, University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 05 47 30 42 80, ilaria.montagni@u-bordeaux.fr %K Escape game %K pilot randomized controlled trial %K Covid-19 %K cocreation %K students %K mobile phone %D 2025 %7 2.4.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 pandemic and the protracted lockdowns have heavily impacted university students’ mental health. Digital Escape Games represent a good means to reach students and propose them solutions for their psychological well-being. Objective: This study aimed to evaluate a cocreated digital Escape Game on students’ mental health in the aftermath of the COVID-19 pandemic, called EscapeCovid Game. The evaluation of the effectiveness of this stand-alone intervention concerns mental health outcomes (mental health literacy, appraisal and change of beliefs about mental health, management of emotions, and development of coping strategies) and the appreciation and relevance of the game. Methods: A randomized controlled trial with pre- and posttest data collection (online questionnaires with validated scales) is conducted among 500 students in Bordeaux, France, to evaluate the EscapeCovid Game cocreated with students, researchers, health professionals, and web developers. A subsample of students is randomly selected for responding to a semistructured interview following a mixed methods design. Recruitment is done through mail invitations from student associations and presentations in university classes. Half of the sample of the trial plays the Escape Game, while the other half receives an email with mental health–related information. Within the game, students discuss their personal experiences. The text is further used for the qualitative analyses. The whole study is carried out online. Results: The EscapeCovid Game has been developed, tested, and finalized by the end of March 2023. As of November 4, 2024, a total of 191 students have answered the baseline questionnaire (90 intervention vs 101 control). A total of 23 students have played the game and 53 are in the control arm. Among participants, by the end of September 20, 2023, twenty were interviewed (10 intervention and 10 control) reaching sample saturation. According to preliminary results, the EscapeCovid Game has had a positive impact on all defined outcomes, while the email has been effective in increasing knowledge on resources available and on coping strategies and meditation techniques. We expect the trial to be completed by the end of June 2025. Conclusions: The mixed methods findings of this study are due to demonstrate the effectiveness of the EscapeCovid Game in improving students’ mental health outcomes. Preliminary results from the qualitative substudy are promising: in the aftermath of the COVID-19 crisis, this intervention is intended to promote players’ mental health through gamification, knowledge transfer, and a learning-by-doing approach. Trial Registration: ClinicalTrials.gov NCT06720792; https://clinicaltrials.gov/study/NCT06720792 International Registered Report Identifier (IRRID): DERR1-10.2196/64068 %M 40173436 %R 10.2196/64068 %U https://www.researchprotocols.org/2025/1/e64068 %U https://doi.org/10.2196/64068 %U http://www.ncbi.nlm.nih.gov/pubmed/40173436 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e56978 %T Gamified Adaptive Approach Bias Modification in Individuals With Methamphetamine Use History From Communities in Sichuan: Pilot Randomized Controlled Trial %A Shen,Danlin %A Jiao,Jianping %A Zhang,Liqun %A Liu,Yanru %A Liu,Xiang %A Li,Yuanhui %A Zhang,Tianjiao %A Li,Dai %A Hao,Wei %K digital therapeutics %K substance use disorder %K game %K pilot RCT %K randomized controlled trial %K methamphetamine %K psychiatric %K gamified design %K engagement %K effectiveness %K smartphone app %K cognitive bias modification %D 2025 %7 10.3.2025 %9 %J JMIR Serious Games %G English %X Background: Cognitive bias modification (CBM) programs have shown promise in treating psychiatric conditions, but they can be perceived as boring and repetitive. Incorporating gamified designs and adaptive algorithms in CBM training may address this issue and enhance engagement and effectiveness. Objectives: This study aims to gather preliminary data and assess the preliminary efficacy of an adaptive approach bias modification (A-ApBM) paradigm in reducing cue-induced craving in individuals with methamphetamine use history. Methods: A randomized controlled trial with 3 arms was conducted. Individuals aged 18‐60 years with methamphetamine dependence and at least 1 year of methamphetamine use were recruited from 12 community-based rehabilitation centers in Sichuan, China. Individuals with the inability to fluently operate a smartphone and the presence of mental health conditions other than methamphetamine use disorder were excluded. The A-ApBM group engaged in ApBM training using a smartphone app for 4 weeks. The A-ApBM used an adaptive algorithm to dynamically adjust the difficulty level based on individual performance. Cue-induced craving scores and relapses were assessed using a visual analogue scale at baseline, postintervention, and at week-16 follow-up. Results: A total of 136 participants were recruited and randomized: 48 were randomized to the A-ApBM group, 48 were randomized to the static approach bias modification (S-ApBM) group, and 40 were randomized to the no-intervention control group. The A-ApBM group showed a significant reduction in cue-induced craving scores at postintervention compared with baseline (Cohen d=0.34; P<.01; 95% CI 0.03-0.54). The reduction remained significant at the week-16 follow-up (Cohen d=0.40; P=.01; 95% CI 0.18-0.57). No significant changes were observed in the S-ApBM and control groups. Conclusions: The A-ApBM paradigm with gamified designs and dynamic difficulty adjustments may be an effective intervention for reducing cue-induced craving in individuals with methamphetamine use history. This approach improves engagement and personalization, potentially enhancing the effectiveness of CBM programs. Further research is needed to validate these findings and explore the application of A-ApBM in other psychiatric conditions. Trial Registration: ClinicalTrials.gov NCT05794438; https://clinicaltrials.gov/study/NCT05794438 %R 10.2196/56978 %U https://games.jmir.org/2025/1/e56978 %U https://doi.org/10.2196/56978 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65562 %T Effects of a Session of Exergames and Traditional Games on Inhibitory Control in Children With Autism Spectrum Disorder: Randomized Controlled Crossover Trial %A Miranda,Juliana Macedo %A Browne,Rodrigo Alberto Vieira %A da Silva,Weslley Quirino Alves %A Rodrigues dos Santos,João Paulo %A Campbell,Carmen Silvia Grubert %A Ramos,Isabela Almeida %K children %K pediatric %K autism %K ASD, autistic %K behavior %K exergame %K physical education %K exercise %K physical activity %K cognition %K anthropometric %K Flanker test %K inhibitory control %K randomized control trial %K crossover %D 2025 %7 5.3.2025 %9 %J JMIR Serious Games %G English %X Background: Autism spectrum disorder (ASD) is characterized by deficits in executive functions, such as inhibitory control, which affect behavior and social adaptation. Although physical activity–based interventions, such as exergames, have shown potential to improve these functions, their comparative effects with active traditional games remain underexplored, particularly regarding inhibitory control in children with ASD. Objective: We aim to analyze the effects of a session of exergames and active traditional games on inhibitory control in children with ASD. Methods: This randomized controlled crossover trial included 9 male children with ASD (mean age 8.6, SD 1.4 y). Participants completed three 20-minute experimental sessions in random order, with a minimum interval of 48 hours: (1) active traditional games, (2) exergames using Just Dance 2022, and (3) a control session with manual painting activities. Inhibitory control was assessed 5 minutes postsession using a modified flanker task in the E-Prime (version 3.0; Psychological Software Tools Inc) program, recording reaction time (RT) and accuracy in congruent and incongruent phases. Repeated measures ANOVA was used to compare RT and accuracy between experimental and control conditions. Data are presented as means and 95% CIs. Results: There was a statistically significant effect of condition on RT in the incongruent phase (P=.02). RT in the exergame session (849 ms, 95% CI 642 to 1057) was lower compared to the traditional games (938 ms, 95% CI 684 to 1191; P=.02) and control (969 ms, 95% CI 742, 1196 to P=.01) sessions. No significant differences were observed in RT during the congruent phase or in accuracy across either phase. Conclusions: A 20-minute session of exergame improved inhibitory control performance in children with ASD compared to active traditional games and painting activities. Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) RBR-5r9xzbq, Universal Trial Number U1111-1302-3490; https://ensaiosclinicos.gov.br/rg/RBR-5r9xzbq %R 10.2196/65562 %U https://games.jmir.org/2025/1/e65562 %U https://doi.org/10.2196/65562 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67000 %T Diaphragmatic Breathing Interfaces to Promote Relaxation for Mitigating Insomnia: Pilot Study %A Lai,Yi-Jen %A Chiu,Hsiao-Yean %A Wu,Ko-Chiu %A Chang,Chun-Wei %+ , Department of Interaction Design, National Taipei University of Technology, Rm. 701-4, Design Building,, No.1 Sec.3 Zhongxiao E Rd, Da'an District, Taipei, 10608, Taiwan, 886 02 2771 2171 ext 4574, kochiuwu@mail.ntut.edu.tw %K brief behavioral treatment for insomnia %K sleep self-efficacy %K mobile health %K mHealth %K breathing training cognitive load %K attention %K gamification %K diaphragmatic breathing %K insomnia %K sleep %K games %K relaxation %K breathing %K breathing guidance %K questionnaire %K mental %K cognition %D 2025 %7 4.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Brief behavioral treatment for insomnia is an effective short-term therapy focusing on stimulus control and sleep restriction to enhance sleep quality. As a crucial part of this therapy, diaphragmatic breathing is often recommended when patients fail to fall asleep within 30 minutes. With the rise of health apps and gamification, these tools are increasingly seen as effective ways to boost self-efficacy and user engagement; however, traditional games tend to increase attention, which can negatively impact sleep and contradicts the aim of sleep therapy. This study thus explored the potential for gamification techniques to promote relaxation without disrupting sleep processes. Objective: The study developed 4 breathing guidance mechanisms, ranging from concrete to abstract: number countdown, zoom-in/out, up/down, and color gradients. The objective was to explore the relationship between game mechanics, cognitive load, relaxation effects, and attention as well as to understand how different designs impact users with varying levels of insomnia. Methods: The study was conducted in 2 phases. The first phase involved a questionnaire on the 4 guidance mechanisms. In the second phase, 33 participants classified by insomnia severity completed a Sleep Self-Efficacy Scale. They then engaged in 5 minutes of diaphragmatic breathing using each of the 4 interfaces. Relaxation effects were measured using heart rate variability via a smartwatch, attention and relaxation levels via an electroencephalogram device, and respiratory rate via a smartphone. Participants also completed the Game Experience Questionnaire and NASA Task Load Index, followed by user interviews. Results: The results indicated that competence, immersion, and challenge significantly influenced cognitive load. Specifically, competence and immersion reduced cognitive load, while challenge, negative affect, and positive affect were correlated with relaxation. Negative affect showed a positive correlation with the mean root mean square of successive differences, while positive affect exhibited a negative correlation with the mean root mean square of successive differences. Cognitive load was found to affect both relaxation and attention, with a negative correlation between mental demand and attention and a positive correlation between temporal demand and respiratory rate. Sleep self-efficacy was negatively correlated with temporal demand and negative affect and positively correlated with competence and immersion. Conclusions: Interfaces offering moderate variability and neither overly abstract nor too concrete guidance are preferable. The up/down interface was most effective, showing the best overall relaxation effect. Conversely, the number countdown interface was stress-inducing, while the zoom-in/out interface had a significant impact on insomnia-related issues, making them less suitable for insomnia-related breathing exercises. Participants showed considerable variability in their response to the color gradient interface. These findings underscore the importance of carefully considering game design elements in relaxation training. It is essential that breathing guidance designs account for the impact of the game experience to effectively promote relaxation in users. %M 40053714 %R 10.2196/67000 %U https://games.jmir.org/2025/1/e67000 %U https://doi.org/10.2196/67000 %U http://www.ncbi.nlm.nih.gov/pubmed/40053714 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67338 %T Reward Feedback Mechanism in Virtual Reality Serious Games in Interventions for Children With Attention Deficits: Pre- and Posttest Experimental Control Group Study %A Fang,Hao %A Fang,Changqing %A Che,Yan %A Peng,Xinyuan %A Zhang,Xiaofan %A Lin,Di %+ , Engineering Research Center for Big Data Application in Private Health Medicine of Fujian Universities, Putian University, No. 1133, Xueyuan Middle Street, Chengxiang District, Putian, 351100, China, 86 15959234669, lindi1015@163.com %K serious games %K virtual reality %K attention deficit %K inhibitory control ability %K reward feedback %D 2025 %7 24.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) serious games, due to their high level of freedom and realism, influence the rehabilitation training of inhibitory control abilities in children with attention-deficit/hyperactivity disorder (ADHD). Although reward feedback has a motivating effect on improving inhibitory control, the effectiveness and differences between various forms of rewards lack empirical research. Objective: This study aimed to investigate the effectiveness of different forms of reward feedback on the inhibitory control abilities of children with attention deficits in a VR serious game environment. Methods: This study focuses on children who meet the diagnostic criteria for ADHD tendencies, using a 2 (material rewards: coin reward and token reward) × 2 (psychological rewards: verbal encouragement and badge reward) factorial between-subject design (N=84), with a control group (n=15) for pre- and posttest experiments. The experimental group received VR feedback reinforcement training, while the control group underwent conventional VR training without feedback. The training period lasted 0.5 months, with each intervention session lasting 25 minutes, occurring twice daily with an interval of at least 5 hours for 28 sessions. Before and after training, the Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) Scale, stop signal task, inhibition conflict task, and Simon task were administered to assess the hyperactivity index and the 3 components of inhibitory control ability. The pretest included the SNAP-IV Scale and 3 task tests to obtain baseline data; the posttest involved repeating the above tests after completing all training. Data were entered and analyzed using SPSS (IBM) software. Independent sample t tests were performed on the experimental and control groups’ pre- and posttest task results to determine whether significant differences existed between group means. Paired sample t tests were also conducted on the SNAP-IV Scale’s pre- and posttest results to assess the intervention effect’s significance. Results: Reward feedback was more effective than no reward feedback in improving behaviors related to attention deficits in children. Material rewards showed significant effects in the Stop-Signal Task (F1=13.04, P=.001), Inhibition Conflict Task (F1=7.34, P=.008), and SNAP-IV test (F1=69.23, P<.001); mental rewards showed significant effects in the Stop-Signal Task (F1=38.54, P<.001) and SNAP-IV test (F1=70.78, P<.001); the interaction between the 2 showed significant effects in the Stop-Signal Task (F1=4.47, P=.04) and SNAP-IV test (F1=23.85, P<.001). Conclusions: Combining material and psychological rewards within a VR platform can effectively improve attention-deficit behaviors in children with ADHD, enhancing their inhibitory control abilities. Among these, coin rewards are more effective than token rewards, and verbal encouragement outperforms badge rewards. The combined feedback of coin rewards and verbal encouragement yields the most significant improvement in inhibitory control abilities. %M 39993290 %R 10.2196/67338 %U https://games.jmir.org/2025/1/e67338 %U https://doi.org/10.2196/67338 %U http://www.ncbi.nlm.nih.gov/pubmed/39993290 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e57201 %T Evaluating the Effectiveness of InsightApp for Anxiety, Valued Action, and Psychological Resilience: Longitudinal Randomized Controlled Trial %A Amo,Victoria %A Lieder,Falk %+ Max Planck Institute for Intelligent Systems, Max-Planck-Ring 8, Tübingen, 72076, Germany, 49 15730645508, victoria.amo@tuebingen.mpg.de %K ecological momentary intervention %K serious game %K mindfulness-based intervention %K acceptance and commitment therapy %K cognitive behavioral therapy %K metacognition %K stress %K anxiety %K mobile phone %D 2025 %7 4.2.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Anxiety disorders are among the most prevalent mental disorders, and stress plays a significant role in their development. Ecological momentary interventions (EMIs) hold great potential to help people manage stress and anxiety by training emotion regulation and coping skills in real-life settings. InsightApp is a gamified EMI and research tool that incorporates elements from evidence-based therapeutic approaches. It is designed to strengthen people’s metacognitive skills for coping with challenging real-life situations and embracing anxiety and other emotions. Objective: This randomized controlled trial aims to examine the effectiveness of InsightApp in (1) improving individuals’ metacognitive strategies for coping with stress and anxiety and (2) promoting value-congruent action. It also evaluates how long these effects are retained. This experiment advances our understanding of the role of metacognition in emotional and behavioral reactivity to stress. Methods: We conducted a randomized controlled trial with 228 participants (completion rate: n=197, 86.4%; mean age 38, SD 11.50 years; age range 20-80 years; female: n=101, 52.6%; and White: n=175, 91.1%), who were randomly assigned to either the treatment or the active placebo control group. During the 1-week intervention phase, the treatment group engaged with InsightApp, while participants in the control group interacted with a placebo version of the app that delivered executive function training. We assessed the differences between the 2 groups in posttest and follow-up assessments of mental health and well-being while controlling for preexisting differences. Moreover, we used a multilevel model to analyze the longitudinal data, focusing on the within-participant causal effects of the intervention on emotional and behavioral reactivity to daily stressors. Specifically, we measured daily anxiety, struggle with anxiety, and value-congruent action. Results: The intervention delivered by InsightApp yielded mixed results. On one hand, we found no significant posttest scores on mental health and well-being measures directly after the intervention or 7 days later (all P>.22). In contrast, when confronted with real-life stress, the treatment group experienced a 15% lower increase in anxiety (1-tailed t test, t197=–2.4; P=.009) and a 12% lower increase in the struggle with anxiety (t197=–1.87; P=.031) than the control group. Furthermore, individuals in the treatment group demonstrated a 7% higher tendency to align their actions with their values compared to the control group (t197=3.23; P=.002). After the intervention period, InsightApp’s positive effects on the struggle with anxiety in reaction to stress were sustained, and increased to an 18% lower reactivity to stress (t197=–2.84; P=.002). Conclusions: As our study yielded mixed results, further studies are needed to obtain an accurate and reliable understanding of the effectiveness of InsightApp. Overall, our findings tentatively suggest that guiding people to apply adaptive metacognitive strategies for coping with real-life stress daily with a gamified EMI is a promising approach that deserves further evaluation. Trial Registration: OSF Registries osf.io/k3b5d; https://osf.io/k3b5d %M 39904504 %R 10.2196/57201 %U https://mental.jmir.org/2025/1/e57201 %U https://doi.org/10.2196/57201 %U http://www.ncbi.nlm.nih.gov/pubmed/39904504 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e59154 %T Considering Comorbidities and Individual Differences in Testing a Gaming Behavioral Activation App for Perinatal Depression and Anxiety: Open Trial Pilot Intervention Study %A Hamlett,Gabriella E %A Schrader,Chloe %A Ferguson,Craig %A Kobylski,Lauren A %A Picard,Rosalind %A Locascio,Joseph J %A McNally,Richard J %A Cohen,Lee S %A Vanderkruik,Rachel %K perinatal anxiety %K perinatal depression %K behavioral activation %K digital mental health %K mobile phone %D 2025 %7 14.1.2025 %9 %J JMIR Form Res %G English %X Background: There is increasing interest in the development of scalable digital mental health interventions for perinatal populations to increase accessibility. Mobile behavioral activation (BA) is efficacious for the treatment of perinatal depression; however, the effect of comorbid anxiety and depression (CAD) on symptom trajectories remains underexplored. This is important given that at least 10% of women in the perinatal period experience CAD. Objective: We assessed whether there were differences in symptom trajectories in pregnant participants with CAD as compared to those with depression only (ie, major depressive disorder [MDD]) during intervention with a BA mobile gaming app. Methods: Pregnant adults with either CAD (n=10) or MDD (n=7) used a BA app for 10 weeks and completed biweekly symptom severity questionnaires for depression and anxiety. We assessed whether baseline diagnoses were associated with differential symptom trajectories across the study with mixed effects longitudinal models. Results: When controlling for baseline symptoms, results revealed a significant interaction between baseline diagnosis and the quadratic component of study week on anxiety (β=.18, SE 0.07; t62=2.61; P=.01), revealing a tendency for anxiety in the CAD group to increase initially and then decrease at an accelerated rate, whereas MDD symptoms were relatively stable across time. There was a significant effect of linear time on depression (β=−.39, SE 0.11; t68=−3.51; P=.001), showing that depression declined steadily across time for both groups. There was a significant effect of baseline diagnosis on depression (β=−8.53, SE 3.93; t13=−2.17; P=.05), suggesting that those with MDD had higher follow-up depression compared to those with CAD when holding other predictors constant. Conclusions: The app was beneficial in reducing depression symptoms in perinatal individuals with different comorbidity profiles. With respect to anxiety symptom trajectories, however, there was more variability. The app may be especially effective for the treatment of anxiety symptoms among individuals with CAD, as it encourages in-the-moment ecologically relevant exposure to anxiety-provoking stimuli. Despite no significant group difference in baseline anxiety symptoms, the MDD group did not have a significant reduction in their anxiety symptoms across the study period, and some individuals had an increase in anxiety. Findings may point to opportunities for the augmentation of BA gaming apps for those with MDD to more effectively target anxiety symptoms. Overall, findings suggest there may be value in considering comorbidities and individual variations in participants when developing scalable mobile interventions for perinatal populations. %R 10.2196/59154 %U https://formative.jmir.org/2025/1/e59154 %U https://doi.org/10.2196/59154 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e59124 %T Effectiveness of a Virtual Reality Serious Video Game (The Secret Trail of Moon) for Emotional Regulation in Children With Attention-Deficit/Hyperactivity Disorder: Randomized Clinical Trial %A Martin-Moratinos,Marina %A Bella-Fernández,Marcos %A Rodrigo-Yanguas,María %A González-Tardón,Carlos %A Li,Chao %A Wang,Ping %A Royuela,Ana %A Lopez-Garcia,Pilar %A Blasco-Fontecilla,Hilario %+ Health Sciences and School of Doctoral Programs, International University of La Rioja, Avda de la Paz, 137, Logroño, 26006, Spain, 34 910149575, hilariomanuel.blasco@unir.net %K attention-deficit/hyperactivity disorder %K ADHD %K emotional regulation %K serious video games %K virtual reality %K cognitive training %K music %K chess %D 2025 %7 8.1.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Difficulties in emotional regulation are often observed in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Innovative complementary treatments, such as video games and virtual reality, have become increasingly appealing to patients. The Secret Trail of Moon (MOON) is a serious video game developed by a multidisciplinary team featuring cognitive training exercises. In this second randomized clinical trial, we evaluated the impact of a 20-session treatment with MOON on emotional regulation, as measured by the Strengths and Difficulties Questionnaire. Objective: We hypothesize that patients with ADHD using MOON will show improvements in (1) emotional regulation, (2) core ADHD symptoms, (3) cognitive functioning, and (4) academic performance, compared to a control group; additionally, we anticipate that (5) changing the platform (from face-to-face using virtual reality to the web) will not affect emotional regulation scores; and (6) the video game will not cause any clinically significant side effects. Methods: This was a prospective, unicentric, randomized, unblinded, pre- and postintervention study with block-randomized sequence masking. Participants included individuals aged between 7 and 18 years who had a clinical diagnosis of ADHD and were receiving pharmacological treatment. They were randomized into 2 groups using an electronic case report form: the MOON group, receiving standard pharmacological treatment plus personalized cognitive training via a serious video game, and the control group, receiving standard pharmacological treatment. We provided both the groups with psychoeducational support on ADHD. Analysis was conducted using the Student 2-tailed t test and 2-factor ANOVA. An independent monitor supervised the study. Results: A total of 76 patients with ADHD participated in the trial, with an equal randomization (MOON: n=38, 50% and control: n=38, 50%) and a total dropout rate of 7. The primary hypothesis, a 3- or 4-point reduction in the global Strengths and Difficulties Questionnaire score, was not met. However, significant improvements were observed in material organization (P=.03), working memory (P=.04), and inhibition (P=.05), particularly among patients more engaged with the MOON treatment. Conclusions: Serious video games, when integrated into a multimodal treatment plan, can enhance outcomes for symptoms associated with ADHD. Trial Registration: ClinicalTrials.gov NCT06006871; https://clinicaltrials.gov/study/NCT06006871 International Registered Report Identifier (IRRID): RR2-10.2196/53191 %M 39773848 %R 10.2196/59124 %U https://games.jmir.org/2025/1/e59124 %U https://doi.org/10.2196/59124 %U http://www.ncbi.nlm.nih.gov/pubmed/39773848 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e56663 %T Use of 4 Open-Ended Text Responses to Help Identify People at Risk of Gaming Disorder: Preregistered Development and Usability Study Using Natural Language Processing %A Strojny,Paweł %A Kapela,Ksawery %A Lipp,Natalia %A Sikström,Sverker %+ Faculty of Management and Social Communication, Jagiellonian University, Łojasiewicza 4, Krakow, 30-348, Poland, 48 12 664 5582, p.strojny@uj.edu.pl %K gaming disorder %K natural language processing %K machine learning %K mental health %K NLP %K text %K open-ended %K response %K risk %K psychological %K Question-based Computational Language Assessment %K QCLA %K transformers-based %K language model analysis %K Polish %K Pearson %K correlation %K Python %D 2024 %7 31.12.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Words are a natural way to describe mental states in humans, while numerical values are a convenient and effective way to carry out quantitative psychological research. With the growing interest of researchers in gaming disorder, the number of screening tools is growing. However, they all require self-quantification of mental states. The rapid development of natural language processing creates an opportunity to supplement traditional rating scales with a question-based computational language assessment approach that gives a deeper understanding of the studied phenomenon without losing the rigor of quantitative data analysis. Objective: The aim of the study was to investigate whether transformer-based language model analysis of text responses from active gamers is a potential supplement to traditional rating scales. We compared a tool consisting of 4 open-ended questions formulated based on the clinician's intuition (not directly related to any existing rating scales for measuring gaming disorders) with the results of one of the commonly used rating scales. Methods: Participants recruited using an online panel were asked to answer the Word-Based Gaming Disorder Test, consisting of 4 open-ended questions about gaming. Subsequently, they completed a closed-ended Gaming Disorders Test based on a numerical scale. Of the initial 522 responses collected, we removed a total of 105 due to 1 of 3 criteria (suspiciously low survey completion time, providing nonrelevant or incomplete responses). Final analyses were conducted on the responses of 417 participants. The responses to the open-ended questions were vectorized using HerBERT, a large language model based on Google's Bidirectional Encoder Representations from Transformers (BERT). Last, a machine learning model, specifically ridge regression, was used to predict the scores of the Gaming Disorder Test based on the features of the vectorized open-ended responses. Results: The Pearson correlation between the observable scores from the Gaming Disorder test and the predictions made by the model was 0.476 when using the answers of the 4 respondents as features. When using only 1 of the 4 text responses, the correlation ranged from 0.274 to 0.406. Conclusions: Short open responses analyzed using natural language processing can contribute to a deeper understanding of gaming disorder at no additional cost in time. The obtained results confirmed 2 of 3 preregistered hypotheses. The written statements analyzed using the results of the model correlated with the rating scale. Furthermore, the inclusion in the model of data from more responses that take into account different perspectives on gaming improved the performance of the model. However, there is room for improvement, especially in terms of supplementing the questions with content that corresponds more directly to the definition of gaming disorder. Trial Registration: OSF Registries osf.io/957nz; https://osf.io/957nz %M 39739378 %R 10.2196/56663 %U https://games.jmir.org/2024/1/e56663 %U https://doi.org/10.2196/56663 %U http://www.ncbi.nlm.nih.gov/pubmed/39739378 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e59381 %T A Narrative-Gamified Mental Health App (Kuamsha) for Adolescents in Uganda: Mixed Methods Feasibility and Acceptability Study %A R Pozuelo,Julia %A Nabulumba,Christine %A Sikoti,Doreen %A Davis,Meghan %A Gumikiriza-Onoria,Joy Louise %A Kinyanda,Eugene %A Moffett,Bianca %A van Heerden,Alastair %A O'Mahen,Heather A %A Craske,Michelle %A , %A Sulaiman,Munshi %A Stein,Alan %+ Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Ln, Headington, Oxford, OX3 7JX, United Kingdom, 44 01865618200, julia_ruizpozuelo@hms.harvard.edu %K adolescents %K mental health %K Uganda %K gamified app %K digital interventions %K mobile phone %K user-centered design %K low- and middle-income countries %D 2024 %7 19.12.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many adolescents in Uganda are affected by common mental disorders, but only a few affordable treatment options are available. Digital mental health interventions offer promising opportunities to reduce these large treatment gaps, but interventions specifically tailored for Ugandan adolescents are limited. Objective: This study aimed to determine the feasibility and acceptability of the Kuamsha program, an intervention delivered through a gamified app with low-intensity telephonic guidance, as a way to promote mental health among adolescents from the general population in Uganda. Methods: A 3-month pre-post single-arm trial was conducted with adolescents aged between 15 and 19 years living in Wakiso District, Central Uganda. The intervention was coproduced with adolescents from the study site to ensure that it was culturally acceptable. The feasibility and acceptability of the intervention were evaluated using an explanatory sequential mixed methods approach. Feasibility was assessed by collecting data on trial retention rates and treatment adherence rates. Acceptability was assessed through a questionnaire and in-depth interviews with participants following the conclusion of the intervention period. As a secondary objective, we explored the changes in participants’ mental health before and after the intervention. Results: A total of 31 adolescents were recruited for the study. Results from the study showed high levels of feasibility and acceptability. Trial retention rates exceeded 90%, and treatment adherence was ≥80%. These results, evaluated against our predefined trial progression criteria, indicate a successful feasibility study, with all criteria exceeding the thresholds necessary to progress to a larger trial. App engagement metrics, such as time spent on the app and modules completed, exceeded existing literature benchmarks, and many adolescents continued to use the app after the intervention. In-depth interviews and questionnaire responses revealed high acceptability levels. Depressive symptoms trended toward reduction (mean difference: 1.41, 95% CI –0.60 to 3.42, Cohen d=0.30), although this was not statistically significant (P=.16). Supporting this trend, we also observed a reduction in the proportion of participants with moderate depressive symptoms from 32% (10/31) to 17% (5/29) after the intervention, but this change was also not significant (P=.10). Conclusions: This study presents evidence to support the Kuamsha program as a feasible and acceptable digital mental health program for adolescents in Uganda. A fully powered randomized controlled trial is needed to assess its effectiveness in improving adolescents’ mental health. %M 39700489 %R 10.2196/59381 %U https://games.jmir.org/2024/1/e59381 %U https://doi.org/10.2196/59381 %U http://www.ncbi.nlm.nih.gov/pubmed/39700489 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63760 %T Open-World Games’ Affordance of Cognitive Escapism, Relaxation, and Mental Well-Being Among Postgraduate Students: Mixed Methods Study %A Anto,Ailin %A Basu,Arunima %A Selim,Rania %A Foscht,Thomas %A Eisingerich,Andreas Benedikt %+ Faculty of Medicine, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2AZ, United Kingdom, 44 020 7589 5111, ailin.anto18@imperial.ac.uk %K open-world games %K cognitive escapism %K relaxation %K mental well-being %K students %K video games %K stress %K freedom to explore %D 2024 %7 17.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Open-world games, characterized by their expansive and interactive environments, may offer unique cognitive escapism opportunities, potentially leading to relaxation and enhanced well-being. These games, such as “The Legend of Zelda: Breath of the Wild” and “The Legend of Zelda: Tears of the Kingdom,” allow players to experience a sense of freedom and autonomy, which can reduce stress and improve mental health. While previous research has examined the general impact of video games on mental well-being, specific studies on the effects of open-world games among postgraduate students are limited. Objective: This study aims to investigate the relationships between cognitive escapism provided by open-world games and their effects on relaxation and well-being. The goal was to understand how the immersive nature of these games contributes to stress reduction and overall mental health improvement among postgraduate students. Methods: A mixed methods approach was used, which involved in-depth exploratory qualitative interviews and a survey of 609 players of popular open-world games. Quantitative data were collected using standardized questionnaires to measure open-world games’ affordance of cognitive escapism, relaxation, and well-being. Qualitative data were obtained through 32 in-depth interviews that explored players’ experiences and perceptions of cognitive escapism, relaxation, and mental well-being. Results: Qualitative data (n=32; n=15, 47% female; n=16, 50% male; n=1, 3% preferred not to disclose gender; mean age 23.19, SD 2.19 y) revealed that cognitive escapism through immersive game worlds allowed players to temporarily disconnect from real-world stressors, resulting in enhanced mood and psychological well-being. Players indicated that the nonlinear gameplay and freedom to explore interactive environments provided a sense of relaxation and mental rejuvenation. Quantitative analysis (N=609) showed a substantial mediating role of relaxation in the relationship between cognitive escapism offered by open-world games and well-being. Specifically, cognitive escapism had a significant positive effect on players’ relaxation (β=.15; SE 0.04; P<.001; 95% CI 0.0695-0.2331), which in turn had a significant and positive effect on players’ well-being scores (β=.12; SE 0.04; P=.002; 95% CI 0.0445-0.2032). Conclusions: The study demonstrates that open-world games offer substantial benefits for cognitive escapism, significantly improving relaxation and well-being among postgraduate students. The immersive and autonomous nature of these games is crucial in reducing stress and enhancing mental health. Future research may investigate the long-term effects of regular engagement with open-world games and explore their potential therapeutic applications for managing stress and anxiety. %M 39689301 %R 10.2196/63760 %U https://www.jmir.org/2024/1/e63760 %U https://doi.org/10.2196/63760 %U http://www.ncbi.nlm.nih.gov/pubmed/39689301 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56598 %T High-Frequency Cognitive Control Training for Depression: Case Report %A Vander Zwalmen,Yannick %A Hoorelbeke,Kristof %A Demeester,David %A Koster,Ernst H W %+ Department of Experimental Clinical and Health Psychology, Ghent University, Henri Dunantlaan 2, Ghent, 9000, Belgium, 32 92649107, y.vander.zwalmen@ugent.be %K cognitive control training %K CCT %K cognitive function %K depression %K recurrence %K relapse %K prevention %K case report %K working memory %K memory training %K task performance %K digital health %D 2024 %7 29.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Cognitive control training (CCT) has gained attention in recent years as a preventative intervention in the context of major depressive disorder. To date, uncertainty exists around the working mechanisms of CCT and how its effects unfold overtime. Objective: This study aimed to examine cognitive and affective transfer effects following an unusually high number of training sessions. Methods: This case report presents data of a participant completing a large amount of training sessions (n=55) over the course of 1 year in 2 training phases: 10 initial sessions, followed by 45 additional sessions. Reliable change indices were calculated for several self-report questionnaires, measuring cognitive and affective functioning. Results: Cognitive task performance suggests improved cognitive functioning after training (accuracy scores increased from 43/181, 24% at baseline to 110/181, 61% shortly after training), which was maintained at follow-up (accuracy scores around 50%). Reliable change indices suggest a decrease in depressive symptoms (Beck Depression Inventory-II score decreased from 23 at baseline to 3 following initial training). Similarly, burnout symptoms following CCT showed a similar decrease. Maladaptive emotion regulation strategies displayed high variability, decreasing after periods of training but increasing when no training was performed. However, no changes in repetitive negative thinking were observed. Thematic analysis from an in-depth interview focusing on CCT adherence and user experience pointed to the importance of independency and accessibility of CCT in perceived agency, as well as the need for clear feedback mechanisms following training. Conclusions: Training task performance indicates further increases in performance beyond typical amounts of training sessions (10-20 sessions), hinting that more sessions could be beneficial for continued improvement in cognitive functioning. In line with previous research, CCT decreased depressive symptomatology. However, its effects on emotion regulation remain unclear. Further mechanistic studies into the temporal unfolding of CCT effects are necessary to investigate potential working mechanisms. Trial Registration: ClinicalTrials.gov NCT05166798; https://clinicaltrials.gov/study/NCT05166798 %M 39612206 %R 10.2196/56598 %U https://formative.jmir.org/2024/1/e56598 %U https://doi.org/10.2196/56598 %U http://www.ncbi.nlm.nih.gov/pubmed/39612206 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56201 %T Facilitating Thought Progression to Reduce Depressive Symptoms: Randomized Controlled Trial %A Yatziv,Shai-Lee %A Pedrelli,Paola %A Baror,Shira %A DeCaro,Sydney Ann %A Shachar,Noam %A Sofer,Bar %A Hull,Sunday %A Curtiss,Joshua %A Bar,Moshe %+ The Leslie and Susan Gonda Brain Science Center, Bar- Ilan University Building number 901, Ramat-Gan, 5290002, Israel, 972 35317795, moshe.bar@biu.ac.il %K depression %K cognitive neuroscience %K facilitating thought progression %K FTP %K mobile phone %K digital health %K gamification %K depression symptoms %K randomized controlled trial %K RCT %K app %K depressive disorder %K web-based platforms %K effectiveness %D 2024 %7 7.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: The constant rise in the prevalence of major depressive disorder calls for new, effective, and accessible interventions that can rapidly and effectively reach a wide range of audiences. Recent developments in the digital health domain suggest that dedicated online platforms may potentially address this gap. Focusing on targeting ruminative thought, a major symptomatic hallmark of depression, in this study we hypothesized that delivering a digital health–based intervention designed to systematically facilitate thought progression would substantially alleviate depression. Objective: The study aims to investigate the efficacy of a novel digital intervention on the reduction of depressive symptoms. This intervention was designed as an easy-to-use gamified app specifically aimed to facilitate thought progression through intense practicing of associative, semantically broad, fast, and creative thought patterns. Methods: A randomized clinical trial was conducted, comparing changes in depression symptoms between participants who used the app in the intervention group (n=74) and waitlist control group (n=27) over the course of 8 weeks. All participants filled out a battery of clinical questionnaires to assess the severity of depression at baseline and 4 and 8 weeks after starting the study. These primarily included the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 as well as the Positive Affect Negative Affect Scale-Negative Affect Score, Ruminative Response Scale, and Symptoms of Depression Questionnaire. Additional questionnaires were implemented to assess anxiety, positive affect, anhedonia, and quality of life. Results: The results indicate that across multiple clinical measurements, participants in the intervention group who played the gamified app showed greater and faster improvement in depressive symptoms compared with their waitlist control counterparts. The difference between the groups in MADRS improvement was –7.01 points (95% CI –10.72 to –3.29; P<.001; Cohen d=0.67). Furthermore, the difference in improvement between groups persisted up to 4 weeks posttrial (MADRS differences at week 12: F49,2=6.62; P=.003; ηp2=0.21). At the end of the trial, participants who played the app showed high interest in continuing using the app. Conclusions: The results demonstrate that a gamified app designed to facilitate thought progression is associated with improvement in depressive symptoms. Given its innovative and accessibility features, this gamified method aiming to facilitate thought progression may successfully complement traditional treatments for depression in the future, providing a safe and impactful way to enhance the lives of individuals experiencing depression and anxiety. Trial Registration: ClinicalTrials.gov NCT05685758; https://clinicaltrials.gov/study/NCT05685758 %M 39350528 %R 10.2196/56201 %U https://www.jmir.org/2024/1/e56201 %U https://doi.org/10.2196/56201 %U http://www.ncbi.nlm.nih.gov/pubmed/39350528 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e54082 %T Acceptability of a Serious Game About Proton Radiotherapy Designed for Children Aged 5 to 14 Years and Its Potential Impact on Perceived Anxiety: Feasibility and Randomized Controlled Pilot Trial %A Cederved,Catarina %A Ljungman,Gustaf %A Back,Jon %A Ångström-Brännström,Charlotte %A Engvall,Gunn %K anxiety %K feasibility %K acceptability %K pediatric oncology %K psychological preparation %K proton radiotherapy %K serious game %K games %K cancer %D 2024 %7 23.9.2024 %9 %J JMIR Serious Games %G English %X Background: Children who are going to undergo radiotherapy have displayed fear and anxiety. Therefore, a web-based serious game was developed as a psychological preparation to investigate if it could affect anxiety levels. In an earlier stage, children with experience of radiotherapy had been part of the developmental process. Objective: The study aimed to investigate the feasibility in terms of reach, usability, and acceptability of a serious game about proton radiotherapy and to pilot that it did not increase anxiety levels in children aged 5 to 14 years undergoing radiotherapy. Methods: The design was a randomized controlled pilot trial with predefined feasibility criteria. In total, 28 children were assessed for eligibility, and 23 met the inclusion criteria. They were consecutively randomized into 1 of 2 study arms. One child was excluded after randomization. If randomized into arm 1, the children received the intervention before treatment started. Children in arm 2 were treated as controls. Questionnaires with fixed answers were used to assess anxiety levels (an adapted version of the State-Trait Anxiety Inventory for Children) and experiences of gameplay (an adapted version of Player Experience of Need Satisfaction [PENS]). The children were asked to answer questionnaires at 5 different measurement occasions during their radiotherapy treatment. Results: In arm 1, age ranged from 5 to 13 (mean 8.4, SD 2.4) years. In arm 2, age ranged from 5 to 11 (mean 7.6, SD 2.3) years. The sample consisted of 15 girls and 7 boys. The feasibility criterion that the children should play the game for 20 minutes or more was not met. Mean playtime for children in arm 1 was 32.1 (SD 23.8) minutes, where 18 children had played for at least 15 minutes. The criterion that 70% (n=16) or more of the participants should return all of the questionnaires was not met; however, more than 73% (n=16) returned the PENS questionnaires. The State-Trait Anxiety Inventory for Children was returned by 73% (n=16) on day 0, 77% (n=17) on day 1, 82% (n=18) on day 3, 82% (n=18) on day 6, and 86% (n=19) on day 15. Conclusions: All feasibility criteria set for the study were not met, suggesting that adaptions need to be made if a future study is to be undertaken. Further, the analysis revealed that there was no indication that playing increased the children’s self-reported anxiety. The PENS questionnaire adapted for children showed promising results regarding player satisfaction when using the serious game. When studying children with severe conditions and young age, 5 measurement occasions seemed to be too many. Measuring both player satisfaction or experience and knowledge transfer would be preferable in future studies. Trial Registration: ClinicalTrials.gov NCT04728555; https://clinicaltrials.gov/study/NCT04728555 %R 10.2196/54082 %U https://games.jmir.org/2024/1/e54082 %U https://doi.org/10.2196/54082 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e55785 %T Effects of Electronic Serious Games on Older Adults With Alzheimer’s Disease and Mild Cognitive Impairment: Systematic Review With Meta-Analysis of Randomized Controlled Trials %A Zuo,Xinyi %A Tang,Yong %A Chen,Yifang %A Zhou,Zhimiao %+ Sociology Department, School of Government, Shenzhen University, 1066 Xueyuan Avenue, Nanshan District, Shenzhen, Guangdong, 518055, China, 86 13670191924, tangyong@szu.edu.cn %K digital serious games %K cognitive ability %K daily behavioral capacity %K mental health %K depression %K older adults with AD and MCI %K AD %K Alzheimer’s disease %K MD %K mild cognitive impairment %K systematic review %K meta-analysis %D 2024 %7 31.7.2024 %9 Review %J JMIR Serious Games %G English %X Background: Serious games (SGs) are nonpharmacological interventions that are widely applied among older adults. To date, no evidence has been published regarding the effect of digital SGs on cognitive ability, daily behavioral capacity, or depression in older adults with Alzheimer’s disease (AD) and mild cognitive impairment (MCI). Objective: This study aimed to assess the effect of SGs on older adults with AD and MCI by summarizing and pooling the results of previous studies. Methods: This meta-analysis examined the effectiveness of digital SGs in improving cognitive ability, enhancing daily behavioral capacity, and alleviating depression in older adults with AD and MCI. We searched the following databases up to December 31, 2023, to identify relevant high-quality randomized controlled trials (RCTs): PubMed, Embase, Web of Science, Scopus, and Cochrane Library. Stata 15.1 and Review Manager 5.3 were used to screen the 14 studies, extract data, code the data, and perform meta-analysis. Mean differences and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables. The Cochrane risk-of-bias assessment tool was used to evaluate the risk of bias. Eligibility criteria were developed in accordance with the Population, Intervention, Comparison, Outcomes, and Study Design framework: (1) population (older adults with AD and MCI), (2) intervention (digital SG intervention), (3) comparison (digital SG intervention vs routine health care), (4) outcomes (cognitive ability, daily behavioral capacity, and depression), and (5) study or research design (RCT). Sensitivity analysis was performed, and a funnel plot was constructed. Results: From January 2017 to December 2023, we enrolled 714 individuals across 14 RCTs, with 374 (52.4%) in the severe game group using digital SGs and 340 (47.6%) in the control group using traditional methods. The results of our meta-analysis indicated that using digital SGs in older adults with AD and MCI is more effective than traditional training methods in several key areas. Specifically, digital SG therapy significantly increased cognitive ability, as found in the Mini-Mental State Examination (SMD 2.11, 95% CI 1.42-2.80; P<.001) and the Montreal Cognitive Assessment (SMD 2.75, 95% CI 1.98-3.51; P<.001), significantly increased daily behavioral capacity (SMD 0.53, 95% CI 0.06-0.99; P=.03), and significantly reduced depression (SMD –2.08, 95% CI –2.94 to –1.22; P<.001) in older adults with AD and MCI. No publication bias was detected based on the results of Begg and Egger tests. Conclusions: Digital SGs offer a viable and effective nonpharmacological approach for older adults with AD and MCI, yielding better results compared to traditional formats. However, caution is warranted in interpreting these findings due to limited RCTs, small sample sizes, and low-quality meta-analyzed evidence. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRDCRD42023486090; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=486090 %R 10.2196/55785 %U https://games.jmir.org/2024/1/e55785 %U https://doi.org/10.2196/55785 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e59197 %T Experience of Youths and Older People With Virtual Reality Games for Cognitive Assessment: Inductive Thematic Analysis and Insights for Key Stakeholders %A Bhargava,Yesoda %A Baths,Veeky %+ Cognitive Neuroscience Lab, Department of Biological Sciences, Birla Institute of Technology and Science, Pilani - K. K. Birla Campus, NH 17B, Bypass, Road, Zuarinagar, Sankval, Goa, 403726, India, 91 9823764987, veeky@goa.bits-pilani.ac.in %K virtual reality %K cognitive assessment games %K inductive thematic analysis %K youth %K older adult %K cognitive %K cognitive assessment %K virtual reality games %K game %K games %K thematic analysis %K neurological %K utility %K cognitive assessment tools %K game based %K cognitive games %D 2024 %7 28.6.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR)–based goal-oriented games for cognitive assessment are rapidly emerging and progressively being used in neuropsychological settings. These games have been validated quantitatively, but minimal qualitative insights from users currently exist. Such insights on user experience are essential to answering critical questions linked to the games’ large-scale usability, adoption in hospital settings, and game design refinement. Current qualitative studies on these games have used general questionnaires or web-based reviews to answer these questions, but direct observation from primary settings is missing. We believe that direct observation of participants playing these games and subsequent interaction with them is critical to developing a more objective, clear, and unbiased view of the games’ efficacy, usability, and acceptability. Objective: In this study, we aimed to extract constructive and relevant insights directly from the participants who played VR-based goal-oriented games. We used these insights to answer vital questions linked to the practical utility of VR-based cognitive assessment. On the basis of these results, we also aimed to provide actionable insights to key stakeholders in the field, such as researchers, game developers, business personnel, and neuropsychology and allied professionals. Methods: Interview data from 82 younger (aged 18-28 years) and 42 older adult (aged >60 years) participants were used. The interview data were obtained from the 2 pilot studies we conducted on VR games for cognitive assessment. Inductive thematic analysis was conducted on the interview data, and later, the findings were carefully interpreted to develop implications for the key stakeholders. Results: We identified 5 themes: ergonomic issues, learning and training, postgame effects, game feedback, and system purpose. Regarding hardware, headset weight, adjustment straps, and controllers need to be improved to promote easy use of the device. Regarding software, graphics quality, immersion experience, and game mechanics are the primary deciding factors for a positive user experience. The younger group prioritized purpose and utility for long-term use, whereas the older participants cherished the entertainment aspect. Researchers and game developers must conceptualize and develop games that can provide maximum insights into real-world abilities. Manufacturing businesses need to improve the headset and accessories to make them more user-friendly. Finally, neuropsychology and allied practitioners must identify strategies to engage and train the participants to try VR-based cognitive assessment games. Conclusions: VR-based games for cognitive assessment are promising tools to improve the current practices of neuropsychological evaluations; however, a few changes are required to make the overall user experience enjoyable, purposeful, and sustainable. In addition, all the key stakeholders need to focus on meaning and purpose over the hype of VR and are advised to work in synergy. %R 10.2196/59197 %U https://xr.jmir.org/2024/1/e59197 %U https://doi.org/10.2196/59197 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e47513 %T Effects of a Serious Game for Adolescent Mental Health on Cognitive Vulnerability: Pilot Usability Study %A De Jaegere,Eva %A van Heeringen,Kees %A Emmery,Peter %A Mommerency,Gijs %A Portzky,Gwendolyn %K e-health %K cognitive psychology %K cognitive distortion %K cognitive vulnerability %K digital health %K serious games %K adolescent mental health %K prototype %K adolescent %K prevention %K eHealth %D 2024 %7 9.5.2024 %9 %J JMIR Serious Games %G English %X Background: Adolescent mental health is of utmost importance. E-mental health interventions, and serious games in particular, are appealing to adolescents and can have beneficial effects on their mental health. A serious game aimed at improving cognitive vulnerability (ie, beliefs or attitudes), which can predispose an individual to mental health problems, can contribute to the prevention of these problems in adolescents. Objective: This study aimed to assess the feasibility of the prototype of a serious game called “Silver.” Methods: The prototype of the serious game was developed using a user-centered participatory design. The prototype of Silver focused on 1 aspect of a serious game for improving cognitive vulnerability in adolescents, that is, the recognition and identification of cognitive distortions. Through the game, players were required to identify and classify the character’s thoughts as helpful or unhelpful. Upon successful advancement to the next level, the task becomes more challenging, as players must also identify specific types of cognitive distortions. A pre- and posttest uncontrolled design was used to evaluate the game, with a 1-week intervention phase in which participants were asked to play the game. Participants aged 12-16 years were recruited in schools. The outcomes of interest were the recognition of cognitive distortions and presence of participants’ cognitive distortions. The game was also evaluated on its effects, content, and usefulness. Results: A total of 630 adolescents played Silver and completed the assessments. Adolescents were significantly better at recognizing cognitive distortions at the pretest (mean 13.09, SD 4.08) compared to the posttest (mean 13.82, SD 5.09; t629=−4.00, P<.001). Furthermore, their cognitive distortions decreased significantly at the posttest (mean 38.73, SD 12.79) compared to the pretest (mean 41.43, SD 10.90; t629=7.98, P<.001). Participants also indicated that the game helped them recognize cognitive distortions. Many participants considered the game appealing (294/610, 48.2%) but boring (317/610, 52%) and preferred a more comprehensive game (299/610, 49%). Conclusions: Findings from this study suggest that a serious game may be an effective tool for improving cognitive vulnerability in adolescents. The development of such a serious game, based on the prototype, is recommended. It may be an important and innovative tool for the universal prevention of mental health problems in adolescents. Future research on the effects of the game is warranted. %R 10.2196/47513 %U https://games.jmir.org/2024/1/e47513 %U https://doi.org/10.2196/47513 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e57714 %T Therapeutic Uses of Gaming in Mental Health: An Untapped Potential %A Eckardt,Jens Peter %+ Bedre Psykiatri Research Unit (Videnscenter), Gammeltorv 14. 2 sal, Copenhagen, 1457, Denmark, 45 28943288, jp-mail@hotmail.com %K digital mental health interventions %K mental health %K psychiatry %K gaming %K serious games %K casual video games %K commercial games %K exergames %K adolescent %K anxiety %K teenage %K video game %K youth %D 2024 %7 25.4.2024 %9 Letter to the Editor %J JMIR Serious Games %G English %X %M 38662422 %R 10.2196/57714 %U https://games.jmir.org/2024/1/e57714 %U https://doi.org/10.2196/57714 %U http://www.ncbi.nlm.nih.gov/pubmed/38662422 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48545 %T An Escape Game on University Students’ Mental Health During the COVID-19 Pandemic: Cocreation Study %A Labrosse,David %A Vié,Clara %A Hajjam,Hana %A Tisseron,Clément %A Thellier,Dimitri %A Montagni,Ilaria %+ University of Bordeaux, Inserm, Bordeaux Population Health Research Center U1219, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 06 42 19 33 63, ilaria.montagni@u-bordeaux.fr %K students %K game %K mental health %K COVID-19 %K cocreation %K university student %K promote %K psychological well-being %K effective tool %K tool %K acceptability %K testing %K questionnaire %K learning %K motivation %K user centered %D 2024 %7 18.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The COVID-19 pandemic has had a severe impact on students’ mental health. Interventions are needed to promote their psychological well-being and prevent mental illnesses in the aftermath of this unprecedented situation. Digital escape games can be an effective tool to support students’ mental health. A cocreation approach can improve the acceptability of these interventions by involving different stakeholders (eg, end users, game designers, and health professionals) to obtain audience-specific games. Objective: This study aims to describe the process of testing and optimizing the game “EscapeCovid” on students’ mental health, to serve as a model for the cocreation of future similar interventions. Methods: The PRODUCES (Problem, Objective, Design, End Users, Cocreators, Evaluation, Scalability) framework was used. Cocreation steps (test and optimization) were detailed for replicability. A total of 45 students tested a pilot version of the game, with 10 undergoing a semistructured interview. Meetings with a group of stakeholders and brainwriting were organized to optimize the game. Results: We produced a new version of the game incorporating the suggestions provided by student testers and following the stakeholders’ guidelines. Improvements were made to both the content and the form of the new version of the pilot game. The storyline, including the protagonist and the scenes, was adapted to the student population. Conclusions: Our results suggested that cocreation can contribute to the design of more widely accepted interventions aimed at promoting mental health and preventing psychological disorders. Results also suggest that an end user–centered approach can facilitate intervention tailoring. When conceiving a health-related escape game for students, we recommend using the cocreation approach to enhance players’ experience, thus positively influencing their learning process and overall well-being. %M 38498033 %R 10.2196/48545 %U https://games.jmir.org/2024/1/e48545 %U https://doi.org/10.2196/48545 %U http://www.ncbi.nlm.nih.gov/pubmed/38498033 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53191 %T Effectiveness of a Serious Video Game (MOON) for Attention Deficit Hyperactivity Disorder: Protocol for a Randomized Clinical Trial %A Martin-Moratinos,Marina %A Bella-Fernández,Marcos %A Rodrigo-Yanguas,Maria %A González-Tardón,Carlos %A Sújar,Aaron %A Li,Chao %A Wang,Ping %A Royuela,Ana %A Lopez-Garcia,Pilar %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Puerta de Hierro University Hospital, Health Research Institute Puerta de Hierro-Segovia de Arana, Avenida Manuel de Falla 1, Majadahonda, Madrid, Spain, 28222, Spain, 34 911916019, hmblasco@yahoo.es %K attention deficit hyperactivity disorder %K ADHD %K emotional dysregulation %K serious video games %K virtual reality %K cognitive training %K music %K chess %K attention deficit hyperactivity disorder %K video game %K video games %K children %K child %K adolescents %K adolescent %K teen %K teens %K emotional regulation %K neurodevelopmental disorder %K multimodal treatment %K intervention %K motivational tools %D 2024 %7 23.2.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood and adolescence, with a prevalence of 5% and associated difficulties and worse prognosis if undetected. Multimodal treatment is the treatment of choice. However, sometimes treatment can be insufficient or have drawbacks. Objective: This study protocol aims to demonstrate the effectiveness of cognitive training through the serious video game The Secret Trail of Moon (MOON) in improving emotional regulation in people with ADHD. Methods: This is a prospective, unicenter, randomized, unblinded, pre- and postintervention study. The groups will be randomized (MOON vs control) via an electronic case report form. The MOON intervention will be performed 2 times per week for 10 weeks (30 minutes per session). The first 5 weeks (10 sessions) will be conducted face-to-face at the Puerta de Hierro University Hospital, and the remaining weeks will be conducted via the internet at the participants’ homes. The total sample consists of 152 patients aged between 7 and 18 years. All participants have a clinical diagnosis of ADHD under pharmacological treatment. Data collection will be used to obtain demographic and clinical data. The data will be recorded using REDCap. Measures will be made through clinical scales for parents and objective tests of cognitive functioning in patients. Additional information on academic performance will be collected. The study has a power greater than 80% to detect differences. Student t test, 2-factor analysis of variance (ANOVA), and Mann-Whitney analyses will be performed according to each variable’s characteristics. Results: The study was approved by the Research Ethics Committee of the Puerta de Hierro University Hospital on December 14, 2022. As of September 26, 2023, we have enrolled 62 participants, and 31 participants have completed the study. This clinical trial was funded by the Comunidad de Madrid (IND2020/BMD-17544). The approximate completion date is March 2024. Conclusions: Serious video games such as MOON can be motivational tools that complement multimodal treatment for ADHD. Trial Registration: ClinicalTrials.gov; NCT06006871; https://clinicaltrials.gov/study/NCT06006871 International Registered Report Identifier (IRRID): DERR1-10.2196/53191 %M 38393773 %R 10.2196/53191 %U https://www.researchprotocols.org/2024/1/e53191 %U https://doi.org/10.2196/53191 %U http://www.ncbi.nlm.nih.gov/pubmed/38393773 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e46697 %T A Novel Casual Video Game With Simple Mental Health and Well-Being Concepts (Match Emoji): Mixed Methods Feasibility Study %A Pine,Russell %A Mbinta,James %A Te Morenga,Lisa %A Fleming,Theresa %+ School of Health, Victoria University of Wellington, Kelburn Parade, Kelburn, Wellington, 6012, New Zealand, 64 4 472 1000, russell.pine@vuw.ac.nz %K adolescent %K anxiety %K casual video games %K digital mental health interventions %K gaming %K mental health %K micro interventions %K serious game %K teenage %K video game %K youth %D 2024 %7 12.2.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adolescence is a crucial phase for early intervention and prevention of mental health problems. Casual video games are popular and have promise as a novel mechanism for reaching young people, but this potential has seldom been explored. Objective: This study aimed to explore the acceptability, feasibility, and possible indicators of therapeutic changes after playing a purpose-built novel casual video game (Match Emoji) with simple mental health and well-being content among young adolescents. Methods: We conducted a single-arm, nonrandomized trial of Match Emoji with 12- to 14-year-old school students (N=45; 26 [57%] New Zealand European, 12 [26%] Māori; 7 [15%] Asian or Pacific; 27 [60%] boys, 3 [6%] non-binary). Participants were invited to play Match Emoji for 15 minutes, 2-3 times a week over 2 weeks (a total of 60 minutes). Acceptability was assessed through the frequency and duration of use (analytics analyzed at the end of the 2-week intervention period and at weeks 4 and 6) and through participant reports. The Child and Adolescent Mindfulness Measure (CAMM), General Help-Seeking Questionnaire (GHSQ), Flourishing Scale (FS), and Revised Children’s Anxiety and Depression Scale (RCADS) were assessed at baseline and week 2 to indicate possible effects. Focus groups were held in week 4. Results: Most participants (n=39, 87%) used Match Emoji for at least 60 minutes over the 2-week intervention, with 80% (36/45) continuing to play the game after the intervention period. Mean change (from baseline to 2 weeks) on each measure was 1.38 (95% CI –0.03 to 2.79; P=.06) for CAMM; 0.8 (95% CI –2.71 to 4.31; P=.64) for GHSQ; –1.09 (95% CI –2.83 to 0.66; P=.21) for FS; and –3.42 (95% CI –6.84 to –0.001; P=0.49) for RCADS. Focus group feedback suggested that Match Emoji was enjoyable and helpful. Conclusions: The casual video game with mental health content appeared to be acceptable and provided a promising indication of possible therapeutic effects. This approach is worthy of further investigation. International Registered Report Identifier (IRRID): RR2-10.2196/31588 %M 38345848 %R 10.2196/46697 %U https://games.jmir.org/2024/1/e46697 %U https://doi.org/10.2196/46697 %U http://www.ncbi.nlm.nih.gov/pubmed/38345848 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e44029 %T Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study %A Vanderkruik,Rachel C %A Ferguson,Craig %A Kobylski,Lauren A %A Locascio,Joseph J %A Hamlett,Gabriella E %A Killenberg,Parker C %A Lewis,Robert %A Jones,Noah %A Rossa,Ella T %A Dineen,Hannah %A Picard,Rosalind %A Cohen,Lee S %+ Center for Women's Mental Health, Massachusetts General Hospital, 185 Cambridge St, Ste 2200, Boston, MA, 02114, United States, 1 781 691 9071, rvanderkruik@mgh.harvard.edu %K perinatal depression %K pregnancy %K behavioral activation %K mobile app %K digital intervention %K mobile phone %D 2024 %7 26.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services. Objective: The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms. Methods: This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews. Results: The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (β=−.35; t61=−3.05; P=.003), number of activities completed (β=−.12; t61=−2.05; P=.04), days played (β=−.12; t58=−2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (β=−3.05; t45=−2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications. Conclusions: Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression. %M 38277191 %R 10.2196/44029 %U https://formative.jmir.org/2024/1/e44029 %U https://doi.org/10.2196/44029 %U http://www.ncbi.nlm.nih.gov/pubmed/38277191 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e46990 %T Identifying Game-Based Digital Biomarkers of Cognitive Risk for Adolescent Substance Misuse: Protocol for a Proof-of-Concept Study %A Aneni,Kammarauche %A Chen,Ching-Hua %A Meyer,Jenny %A Cho,Youngsun T %A Lipton,Zachary Chase %A Kher,Saatvik %A Jiao,Megan G %A Gomati de la Vega,Isabella %A Umutoni,Feza Anaise %A McDougal,Robert A %A Fiellin,Lynn E %+ Child Study Center, Yale School of Medicine, 230 S Frontage Road, New Haven, CT, 06519, United States, 1 844 362 9272, uche.aneni@yale.edu %K game-based digital biomarkers %K cognition %K adolescent substance misuse %K cognitive risk factors %K game-based measurement of cognitive function %K biomarker %K adolescent %K screening %K game %K barrier %K digital %K substance %K use %K misuse %D 2023 %7 23.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents at risk for substance misuse are rarely identified early due to existing barriers to screening that include the lack of time and privacy in clinic settings. Games can be used for screening and thus mitigate these barriers. Performance in a game is influenced by cognitive processes such as working memory and inhibitory control. Deficits in these cognitive processes can increase the risk of substance use. Further, substance misuse affects these cognitive processes and may influence game performance, captured by in-game metrics such as reaction time or time for task completion. Digital biomarkers are measures generated from digital tools that explain underlying health processes and can be used to predict, identify, and monitor health outcomes. As such, in-game performance metrics may represent digital biomarkers of cognitive processes that can offer an objective method for assessing underlying risk for substance misuse. Objective: This is a protocol for a proof-of-concept study to investigate the utility of in-game performance metrics as digital biomarkers of cognitive processes implicated in the development of substance misuse. Methods: This study has 2 aims. In aim 1, using previously collected data from 166 adolescents aged 11-14 years, we extracted in-game performance metrics from a video game and are using machine learning methods to determine whether these metrics predict substance misuse. The extraction of in-game performance metrics was guided by literature review of in-game performance metrics and gameplay guidebooks provided by the game developers. In aim 2, using data from a new sample of 30 adolescents playing the same video game, we will test if metrics identified in aim 1 correlate with cognitive processes. Our hypothesis is that in-game performance metrics that are predictive of substance misuse in aim 1 will correlate with poor cognitive function in our second sample. Results: This study was funded by National Institute on Drug Abuse through the Center for Technology and Behavioral Health Pilot Core in May 2022. To date, we have extracted 285 in-game performance metrics. We obtained institutional review board approval on October 11, 2022. Data collection for aim 2 is ongoing and projected to end in February 2024. Currently, we have enrolled 12 participants. Data analysis for aim 2 will begin once data collection is completed. The results from both aims will be reported in a subsequent publication, expected to be published in late 2024. Conclusions: Screening adolescents for substance use is not consistently done due to barriers that include the lack of time. Using games that provide an objective measure to identify adolescents at risk for substance misuse can increase screening rates, early identification, and intervention. The results will inform the utility of in-game performance metrics as digital biomarkers for identifying adolescents at high risk for substance misuse. International Registered Report Identifier (IRRID): DERR1-10.2196/46990 %M 37995115 %R 10.2196/46990 %U https://www.researchprotocols.org/2023/1/e46990 %U https://doi.org/10.2196/46990 %U http://www.ncbi.nlm.nih.gov/pubmed/37995115 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e40190 %T The Relationship Between Lockdowns and Video Game Playtime: Multilevel Time-Series Analysis Using Massive-Scale Data Telemetry %A Zendle,David %A Flick,Catherine %A Halgarth,Darel %A Ballou,Nick %A Cutting,Joe %A Drachen,Anders %+ Department of Computer Science, University of York, Heslington Way, York, YO10 5GH, United Kingdom, 44 1904320000, david.zendle@york.ac.uk %K COVID-19 %K lockdown policy %K disordered gaming %K big data %K playtime %K policy %K lockdown %K public health %K side effects %K pandemic %K video games %K playing %K gaming %K time %K disordered %D 2023 %7 8.11.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: COVID-19 led governments worldwide to enact a variety of containment and closure policies. Substantial attention has been directed toward the idea that these public health measures may have unanticipated negative side effects. One proposed effect relates to video games. There is a nascent evidence base suggesting that individuals played video games for longer and in a more disordered manner during lockdowns and school closures specifically. These increases are commonly framed as a potential health concern in relation to disordered gaming. However, the evidence base regarding changes in gaming during the COVID-19 pandemic is based on self-report and, thus, is susceptible to bias. Therefore, it is unclear what the true consequences of lockdowns were for gaming behavior worldwide. Objective: The primary objective of this study was to estimate whether any specific lockdown policy led to meaningful increases in the amount of time individuals spent playing video games. Methods: Rather than relying on self-report, we used >251 billion hours of raw gameplay telemetry data from 184 separate countries to assess the behavioral correlates of COVID-19–related policy decisions. A multilevel model estimated the impact of varying enforcement levels of 8 containment and closure policies on the amount of time that individual users spent in-game. Similar models estimated the impact of policy on overall playtime and the number of users within a country. Results: No lockdown policy can explain substantial variance in playtime per gamer. School closures were uniquely associated with meaningful increases in total playtime within a country (r2=0.048). However, this was associated with increases in the number of unique individuals playing games (r2=0.057) rather than increases in playtime per gamer (r2<0.001). Conclusions: Previous work using self-report data has suggested that important increases in heavy gaming may occur during pandemics because of containment and closure (“lockdown”) procedures. This study contrasts with the previous evidence base and finds no evidence of such a relationship. It suggests that significant further work is needed before increases in disordered or heavy gaming are considered when planning public health policies for pandemic preparedness. %M 37938889 %R 10.2196/40190 %U https://www.jmir.org/2023/1/e40190 %U https://doi.org/10.2196/40190 %U http://www.ncbi.nlm.nih.gov/pubmed/37938889 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46912 %T A Video Game Intervention to Prevent Opioid Misuse Among Older Adolescents: Development and Preimplementation Study %A Aneni,Kammarauche %A Fernandes,Claudia-Santi F %A Hoerner,Lily A %A Szapary,Claire %A Pendergrass Boomer,Tyra M %A Fiellin,Lynn E %+ Department of Internal Medicine, Yale University School of Medicine, 2 Church Street South, Suite 515, New Haven, CT, 06519, United States, 1 203 785 2885, lynn.sullivan@yale.edu %K videogames %K serious games %K opioid misuse %K mental health %K adolescents %D 2023 %7 3.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Opioid misuse and mental disorders are highly comorbid conditions. The ongoing substance misuse and mental health crises among adolescents in the United States underscores the importance of widely scalable substance misuse preventive interventions that also address mental health risks. Serious video games offer an engaging, widely scalable method for delivering and implementing preventive interventions. However, there are no video game interventions that focus on preventing opioid misuse among older adolescents, and there are limited existing video game interventions that address mental health. Objective: This study aims to develop and conduct a formative evaluation of a video game intervention to prevent opioid misuse and promote mental health among adolescents aged 16-19 years (PlaySmart). We conducted formative work in preparation for a subsequent randomized controlled trial. Methods: We conducted development and formative evaluation of PlaySmart in 3 phases (development, playtesting, and preimplementation) through individual interviews and focus groups with multiple stakeholders (adolescents: n=103; school-based health care providers: n=51; and addiction treatment providers: n=6). PlaySmart content development was informed by the health belief model, the theory of planned behavior, and social cognitive theory. User-centered design principles informed the approach to development and play testing. The Exploration, Preparation, Implementation, and Sustainability framework informed preimplementation activities. Thematic analysis was used to identify themes from interviews and focus groups that informed PlaySmart game content and approaches to future implementation of PlaySmart. Results: We developed a novel video game PlaySmart for older adolescents that addresses the risk and protective factors for opioid misuse and mental health. Nine themes emerged from the focus groups that provided information regarding game content. Playtesting revealed areas of the game that required improvement, which were modified for the final game. Preimplementation focus groups identified potential barriers and facilitators for implementing PlaySmart in school settings. Conclusions: PlaySmart offers a promising digital intervention to address the current opioid and mental health crises among adolescents in a scalable manner. %M 37921851 %R 10.2196/46912 %U https://games.jmir.org/2023/1/e46912 %U https://doi.org/10.2196/46912 %U http://www.ncbi.nlm.nih.gov/pubmed/37921851 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45539 %T The Application of Fully Immersive Virtual Reality on Reminiscence Interventions for Older Adults: Scoping Review %A Lu,Zhipeng %A Wang,Wenjin %A Yan,Wei %A Kew,Chung Lin %A Seo,Jinsil Hwaryoung %A Ory,Marcia %+ Department of Architecture, Texas A&M University, 3137 TAMU, College Station, TX, 77845, United States, 1 9798456183, luzhipeng@live.com %K older adults %K fully immersive virtual reality %K reminiscence %K Alzheimer %K cognitive function %K mental health %K psychological well-being %K memory care %K dementia %K scoping review %D 2023 %7 6.10.2023 %9 Review %J JMIR Serious Games %G English %X Background: The increasing number of older adults with mental, behavioral, and memory challenges presents significant public health concerns. Reminiscence is one type of nonpharmacological intervention that can effectively evoke memories, stimulate mental activities, and improve psychological well-being in older adults through a series of discussions on previous experiences. Fully immersive virtual reality (FIVR) may be a useful tool for reminiscence interventions because it uses realistic virtual environments connected to a person’s significant past stories. Objective: This review aims to examine empirical evidence regarding the application of FIVR in reminiscence interventions, its usability and acceptability, and its effectiveness in assisting the intervention to achieve optimal outcomes. Methods: We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach for scoping reviews. The PubMed, PsycINFO, Embase, CINAHL, Web of Science, ACM, and IEEE Xplore electronic databases were used for the search. We included peer-reviewed studies that used FIVR as an assistive tool for reminiscence interventions; were published between January 1, 2000, and August 1, 2022; reported empirical research; involved older adults as participants; and addressed health- and behavior-related outcomes or the feasibility and usability of FIVR. We used Endnote X9 to organize the search results and Microsoft Excel for data extraction and synthesis. Results: Of the 806 articles collected from the databases and other resources, 11 were identified. Most of the studies involved participants aged between 70 and 90 years. Only 1 study did not involve those with cognitive impairments, whereas 3 specifically targeted people living with dementia. The results indicated that FIVR reminiscence interventions enhanced engagement and reduced fatigue. Although some studies have observed positive effects on anxiety, apathy, depression, cognitive functions, and caregiver burden reduction, these findings were inconsistent across other research. In addition, FIVR showed overall usability and acceptability with manageable side effects among older adults across various health conditions during reminiscence sessions. However, 1 study reported adverse feelings among participants, triggered by unpleasant memories evoked by the virtual reality content. Conclusions: The role of FIVR in reminiscence interventions remains nascent, with limited studies evaluating its impacts on older adults. Many of the reviewed studies had notable limitations: small sample sizes, absence of rigorous research design, limited assessment of long-term effects, lack of measures for health and behavior outcomes, and quality of life. Beyond these limitations, this review identified a list of future research directions in 6 categories. On the basis of the review findings, we provide practical recommendations to enhance FIVR reminiscence interventions, covering topics such as virtual reality content, device choice, intervention types, and the role and responsibility of facilitators. %M 37801360 %R 10.2196/45539 %U https://games.jmir.org/2023/1/e45539 %U https://doi.org/10.2196/45539 %U http://www.ncbi.nlm.nih.gov/pubmed/37801360 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45969 %T Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review %A Stathakarou,Natalia %A Kononowicz,Andrzej A %A Swain,Cara %A Karlgren,Klas %+ Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, Solna, Stockholm, 171 77, Sweden, 46 8 524 852 98, natalia.stathakarou@ki.se %K gamification %K game elements %K military medicine %K trauma %K medical education %K military training %K systematic review %K game %K gaming %K simulation %D 2023 %7 8.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. Objective: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. Methods: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. Results: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20% (126/630) of the identified abstracts in groups of 2 reviewers. Conclusions: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. International Registered Report Identifier (IRRID): DERR1-10.2196/45969 %M 37682596 %R 10.2196/45969 %U https://www.researchprotocols.org/2023/1/e45969 %U https://doi.org/10.2196/45969 %U http://www.ncbi.nlm.nih.gov/pubmed/37682596 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47285 %T The Impact of a Gamified Mobile Mental Health App (eQuoo) on Resilience and Mental Health in a Student Population: Large-Scale Randomized Controlled Trial %A Litvin,Silja %A Saunders,Rob %A Jefferies,Philip %A Seely,Hayley %A Pössel,Patrick %A Lüttke,Stefan %+ Department Psychologie, Ludwig-Maximilians-Universität, Geschwister-Scholl-Platz 1, München, 80539, Germany, 49 89 21800, silja@psycapps.com %K mobile health %K mHealth %K gamification %K resilience %K randomized controlled trial %K RCT %K mental health %K apps %K mobile health %K mobile game %K mobile games %K serious game %K depression %K anxiety %K university %K college %K student %K students %K controlled trial %K controlled trials %K young adult %K mobile phone %D 2023 %7 21.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X 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 %M 37477955 %R 10.2196/47285 %U https://mental.jmir.org/2023/1/e47285 %U https://doi.org/10.2196/47285 %U http://www.ncbi.nlm.nih.gov/pubmed/37477955 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e43987 %T Evaluating the Feasibility of a Multiplayer Role-Playing Game as a Behavioral Health Intervention in Adolescent Patients With Chronic Physical or Mental Conditions: Protocol for a Cohort Study %A Babichenko,Dmitriy %A Radovic,Ana %A Patel,Ravi %A Hester,Alexis %A Powell,Koehler %A Eggers,Nicholas %A Happe,David %+ School of Computing and Information, University of Pittsburgh, 135 N. Bellefield Avenue, Room 721, Pittsburgh, PA, 15213, United States, 1 4122609194, dmb72@pitt.edu %K role-playing games %K social isolation %K depression %K game-based interventions %K development %K intervention %K game %K teen %K patient %K chronic %K mental condition %K quality of life %K engagement %K symptoms %K data %K clinical %D 2023 %7 27.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Numerous studies have revealed that adolescents with chronic physical or mental conditions (CPMCs) are at an increased risk for depression and anxiety, with serious direct and indirect negative effects on treatment adherence, family functioning, and health-related quality of life. As game-based approaches are effective interventions in treating anxiety and depression, we propose to explore the use of a multiplayer role-playing game (RPG) as a potential intervention for social isolation, anxiety, and depression. Objective: The objectives of this study were to (1) determine the feasibility of using Masks, a multiplayer RPG, as an intervention for social isolation, anxiety, and depression in adolescents with CPMCs; (2) evaluate the viability of the research process; and (3) gauge participation in and engagement with RPG-based interventions. Methods: This study is a remote synchronous game-based intervention for adolescents with CPMCs aged 14-19 years. Eligible participants completed a web-based baseline survey to assess anxiety, depression, and social isolation and to identify their gaming habits. After completing the baseline survey, they participated in 5 moderated Masks game sessions. In Masks, players assume the roles of young superheroes; select their character types, superpowers; and perform actions determined by the game’s rule system and dice rolls. All game sessions were played using Discord, a communication platform commonly used by gaming communities. Games were led and moderated by game masters (GMs). After each game session, participants completed surveys to assess changes in anxiety, depression, and social isolation, and their attitude toward the game and the user experience. The participants also completed an exit survey after all 5 game sessions (modified version of the Patient Health Questionnaire and the Generalized Anxiety Disorder Questionnaire, and 17 open-ended questions). The GMs rated each game session and reported on gameplay, player behavior, comfort, and engagement levels of the players. Results: As of March 2020, six participants were recruited for the pilot study to participate in moderated web-based game sessions of Masks; 3 completed all game sessions and all required assessments. Although the number of participants was too low to draw generalizable conclusions, self-reported clinical outcomes did seem to indicate a positive change in depression, anxiety, and social isolation symptoms. Qualitative analysis of postgame survey data from participants and GMs indicated high levels of engagement and enjoyment. Furthermore, the participants provided feedback about improved mood and engagement related to weekly participation in Masks. Lastly, responses to the exit survey showed interest in future RPG-related studies. Conclusions: We established a workflow for gameplay and evaluated a research protocol for evaluating the impact of RPG participation on isolation, anxiety, and depression symptoms in adolescents with CPMCs. Preliminary data collected from the pilot study support the validity of the research protocol and the use of RPG-based interventions in larger clinical studies. International Registered Report Identifier (IRRID): RR1-10.2196/43987 %M 37368477 %R 10.2196/43987 %U https://www.researchprotocols.org/2023/1/e43987 %U https://doi.org/10.2196/43987 %U http://www.ncbi.nlm.nih.gov/pubmed/37368477 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41638 %T Gamifying Cognitive Behavioral Therapy Techniques on Smartphones for Bangkok’s Millennials With Depressive Symptoms: Interdisciplinary Game Development %A Sriwatanathamma,Poe %A Sirivesmas,Veerawat %A Simatrang,Sone %A Bhowmik,Nobonita Himani %+ Doctor of Philosophy Program in Design Arts (International Program), Faculty of Decorative Arts, Silpakorn University, 22 Borommaratchachonnani Rd, Khwaeng Taling Chan, Khet Taling Chan, Bangkok, 10170, Thailand, 66 917655317, poesriwatana@gmail.com %K cognitive behavioral therapy %K gamification %K Bangkok’s millennials %K depressive symptoms %K mobile phone %D 2023 %7 12.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand. Objective: This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok’s millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones. Methods: First, this paper follows each development step of solidifying BlueLine’s game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player’s interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions. Results: With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions. Conclusions: This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine’s game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism. %M 37171845 %R 10.2196/41638 %U https://games.jmir.org/2023/1/e41638 %U https://doi.org/10.2196/41638 %U http://www.ncbi.nlm.nih.gov/pubmed/37171845 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e37105 %T Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study %A Ghosh,Arka %A Agnihotri,Jagriti %A Bhalotia,Sradha %A Sati,Bharat Kumar %A Agarwal,Latika %A A,Akash %A Tandon,Swastika %A Meena,Komal %A Raj,Shreyash %A Azad,Yatin %A Gupta,Silky %A Gupta,Nitin %+ Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kalyanpur, Kanpur, 208016, India, 91 5122594384, guptan@iitk.ac.in %K serious games %K cognitive bias modification %K learned helplessness %K depression %K digital intervention %K mobile phone %D 2023 %7 3.5.2023 %9 Original Paper %J JMIR Serious Games %G English %X 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. %M 37133923 %R 10.2196/37105 %U https://games.jmir.org/2023/1/e37105 %U https://doi.org/10.2196/37105 %U http://www.ncbi.nlm.nih.gov/pubmed/37133923 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e38493 %T Evaluating the Utility of a Psychoeducational Serious Game (SPARX) in Protecting Inuit Youth From Depression: Pilot Randomized Controlled Trial %A Bohr,Yvonne %A Litwin,Leah %A Hankey,Jeffrey Ryan %A McCague,Hugh %A Singoorie,Chelsea %A Lucassen,Mathijs F G %A Shepherd,Matthew %A Barnhardt,Jenna %+ LaMarsh Centre for Child and Youth Research, York University, 4700 Keele Street, Toronto, ON, M3J1P3, Canada, 1 6475616464, jrhankey@yorku.ca %K psychoeducation %K cognitive behavioral therapy %K Inuit youth %K Nunavut %K depression %K suicide %K resilience %K serious game %K youth %K mental health %K teen %K adolescent %K pilot study %K community %D 2023 %7 9.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Inuit youth in Northern Canada show considerable resilience in the face of extreme adversities. However, they also experience significant mental health needs and some of the highest adolescent suicide rates in the world. Disproportionate rates of truancy, depression, and suicide among Inuit adolescents have captured the attention of all levels of government and the country. Inuit communities have expressed an urgent imperative to create, or adapt, and then evaluate prevention and intervention tools for mental health. These tools should build upon existing strengths, be culturally appropriate for Inuit communities, and be accessible and sustainable in Northern contexts, where mental health resources are often scarce. Objective: This pilot study assesses the utility, for Inuit youth in Canada, of a psychoeducational e-intervention designed to teach cognitive behavioral therapy strategies and techniques. This serious game, SPARX, had previously demonstrated effectiveness in addressing depression with Māori youth in New Zealand. Methods: The Nunavut Territorial Department of Health sponsored this study, and a team of Nunavut-based community mental health staff facilitated youth’s participation in an entirely remotely administered pilot trial using a modified randomized control approach with 24 youths aged 13-18 across 11 communities in Nunavut. These youth had been identified by the community facilitators as exhibiting low mood, negative affect, depressive presentations, or significant levels of stress. Entire communities, instead of individual youth, were randomly assigned to an intervention group or a waitlist control group. Results: Mixed models (multilevel regression) revealed that participating youth felt less hopeless (P=.02) and engaged in less self-blame (P=.03), rumination (P=.04), and catastrophizing (P=.03) following the SPARX intervention. However, participants did not show a decrease in depressive symptoms or an increase in formal resilience indicators. Conclusions: Preliminary results suggest that SPARX may be a good first step for supporting Inuit youth with skill development to regulate their emotions, challenge maladaptive thoughts, and provide behavioral management techniques such as deep breathing. However, it will be imperative to work with youth and communities to design, develop, and test an Inuit version of the SPARX program, tailored to fit the interests of Inuit youth and Elders in Canada and to increase engagement and effectiveness of the program. Trial Registration: ClinicalTrials.gov NCT05702086; https://www.clinicaltrials.gov/ct2/show/NCT05702086 %M 36892940 %R 10.2196/38493 %U https://games.jmir.org/2023/1/e38493 %U https://doi.org/10.2196/38493 %U http://www.ncbi.nlm.nih.gov/pubmed/36892940 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38133 %T Applying Gamification Principles and Therapeutic Movement Sequences to Design an Interactive Physical Activity Game: Development Study %A Kim,Hyungsook %A O'Sullivan,David Michael %A Chung,Seong Hee %+ Division of Sport Science, Pusan National University, 2, Busandaehak-ro 63beon-gil, Geumjeong-gu, Pusan, 46241, Republic of Korea, 82 1076845811, davidosullivan@pusan.ac.kr %K home workout %K mobile assistant %K movement %K physical activity %K depression %D 2022 %7 16.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a severe illness that has accelerated with the spread of COVID-19 and associated lockdowns. As a result, reported physical activity has substantially decreased, further increasing depressive symptoms. Objective: This study aims to explain the use of gamification principles to develop content for an interactive physical activity game for depression based on clinically proven depression diagnostic criteria. Methods: We discuss related work in this field, the game design framework, the users’ depression severity, how we customize the contents accordingly, the gradual progression of the game to match exercise principles, and user flow optimization. Results: We provide a brief description of each of the games developed, including instructions on how to play and design aspects for flow, audio, and visual feedback methods. Exergames (interactive physical activity–based games) stimulate certain physical fitness factors such as improving reaction time, endurance, cardiovascular fitness, and flexibility. In addition, the game difficulty progresses based on various factors, such as the user’s performance for successful completion, reaction time, movement speed, and stimulated larger joint range of motions. Cognitive aspects are included, as the user has to memorize particular movement sequences. Conclusions: Mental health issues are linked to behavior and movement; therefore, future physical activity–based interactive games may provide excellent stimulation for inducing user flow, while physical activity can help train various physical fitness factors linked to depression. %M 36525298 %R 10.2196/38133 %U https://games.jmir.org/2022/4/e38133 %U https://doi.org/10.2196/38133 %U http://www.ncbi.nlm.nih.gov/pubmed/36525298 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 12 %P e36390 %T An Emotional Bias Modification for Children With Attention-Deficit/Hyperactivity Disorder: Co-design Study %A Zhang,Melvyn %A Ranganath,Vallabhajosyula %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Level 11, Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 98556631, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K attention-deficit/hyperactivity disorder %K ADHD %K child psychiatry %D 2022 %7 9.12.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the common neurodevelopment disorders. Children with ADHD typically have difficulties with emotional regulation. Previous studies have investigated the assessment for underlying emotional biases using the visual probe task. However, one of the significant limitations of the visual probe task is that it is demanding and repetitive over time. Previous studies have examined the use of gamification methods in addressing the limitations of the emotional bias visual probe task. There has also been increased recognition of the potential of participatory action research methods and how it could help to make the conceptualized interventions more relevant. Objective: The primary aim of this study was to collate health care professionals’ perspectives on the limitations of the existing visual probe task and to determine if gamification elements were viable to be incorporated into an emotional bias modification task. Methods: A co-design workshop was conducted. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore, were invited to participate. Considering the COVID-19 pandemic and the restrictions, a web-based workshop was conducted. There were 3 main phases in the workshops. First, participants were asked to identify limitations and suggest potential methods to overcome some of the identified limitations. Second, participants were shown examples of existing gaming interventions in published literature and commercial stores. They were also asked to comment on the advantages and limitations of these interventions. Finally, participants were asked if gamification techniques would be appropriate. Results: Overall, 4 health care professionals consented and participated. Several limitations were identified regarding the conventional emotional bias intervention. These included the nature of the task parameters, included stimulus set, and factors that could have an impact on the accuracy of responding to the task. After examining the existing ADHD games, participants raised concerns about the evidence base of some of the apps. They articulated that any developed ADHD game ought to identify the specific skill set that was targeted clearly. Regarding gamification strategies, participants preferred economic and performance-based gamification approaches. Conclusions: This study has managed to elucidate health care professionals’ perspectives toward refining a conventional emotional bias intervention for children with ADHD. In view of the repetitiveness of the conventional task, the suggested gamification techniques might help in influencing task adherence and reduce the attrition rates. %M 36485019 %R 10.2196/36390 %U https://formative.jmir.org/2022/12/e36390 %U https://doi.org/10.2196/36390 %U http://www.ncbi.nlm.nih.gov/pubmed/36485019 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 8 %P e26615 %T A Game-Based School Program for Mental Health Literacy and Stigma on Depression (Moving Stories): Cluster Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Olthof,Merlijn %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University Nijmegen, Postbus 9104, Nijmegen, 6500 HE, Netherlands, 31 243610082, anouk.tuijnman@ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %K mental health %K digital health %D 2022 %7 17.8.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depressive symptoms are highly prevalent among adolescents in Western countries. However, although treatment for depressive symptoms is available, many adolescents do not seek help when they need it. Important barriers to help-seeking among adolescents include low mental health literacy and high stigma. Therefore, we have developed a game-based school program, Moving Stories, which combines mental health literacy training for depression with contact with someone with lived experience both in the digital and nondigital world. Objective: The aim of this study is to conduct a first test of the effectiveness of the newly developed game-based program, Moving Stories, using a cluster randomized controlled trial. Methods: A total of 185 adolescents participated, divided over 10 classes from 4 schools. Half of the classes were randomly selected to follow the Moving Stories program, whereas the other half were in the control group, where no intervention was provided. The adolescents filled out digital questionnaires at 4 time points, with questions on mental health literacy, stigma, depressive symptoms, and the program itself (before the program, after the program, 3-month follow-up, and 6-month follow-up). Using R (R Foundation for Statistical Computing), we ran linear mixed-effects models for all continuous outcome variables and generalized linear mixed-effects models for all binary outcome variables. Results: Compared with the control group, participants in the Moving Stories group improved after the program in personal stigma (b=−0.53, 95% CI −1.02 to −0.03; t179.16=−2.08; P=.04). Effects on personal stigma lasted over time (3-month follow-up: b=−0.57, 95% CI −1.11 to −0.03; t174.39=−2.07; P=.04). Most adolescents in the Moving Stories group participated in the introduction (97/99, 98%) and contact session (93/99, 94%), played the game for 4 or 5 days (83/99, 83%), and indicated that they would recommend the game to their peers (90/98, 92%). Conclusions: The results of this study show the potential of Moving Stories as a stigma reduction program. With changes in the program to improve its effects on mental health literacy, Moving Stories could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms. Trial Registration: Dutch Trial Register NTR7033; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7033 International Registered Report Identifier (IRRID): RR2-10.2196/11255 %M 35976200 %R 10.2196/26615 %U https://mental.jmir.org/2022/8/e26615 %U https://doi.org/10.2196/26615 %U http://www.ncbi.nlm.nih.gov/pubmed/35976200 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e33884 %T Developing Serious Video Games to Treat Attention Deficit Hyperactivity Disorder: Tutorial Guide %A Sújar,Aarón %A Martín-Moratinos,Marina %A Rodrigo-Yanguas,María %A Bella-Fernández,Marcos %A González-Tardón,Carlos %A Delgado-Gómez,David %A Blasco-Fontecilla,Hilario %+ Department of Psychiatry, Hospital Universitario Puerta de Hierro Majadahonda, 1 C Joaquín Rodrigo, Majadahonda, 28222, Spain, 34 911916019, hmblasco@yahoo.es %K serious video games %K ADHD %K treatment %K video games %K cognitive %K cognitive disorder %K games %D 2022 %7 1.8.2022 %9 Tutorial %J JMIR Serious Games %G English %X Video game–based therapeutic interventions have demonstrated some effectiveness in decreasing the symptoms of attention deficit hyperactivity disorder (ADHD). Compared with more traditional strategies within the multimodal treatment of ADHD, video games have certain advantages such as being comfortable, flexible, and cost-efficient. However, establishing the most appropriate type(s) of video games that should be used for this treatment remains a matter of debate, including the commercial existing video games or serious video games that are specifically constructed to target specific disorders. This guide represents a starting point for developing serious video games aimed at treating ADHD. We summarize the key points that need to be addressed to generate an effective and motivating game-based treatment. Following recommendations from the literature to create game-based treatments, we describe the development stages of a serious video game for treating ADHD. Game design should consider the interests of future users; game mechanics should be based on cognitive exercises; and therapeutic mechanisms must include the control of difficulty, engagement, motivation, time constraints, and reinforcement. To elaborate upon this guide, we performed a narrative review focused on the use of video games for the treatment of ADHD, and were inspired by our own experience during the development of the game “The Secret Trail of Moon.” %M 35916694 %R 10.2196/33884 %U https://games.jmir.org/2022/3/e33884 %U https://doi.org/10.2196/33884 %U http://www.ncbi.nlm.nih.gov/pubmed/35916694 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35099 %T Innovative Technology–Based Interventions to Reduce Stigma Toward People With Mental Illness: Systematic Review and Meta-analysis %A Rodríguez-Rivas,Matías E %A Cangas,Adolfo J %A Cariola,Laura A %A Varela,Jorge J %A Valdebenito,Sara %+ Facultad de Psicología, Universidad del Desarrollo, Avenida Plaza 680, Santiago, Chile, 56 223279110, matrodriguezr@udd.cl %K stigma %K mental illness %K technology-based %K serious games %K virtual reality %K e-contact %K simulation intervention %K internet intervention %K meta-analysis %D 2022 %7 30.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Stigma toward people with mental illness presents serious consequences for the impacted individuals, such as social exclusion and increased difficulties in the recovery process. Recently, several interventions have been developed to mitigate public stigma, based on the use of innovative technologies, such as virtual reality and video games. Objective: This review aims to systematically review, synthesize, measure, and critically discuss experimental studies that measure the effect of technological interventions on stigmatization levels. Methods: This systematic review and meta-analysis was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and included studies in English and Spanish published between 2016 and 2021. Searches were run in 5 different databases (ie, PubMed, PsycInfo, Scopus, Cochrane Library, and ScienceDirect). Only randomized controlled trials were included. Two independent reviewers determined the eligibility, extracted data, and rated methodological quality of the studies. Meta-analyses were performed using the Comprehensive Meta-Analysis software. Results: Based on the 1158 articles screened, 72 articles were evaluated as full text, of which 9 were included in the qualitative and quantitative syntheses. A diversity of interventions was observed, including video games, audiovisual simulation of hallucinations, virtual reality, and electronic contact with mental health services users. The meta-analysis (n=1832 participants) demonstrated that these interventions had a consistent medium effect on reducing the level of public stigma (d=–0.64; 95% CI 0.31-0.96; P<.001). Conclusions: Innovative interventions involving the use of technologies are an effective tool in stigma reduction, therefore new challenges are proposed and discussed for the demonstration of their adaptability to different contexts and countries, thus leading to their massification. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021261935; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021261935 %M 35635744 %R 10.2196/35099 %U https://games.jmir.org/2022/2/e35099 %U https://doi.org/10.2196/35099 %U http://www.ncbi.nlm.nih.gov/pubmed/35635744 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e21376 %T Designing a Serious Game (Above Water) for Stigma Reduction Surrounding Mental Health: Semistructured Interview Study With Expert Participants %A Wehbe,Rina R %A Whaley,Colin %A Eskandari,Yasaman %A Suarez,Ally %A Nacke,Lennart E %A Hammer,Jessica %A Lank,Edward %+ Human Computer Interaction for Social Good (HCI4GOOD), Faculty of Computer Science, Dalhousie University, 6299 South Street, Halifax, NS, B3H4R2, Canada, 1 902 494 2211, rina.wehbe@dal.ca %K human–computer interaction %K games for change %K games for mental health %K sensitive topics %K game design %K empirical analysis %K expert participants %D 2022 %7 19.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although in many contexts unsuccessful games targeting learning, social interaction, or behavioral change have few downsides, when covering a sensitive domain such as mental health (MH), care must be taken to avoid harm and stigmatization of people who live with MH conditions. As a result, evaluation of the game to identify benefits and risks is crucial in understanding the game’s success; however, assessment of these apps is often compared with the nongame control condition, resulting in findings specifically regarding entertainment value and user preferences. Research exploring the design process, integrating field experts, and guidelines for designing a successful serious game for sensitive topics is limited. Objective: The aim of this study is to understand which elements of game design can guide a designer when designing a game for sensitive topics. Methods: To carefully probe the design space of serious games for MH, we present Above Water (AbW), a game targeting the reduction of stigma surrounding MH, now in its second iteration. The game, AbW, serves as a consistent research probe to solicit expert feedback. Experts were recruited from a range of topic domains related to MH and wellness, game design, and user experience. Results: By using this deployment as a research probe, this study demonstrates how to synthesize gained insights from multiple expert perspectives and create actionable guidelines for successful design of serious games targeting sensitive topics. Conclusions: Our work contributes to a better understanding of how to design specialized games to address sensitive topics. We present a set of guidelines for designing games for sensitive subjects, and for each guideline, we present an example of how to apply the finding to the sample game (AbW). Furthermore, we demonstrate the generalizability to other sensitive topics by providing an additional example of a game that could be designed with the presented guidelines. %M 35588056 %R 10.2196/21376 %U https://games.jmir.org/2022/2/e21376 %U https://doi.org/10.2196/21376 %U http://www.ncbi.nlm.nih.gov/pubmed/35588056 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 5 %P e36820 %T Video Game to Attenuate Pandemic-Related Stress From an Equity Lens: Development and Usability Study %A Minian,Nadia %A Saiva,Anika %A Gayapersad,Allison %A Dragonetti,Rosa %A Proulx,Catherine %A Debergue,Patricia %A Lecce,Julia %A Hussain,Sarwar %A Desjardins,Eric %A Selby,Peter %+ Nicotine Dependence Service, Centre for Addiction and Mental Health, 1025 Queen St W, Toronto, ON, M6H 1H4, Canada, 1 416 535 8501, peter_selby@camh.net %K video games %K cognitive behavioral therapy %K usability study %K self-care %K digital health %K technological infrastructure %K video game development %K user engagement %K user perception %K COVID-19 %K Mental health %K mental health care system %K depression %K anxiety %K digital therapy %D 2022 %7 12.5.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The emergence of the novel coronavirus (COVID-19) has introduced additional pressures on an already fragile mental health care system due to a significant rise in depression, anxiety, and stress among Canadians. Although cognitive behavioral therapy (CBT) is known to be an efficacious treatment to reduce such mental health issues, few people have access to CBT in an engaging and sustainable manner. To address this gap, a collaboration between the Centre for Addiction and Mental Health (CAMH) and the National Research Council of Canada (NRC) developed CBT-based self-led, online, clinician-tested modules in the form of a video game, named Legend of Evelys, and evaluated its usability in the attenuation of a COVID-19–related increase in stress. Objective: We here present the conceptualization and design of new self-care modules in the form of a video game, its implementation in a technological infrastructure, and inclusivity and privacy considerations that informed the development. A usability study of the modules was performed to assess the video game’s usability, user engagement, and user perceptions. Methods: The development of the video game involved establishment of a technology infrastructure for secure implementation of the software for the modules and a clinician-led assessment of the clinical utility of these modules through two “whiteboard” sessions. The usability study was informed by a mixed methods sequential explanatory design to evaluate the intervention of the mobile app through two distinct phases: quantitative data collection using in-app analytics data and two surveys, followed by qualitative data collection by semistructured interviews. Results: A total of 32 participants trialed the app for 2 weeks. They used the video game an average of six times and rated the game as “good” based on the Systems Usability Scale score. In terms of stress reduction, the study demonstrated a significant difference in the participants’ Perceived Stress Scale score at baseline (mean 22.14, SD 6.187) compared with that at the 2-week follow-up (mean 18.04, SD 6.083; t27=3.628, P=.001). Qualitative interviews helped participants identify numerous functionality issues and provided specific recommendations, most of which were successfully integrated into the video game for future release. Conclusions: Through this collaboration, we have established that it is possible to incorporate CBT exercises into a video game and have these exercises adopted to address stress. While video games are a promising strategy to help people with their stress and anxiety, there is a further need to examine the real-world effectiveness of the Legend of Evelys in reducing anxiety. %M 35413001 %R 10.2196/36820 %U https://formative.jmir.org/2022/5/e36820 %U https://doi.org/10.2196/36820 %U http://www.ncbi.nlm.nih.gov/pubmed/35413001 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34222 %T A Web-Based Escape Room to Raise Awareness About Severe Mental Illness Among University Students: Randomized Controlled Trial %A Rodriguez-Ferrer,Jose M %A Manzano-León,Ana %A Cangas,Adolfo J %A Aguilar-Parra,Jose M %+ Faculty of Psychology, University of Almeria, Carretera Sacramento s/n, La Cañada de San Urbano, Almería, 04120, Spain, 34 950 01 55 50, aml570@ual.es %K escape room %K severe mental disorder %K higher education %K nursing education %K mental health %K mental disorder %K serious games %D 2022 %7 5.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: People with severe mental illness (SMI) face discriminatory situations because of prejudice toward them, even among health care personnel. Escape rooms can be a novel educational strategy for learning about and empathizing with SMI, thus reducing stigma among health care students. Objective: This study aimed to examine the effect of the Without Memories escape room on nursing students’ stigma against SMI. Methods: A pre- and postintervention study was conducted with a control group and an experimental group. A total of 306 students from 2 Andalusian universities participated in the study. Data were collected through a pre-post study questionnaire, consisting of an adapted version of the Attributional Style Questionnaire and a questionnaire on motivation for cooperative playful learning strategies. The control group carried out an escape room scenario without sensitizing content, whereas the experimental group carried out an escape room scenario on SMI, with both escape rooms being carried out in a 1-hour session of subjects related to mental health. To answer the research questions, a 2-way analysis of variance with repeated measures, a linear regression, and a 2-way analysis of variance were performed. Results: After the intervention, a significant reduction (P<.001) was observed in the experimental group in stigmatizing attitudes compared with the control group, in which no statistically significant changes (P>.05) were observed. In contrast, the linear regression (t195=−22.15; P<.001) showed that there was an inverse relationship between flow and the level of reduced stigma. When controlling for having or not having a close relative, the intervention was also shown to be effective (P<.001) in reducing the stigma displayed, both for people with affected and unaffected relatives. Conclusions: Our findings suggest that the Without Memories escape room can be used as an effective tool to educate and raise awareness about stigmatizing attitudes toward SMI in university students studying health care. Future testing of the effectiveness of educational escape rooms should be designed with new programs through playful strategies of longer duration to evaluate whether they can achieve a greater impact on motivation, acquisition of knowledge, and awareness. In addition, the feasibility of implementing the Without Memories escape room in other careers related to health and community should be investigated. %M 35511232 %R 10.2196/34222 %U https://games.jmir.org/2022/2/e34222 %U https://doi.org/10.2196/34222 %U http://www.ncbi.nlm.nih.gov/pubmed/35511232 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 4 %P e33526 %T A Serious Game for Young People With First Episode Psychosis (OnTrack>The Game): Qualitative Findings of a Randomized Controlled Trial %A Jankowski,Samantha %A Ferreira,Kathleen %A Mascayano,Franco %A Donovan,Effy %A Rahim,Reanne %A Birnbaum,Michael L %A Yum-Chan,Sabrina %A Medoff,Deborah %A Marcogliese,Bethany %A Fang,Lijuan %A Nicholson,Terriann %A Dixon,Lisa %+ Department of Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, United States, 1 212 326 8441, Lisa.Dixon@nyspi.columbia.edu %K video gaming %K internet %K recovery %K schizophrenia %K psychosis %K clinicians %K mobile phone %D 2022 %7 6.4.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Several studies have shown the benefits of coordinated specialty care (CSC) for individuals with first episode psychosis; however, pathways to care are marred by lack of knowledge, stigma, and difficulties with treatment engagement. Serious games or video interventions may provide a way to address these factors. Objective: This study focuses on qualitative results of a randomized controlled trial comparing OnTrack>The Game (OTG) with recovery videos (RVs) on engagement, stigma, empowerment, hope, recovery, and understanding of psychosis in clients receiving CSC. Clinicians are also interviewed regarding their perceptions of the interventions and suggestions for improvement. Methods: A total of 16 clients aged 16-30 years, with first episode psychosis attending a CSC program in New York State, and 9 clinicians participated in the qualitative interviews. Interviews were analyzed using the rapid identification of themes from audio recordings method. Results: For clients, themes included relatability of game content, an increased sense of hope and the possibility of recovery, decreased self-stigma and public stigma, increased understanding of the importance of social support, and increased empowerment in the OTG group. Clinicians had a preference for RV and provided suggestions for dissemination and implementation. Conclusions: Themes that may help inform future research in this area, particularly regarding dissemination and implementation of OTG and RV, emerged. Trial Registration: ClinicalTrials.gov NCT03390491; https://clinicaltrials.gov/ct2/show/NCT03390491 %M 35384847 %R 10.2196/33526 %U https://mental.jmir.org/2022/4/e33526 %U https://doi.org/10.2196/33526 %U http://www.ncbi.nlm.nih.gov/pubmed/35384847 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e33169 %T The Effectiveness of a Serious Game (MemoreBox) for Cognitive Functioning Among Seniors in Care Facilities: Field Study %A Kleschnitzki,Jana Marina %A Beyer,Luzi %A Beyer,Reinhard %A Großmann,Inga %+ Department of Psychology, Humboldt-University of Berlin, Rudower Chaussee 18, Berlin, 12489, Germany, 49 15231964606, janakleschnitzki@posteo.de %K serious game %K cognitive function %K mental health %K seniors %K care facilities %K aging %K cognitive impairments %K health technology %D 2022 %7 1.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games have been found to have enhancing and preventative effects on cognitive abilities in healthy older adults. Yet, there are few results on the effects in older seniors with age-related low cognitive impairments. Their special needs were considered when designing and using innovate technology in the area of prevention, which is especially relevant owing to the continuously aging population. Objective: The objective of this study was to evaluate the impact of a serious game on the cognitive abilities of seniors in order to potentially implement innovative resource-oriented technological interventions that can help to meet future challenges. Methods: In this controlled trial, we tested the serious game MemoreBox, which features modules specifically designed for seniors in nursing homes. Over a period of 1 year, we tested the cognitive abilities of 1000 seniors at 4 time points using the Mini-Mental Status Test. Only half of the participating seniors engaged with the serious game. Results: The study included an intervention group (n=56) and a control group (did not play; n=55). Based on the in-game data collection, a second intervention group (n=38) was identified within the original intervention group, which exactly followed the planned protocol. There were no noteworthy differences between the demographic and main variables of the overall sample. The large reduction in the sample size was due to the effects of the COVID-19 pandemic (drop-out rate: 88.9%). The CI was set at 5%. Mixed analysis of variance (ANOVA) between the cognitive abilities of the intervention and control groups did not show a statistically significant difference between time and group (F2.710,295.379=1.942; P=.13; partial η²=0.018). We noted approximately the same findings for mixed ANOVA between the cognitive abilities of the second intervention and control groups (F3,273=2.574; P=.054; partial η²=0.028). However, we did observe clear tendencies and a statistically significant difference between the 2 groups after 9 months of the intervention (t88.1=−2.394; P=.02). Conclusions: The results of this study show similarities with the current research situation. Moreover, the data indicate that the intervention can have an effect on the cognitive abilities of seniors, provided that they regularly play the serious game of MemoreBox. The small sample size means that the tendency toward improvement cannot be proven as statistically significant. However, the tendency shown warrants further research. Establishing an effective prevention tool as part of standard care in nursing homes by means of an easy-to-use serious game would be a considerable contribution to the weakened health care system in Germany as it would offer a means of activating senior citizens in partially and fully inpatient care facilities. Trial Registration: German Clinical Trials Register DRKS00016633; https://tinyurl.com/2e4765nj %M 35172959 %R 10.2196/33169 %U https://games.jmir.org/2022/2/e33169 %U https://doi.org/10.2196/33169 %U http://www.ncbi.nlm.nih.gov/pubmed/35172959 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e34592 %T The Effectiveness and Safety of Serious Games for Improving Cognitive Abilities Among Elderly People With Cognitive Impairment: Systematic Review and Meta-Analysis %A Abd-alrazaq,Alaa %A Alajlani,Mohannad %A Alhuwail,Dari %A Toro,Carla T %A Giannicchi,Anna %A Ahmed,Arfan %A Makhlouf,Ahmed %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, P.O. Box 5825, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K cognitive training %K exergames %K mild cognitive impairment %K Alzheimer disease %K dementia %K global cognition %K systematic review %K meta-analysis %D 2022 %7 10.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Cognitive impairment is a mental disorder that commonly affects elderly people. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological intervention for improving cognitive abilities. The effectiveness and safety of serious games for improving cognitive abilities have been investigated by several systematic reviews; however, they are limited by design and methodological weaknesses. Objective: This study aims to assess the effectiveness and safety of serious games for improving cognitive abilities among elderly people with cognitive impairment. Methods: A systematic review of randomized controlled trials (RCTs) was conducted. The following 8 electronic databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also screened reference lists of the included studies and relevant reviews, as well as checked studies citing our included studies. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies. Results: Fifteen studies met the eligibility criteria among 466 citations retrieved. Of those, 14 RCTs were eventually included in the meta-analysis. We found that, regardless of their type, serious games were more effective than no intervention (P=.04) and conventional exercises (P=.002) for improving global cognition among elderly people with cognitive impairment. Further, a subgroup analysis showed that cognitive training games were more effective than no intervention (P=.05) and conventional exercises (P<.001) for improving global cognition among elderly people with cognitive impairment. Another subgroup analysis demonstrated that exergames (a category of serious games that includes physical exercises) are as effective as no intervention and conventional exercises (P=.38) for improving global cognition among elderly people with cognitive impairment. Although some studies found adverse events from using serious games, the number of adverse events (ie, falls and exacerbations of pre-existing arthritis symptoms) was comparable between the serious game and control groups. Conclusions: Serious games and specifically cognitive training games have the potential to improve global cognition among elderly people with cognitive impairment. However, our findings remain inconclusive because the quality of evidence in all meta-analyses was very low, mainly due to the risk of bias raised in the majority of the included studies, high heterogeneity of the evidence, and imprecision of total effect sizes. Therefore, psychologists, psychiatrists, and patients should consider offering serious games as a complement and not a substitute to existing interventions until further more robust evidence is available. Further studies are needed to assess the effect of exergames, the safety of serious games, and their long-term effects. %M 35266877 %R 10.2196/34592 %U https://games.jmir.org/2022/1/e34592 %U https://doi.org/10.2196/34592 %U http://www.ncbi.nlm.nih.gov/pubmed/35266877 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 1 %P e29008 %T Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study %A Lockwood,Joanna %A Williams,Laura %A Martin,Jennifer L %A Rathee,Manjul %A Hill,Claire %+ National Institute of Health Research MindTech MedTech Co-operative, School of Medicine, University of Nottingham, Institute of Mental Health, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231294, joanna.lockwood@nottingham.ac.uk %K anxiety %K children %K exposure therapy %K cognitive behavioral therapy %K immersive gaming %K digital intervention %K app %K smartphone %K mobile phone %D 2022 %7 24.1.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition. Objective: In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova. Methods: Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app’s effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined. Results: Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t29=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data. Conclusions: This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch. %M 35072644 %R 10.2196/29008 %U https://mental.jmir.org/2022/1/e29008 %U https://doi.org/10.2196/29008 %U http://www.ncbi.nlm.nih.gov/pubmed/35072644 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32331 %T The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis %A Abd-Alrazaq,Alaa %A Al-Jafar,Eiman %A Alajlani,Mohannad %A Toro,Carla %A Alhuwail,Dari %A Ahmed,Arfan %A Reagu,Shuja Mohd %A Al-Shorbaji,Najeeb %A Househ,Mowafa %+ Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110, Doha Al Luqta St, Ar-Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K serious games %K exergames %K depression %K cognitive behavioral therapy %K systematic reviews %K meta-analysis %D 2022 %7 14.1.2022 %9 Review %J JMIR Serious Games %G English %X Background: Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings. Objective: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. Methods: A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games). Results: From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). Conclusions: Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969 %M 35029530 %R 10.2196/32331 %U https://games.jmir.org/2022/1/e32331 %U https://doi.org/10.2196/32331 %U http://www.ncbi.nlm.nih.gov/pubmed/35029530 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e27058 %T The Effect of Video Game–Based Interventions on Performance and Cognitive Function in Older Adults: Bayesian Network Meta-analysis %A Yang,Chao %A Han,Xiaolei %A Jin,Mingxue %A Xu,Jianhui %A Wang,Yiren %A Zhang,Yajun %A Xu,Chonglong %A Zhang,Yingshi %A Jin,Enshi %A Piao,Chengzhe %+ Department of Ethnic Culture and Vocational Education, Liaoning National Normal College, No. 45 Chongshan Dong Road, Shenyang, 110032, China, 86 18642065021, jes61@163.com %K video game %K performance %K cognitive function %K older %K Bayesian network meta-analysis %D 2021 %7 30.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The decline in performance of older people includes balance function, physical function, and fear of falling and depression. General cognitive function decline is described in terms of processing speed, working memory, attention, and executive functioning, and video game interventions may be effective. Objective: This study evaluates the effect of video game interventions on performance and cognitive function in older participants in terms of 6 indicators: balance function, executive function, general cognitive function, physical function, processing speed, and fear of falling and depression. Methods: Electronic databases were searched for studies from inception to June 30, 2020. Randomized controlled trials and case-controlled trials comparing video game interventions versus nonvideo game control in terms of performance and cognitive function outcomes were incorporated into a Bayesian network meta-analysis. All data were continuous variables. Results: In total, 47 studies (3244 participants) were included. In pairwise meta-analysis, compared with nonvideo game control, video game interventions improved processing speed, general cognitive function, and depression scores. In the Bayesian network meta-analysis, interventions with video games improved balance function time (standardized mean difference [SMD] –3.34, 95% credible interval [CrI] –5.54 to –2.56), the cognitive function score (SMD 1.23, 95% CrI 0.82-1.86), processing speed time (SMD –0.29, 95% CrI –0.49 to –0.08), and processing speed number (SMD 0.72, 95% CrI 0.36-1.09), similar to the pairwise meta-analysis. Interventions with video games with strong visual senses and good interactivity ranked first, and these might be more beneficial for the elderly. Conclusions: Our comprehensive Bayesian network meta-analysis provides evidence that video game interventions could be considered for the elderly for improving performance and cognitive function, especially general cognitive scores and processing speed. Games with better interactivity and visual stimulation have better curative effects. Based on the available evidence, we recommend video game interventions for the elderly. Trial Registration: PROSPERO CRD42020197158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197158 %M 34967759 %R 10.2196/27058 %U https://games.jmir.org/2021/4/e27058 %U https://doi.org/10.2196/27058 %U http://www.ncbi.nlm.nih.gov/pubmed/34967759 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30482 %T Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review %A Martinez,Kim %A Menéndez-Menéndez,Maria Isabel %A Bustillo,Andres %+ Department of History, Geography and Communication, University of Burgos, Don Juan de Austria, Burgos, 09001, Spain, 34 947 49 91 12, kmartinez@ubu.es %K serious games %K depression %K anxiety %K children %K adolescents %K virtual reality %K mental health %K detection %K awareness %K prevention %K therapy %D 2021 %7 16.12.2021 %9 Review %J JMIR Serious Games %G English %X Background: Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities. Objective: This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines. Methods: The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents. Results: A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play. Conclusions: The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology. %M 34927589 %R 10.2196/30482 %U https://games.jmir.org/2021/4/e30482 %U https://doi.org/10.2196/30482 %U http://www.ncbi.nlm.nih.gov/pubmed/34927589 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e32199 %T Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis %A Six,Stephanie G %A Byrne,Kaileigh A %A Tibbett,Thomas P %A Pericot-Valverde,Irene %+ Department of Psychology, Clemson University, 418 Brackett Hall, Clemson, SC, 29634, United States, 1 864 656 3935, kaileib@clemson.edu %K depression %K reward %K gamification %K mental health apps %K apps %D 2021 %7 29.11.2021 %9 Review %J JMIR Ment Health %G English %X Background: Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification. Objective: The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements. Methods: A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis. Results: A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=–0.27, 95% CI –0.36 to –0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=–0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=–1.93, SE=2.28; P=.40). Conclusions: The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms. %M 34847058 %R 10.2196/32199 %U https://mental.jmir.org/2021/11/e32199 %U https://doi.org/10.2196/32199 %U http://www.ncbi.nlm.nih.gov/pubmed/34847058 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e29873 %T Reducing Intrusive Memories of Childhood Trauma Using a Visuospatial Intervention: Case Study in Iceland %A Thorarinsdottir,Kristjana %A Holmes,Emily A %A Hardarson,Johann %A Hedinsdottir,Unnur %A Kanstrup,Marie %A Singh,Laura %A Hauksdottir,Arna %A Halldorsdottir,Thorhildur %A Gudmundsdottir,Berglind %A Valdimarsdottir,Unnur %A Thordardottir,Edda Bjork %A Gamble,Beau %A Bjornsson,Andri %+ Department of Psychology, University of Iceland, Sæmundargata 12, Reykjavik, 101, Iceland, 354 6942001, kth35@hi.is %K psychological trauma %K intrusive memories %K case report %K visuospatial interference task %K Tetris gameplay %K mental imagery %K mobile phone %D 2021 %7 4.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Additional interventions are needed for survivors of psychological trauma because of several barriers to and limitations of existing treatment options (eg, need to talk about the trauma in detail). Case studies are an important step in exploring the development of novel interventions, allowing detailed examination of individual responses to treatment over time. Here, we present a case study that aims to test a novel intervention designed to disrupt memory reconsolidation, taking a single-symptom approach by focusing on intrusive memories of a traumatic event. Objective: This study aims to examine a novel brief cognitive intervention to reduce the number of intrusive memories of trauma in an Icelandic setting and to extend previous studies by examining long-term effects for up to 3 months. The intervention was guided by a clinical psychologist and comprised a brief memory reminder, followed by Tetris gameplay with mental rotation, targeting one memory at a time in each session. Methods: This was a single case study in Iceland with a woman in her 50s (drawn from an epidemiological study of trauma) with subthreshold posttraumatic stress disorder and a diagnosis of obsessive-compulsive disorder and social anxiety disorder. The participant had four different intrusive memories from a traumatic event that happened in her childhood. The primary outcome was the change in the number of intrusive memories from baseline to intervention phase and to follow-ups. The number of intrusions was monitored in a daily diary for 4 weeks preintervention, 8 weeks during the intervention, and 1 week at 1-month and 3-month follow-ups. Intrusions were targeted one by one over six intervention sessions, creating four repetitions of an AB design (ie, length of baseline A and intervention phase B varied for each memory). We examined changes in both the total number of intrusions (summed across all four memories) and individually for each memory. In addition, we explored whether having fewer intrusive memories would have an impact on functioning, posttraumatic stress, and depression or anxiety symptoms. Results: The total number of intrusions per week was 12.6 at baseline, 6.1 at the intervention phase (52% reduction from baseline), 3.0 at the 1-month follow-up (76% reduction), and 1.0 at the 3-month follow-up (92% reduction). Reductions in the symptoms of posttraumatic stress and depression were observed postintervention. Sleep, concentration, stress, and functioning improved. The participant considered the gameplay intervention acceptable and helpful in that she found that the memories disappeared while she was playing. Conclusions: This guided brief cognitive intervention reduced the number of intrusive memories over the intervention phase and follow-ups. The brief memory reminder was well tolerated, removing the need to discuss trauma in detail. The next steps require an extension to more cases and exploring remote delivery of the intervention. %M 34734830 %R 10.2196/29873 %U https://formative.jmir.org/2021/11/e29873 %U https://doi.org/10.2196/29873 %U http://www.ncbi.nlm.nih.gov/pubmed/34734830 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26084 %T A Cognitive Behavioral Therapy–, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial %A Thabrew,Hiran %A Stasiak,Karolina %A Kumar,Harshali %A Naseem,Tarique %A Frampton,Christopher %A Merry,Sally %+ Department of Psychological Medicine, University of Auckland, Building 507, School of Medicine, Level 3, 22-30 Park Avenue, Grafton, Auckland, 1011, New Zealand, 64 21 402 055, h.thabrew@auckland.ac.nz %K long-term physical conditions %K chronic illness %K anxiety %K eHealth %K gaming %K young people %K treatment %K cognitive behavioral therapy %K biofeedback %D 2021 %7 24.9.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues. Objective: This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. Methods: Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale. Results: Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (−4.6; P<.001), Spence Child Anxiety Scale (−9.6; P=.005), and the Likert visual analog scales (−2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up. Conclusions: This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443 %M 34559053 %R 10.2196/26084 %U https://games.jmir.org/2021/3/e26084 %U https://doi.org/10.2196/26084 %U http://www.ncbi.nlm.nih.gov/pubmed/34559053 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e22942 %T Comparing a Virtual Reality–Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial %A Stunden,Chelsea %A Stratton,Kirsten %A Zakani,Sima %A Jacob,John %+ Department of Pediatrics, Faculty of Medicine, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada, 1 604 875 2345 ext 2393, john.jacob@cw.bc.ca %K virtual reality %K magnetic resonance imaging simulation %K certified child life specialists %K pediatrics %K magnetic resonance imaging procedures %K alternatives to sedation %K preparing children for MRI %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed. Objective: This study aims to compare the effectiveness of a virtual reality (VR)—based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers’ reported anxiety, procedural data, caregiver usability, child satisfaction, and fun. Methods: This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers’ reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales). Results: A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36%; SPM: 24/84, 29%; and CLP: 30/84, 36%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children’s reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r84=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37). Conclusions: Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting. Trial Registration: Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382 %M 34550072 %R 10.2196/22942 %U https://www.jmir.org/2021/9/e22942 %U https://doi.org/10.2196/22942 %U http://www.ncbi.nlm.nih.gov/pubmed/34550072 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 8 %P e28150 %T Commercial Off-The-Shelf Video Games for Reducing Stress and Anxiety: Systematic Review %A Pallavicini,Federica %A Pepe,Alessandro %A Mantovani,Fabrizia %+ Department of Human Sciences for Education “Riccardo Massa”, University of Milano Bicocca, Piazza dell'Ateneo Nuovo 1, Milano, 20126, Italy, 39 0264484903, federica.pallavicini@gmail.com %K commercial off-the-shelf video games %K video games %K stress %K anxiety %K relaxation %D 2021 %7 16.8.2021 %9 Review %J JMIR Ment Health %G English %X 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 %M 34398795 %R 10.2196/28150 %U https://mental.jmir.org/2021/8/e28150 %U https://doi.org/10.2196/28150 %U http://www.ncbi.nlm.nih.gov/pubmed/34398795 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e31588 %T A Casual Video Game With Psychological Well-being Concepts for Young Adolescents: Protocol for an Acceptability and Feasibility Study %A Pine,Russell %A Mbinta,James %A Te Morenga,Lisa %A Fleming,Theresa %+ School of Health, Victoria University of Wellington, Kelburn, Wellington, 6032, New Zealand, 64 02040864377, Russell.pine@vuw.ac.nz %K digital mental health tools %K casual video games %K young people %D 2021 %7 12.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Many face-to-face and digital therapeutic supports are designed for adolescents experiencing high levels of psychological distress. However, promoting psychological well-being among adolescents is often neglected despite significant short-term and long-term benefits. Objective: This research has 3 main objectives: (1) to assess the acceptability of Match Emoji, a casual video game with psychological well-being concepts among 13-15-year-old students in a New Zealand secondary school; (2) to identify the feasibility of the research process; and (3) to explore the preliminary well-being and therapeutic potential of Match Emoji. Methods: Approximately 40 participants aged 13-15 years from a local secondary college in Wellington, New Zealand, will be invited to download and play Match Emoji 3-4 times a week for 5-15 minutes over a 2-week period. Participants will complete 4 assessments at baseline, postintervention, and 3 weeks later to assess psychological well-being and therapeutic changes. Statistical analysis will be used to synthesize data from interviews and triangulated with assessment changes and game analytics. This synthesis will help to assess the acceptability and feasibility of the Match Emoji. Results: The key outputs from the project will include the acceptability, feasibility, and therapeutic potential of Match Emoji. It is anticipated that participants will have finished playing the recommended game play regimen by August 2021 with analysis of results completed by October 2021. Conclusions: Data from the study are expected to inform future research on Match Emoji including a randomized controlled trial and further adjustments to the design and development of the game. International Registered Report Identifier (IRRID): PRR1-10.2196/31588 %M 34387558 %R 10.2196/31588 %U https://www.researchprotocols.org/2021/8/e31588 %U https://doi.org/10.2196/31588 %U http://www.ncbi.nlm.nih.gov/pubmed/34387558 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26062 %T A Therapeutic Game for Sexually Abused Children and Adolescents (Vil Du?!): Exploratory Mixed Methods Evaluation %A Endendijk,Joyce Johanna %A Tichelaar,Henny %A Deen,Menno %A Deković,Maja %+ Child and Adolescent Studies, Utrecht University, Heidelberglaan 1, Utrecht, 3548 CS, Netherlands, 31 30 253 4896, j.j.endendijk@uu.nl %K child sexual abuse %K psychotherapy %K serious games %K evaluation %K working elements %K acceptability %D 2021 %7 3.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Talking about experiences of sexual abuse in therapy is difficult for children and adolescents. Possible reasons for this difficulty are a lack of vocabulary to describe the situation or feelings of shame, fear, and self-blame associated with sexual abuse. The serious game Vil Du?! was developed to help children open up about their sexual abuse experiences. Vil Du?! is a nonverbal communication game that resembles a dress-up game in which children can show the therapist what happened to them. Objective: This exploratory evaluation study examines which working elements of the game could be identified in therapy with victims of sexual abuse (aim 1). In addition, this study examines how therapists evaluate the acceptability of the game (aim 2). Methods: The therapists completed 23 web-based surveys on the use of Vil Du?! In addition, semistructured interviews were conducted with 10 therapists. The data were analyzed in NVivo following previously reported stepwise guidelines. Results: Regarding aim 1, therapists mentioned various working elements of Vil Du?!; for instance, Vil Du?! puts the child in control of the situation. In addition, Vil Du?! reduces barriers to disclosure because there is no need to talk or have eye contact with the therapist. Regarding aim 2, Vil Du?! was generally evaluated more positively than negatively by the therapists. For instance, therapists indicated that using Vil Du?! is time efficient and might make the treatment process less confronting and difficult for the client. According to therapists, most clients indeed experienced less tension and more positive (or neutral) emotions than negative emotions when using Vil Du?! Conclusions: The most important working elements of Vil Du?!, according to therapists, are that it enables children to regain control over their sexual abuse experiences and reduces barriers to disclosing sexual abuse experiences. The more positive evaluation of Vil Du?! indicates the acceptability of the game for therapists as well as their clients. %M 34342592 %R 10.2196/26062 %U https://games.jmir.org/2021/3/e26062 %U https://doi.org/10.2196/26062 %U http://www.ncbi.nlm.nih.gov/pubmed/34342592 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e26575 %T Gaming Your Mental Health: A Narrative Review on Mitigating Symptoms of Depression and Anxiety Using Commercial Video Games %A Kowal,Magdalena %A Conroy,Eoin %A Ramsbottom,Niall %A Smithies,Tim %A Toth,Adam %A Campbell,Mark %+ Lero, The Science Foundation Ireland Research Centre for Software, Physical Education and Sport Sciences Department, University of Limerick, p1041 PESS building, Castletroy, Limerick, Ireland, 353 061234944, mark.campbell@ul.ie %K commercial video games %K mobile phone %K clinical %K mental health disorders %K psychotherapy %K pandemic %K accessibility %K health care %D 2021 %7 16.6.2021 %9 Viewpoint %J JMIR Serious Games %G English %X Globally, depression and anxiety are the two most prevalent mental health disorders. They occur both acutely and chronically, with various symptoms commonly expressed subclinically. The treatment gap and stigma associated with such mental health disorders are common issues encountered worldwide. Given the economic and health care service burden of mental illnesses, there is a heightened demand for accessible and cost-effective methods that prevent occurrence of mental health illnesses and facilitate coping with mental health illnesses. This demand has been exacerbated post the advent of the COVID-19 pandemic and the subsequent increase in incidence of mental health disorders. To address these demands, a growing body of research is exploring alternative solutions to traditional mental health treatment methods. Commercial video games have been shown to impart cognitive benefits to those playing regularly (ie, attention control, cognitive flexibility, and information processing). In this paper, we specifically focus on the mental health benefits associated with playing commercial video games to address symptoms of depression and anxiety. In light of the current research, we conclude that commercial video games show great promise as inexpensive, readily accessible, internationally available, effective, and stigma-free resources for the mitigation of some mental health issues in the absence of, or in addition to, traditional therapeutic treatments. %M 34132648 %R 10.2196/26575 %U https://games.jmir.org/2021/2/e26575 %U https://doi.org/10.2196/26575 %U http://www.ncbi.nlm.nih.gov/pubmed/34132648 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e24566 %T The Adaptive GameSquad Xbox-Based Physical Activity and Health Coaching Intervention for Youth With Neurodevelopmental and Psychiatric Diagnoses: Pilot Feasibility Study %A Bowling,April B %A Slavet,James %A Hendrick,Chelsea %A Beyl,Robbie %A Nauta,Phillip %A Augustyn,Marilyn %A Mbamalu,Mediatrix %A Curtin,Carol %A Bandini,Linda %A Must,Aviva %A Staiano,Amanda E %+ Department of Public Health and Nutrition, School of Health Sciences, Merrimack College, 315 Turnpike Street, North Andover, MA, 01845, United States, 1 978 837 5187, bowlinga@merrimack.edu %K exercise %K diet %K sleep %K mental health %K children %K adolescent %K health promotion %K telehealth %K exergaming %D 2021 %7 14.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The prevalence of neurodevelopmental and psychiatric diagnoses (NPDs) in youth is increasing, and unhealthy physical activity (PA), diet, screen time, and sleep habits contribute to the chronic disease disparities and behavioral challenges this population experiences. Objective: This pilot study aims to adapt a proven exergaming and telehealth PA coaching intervention for typically developing youth with overweight or obesity; expand it to address diet, screen, and sleep behaviors; and then test its feasibility and acceptability, including PA engagement, among youth with NPDs. Methods: Participants (N=23; mean age 15.1 years, SD 1.5; 17 males, 9 people of color) recruited in person from clinic and special education settings were randomized to the Adaptive GameSquad (AGS) intervention or wait-list control. The 10-week adapted intervention included 3 exergaming sessions per week and 6 real-time telehealth coaching sessions. The primary outcomes included feasibility (adherence to planned sessions), engagement (uptake and acceptability as reported on process questionnaires), and PA level (combined light, moderate, and vigorous as measured by accelerometer). Descriptive statistics summarized feasibility and engagement data, whereas paired, two-tailed t tests assessed group differences in pre-post PA. Results: Of the 6 coaching sessions, AGS participants (n=11; mean age 15.3 years, SD 1.2; 7 males, 4 people of color) completed an average of 5 (83%), averaging 81.2 minutes per week of exergaming. Of 9 participants who completed the exit questionnaire, 6 (67%) reported intention to continue, and 8 (89%) reported feeling that the coaching sessions were helpful. PA and sleep appeared to increase during the course of the intervention over baseline, video game use appeared to decrease, and pre-post intervention PA per day significantly decreased for the control (−58.8 min; P=.04) but not for the intervention group (−5.3 min; P=.77), despite potential seasonality effects. However, beta testers and some intervention participants indicated a need for reduced complexity of technology and more choice in exergames. Conclusions: AGS shows promise in delivering a health behavior intervention remotely to youth with NPDs, but a full-scale efficacy trial with a larger sample size is needed to confirm this finding. On the basis of feedback from beta testers and intervention participants, the next steps should include reduced technology burden and increased exergame choice before efficacy testing. Trial Registration: ClinicalTrials.gov NCT03665415; https://clinicaltrials.gov/ct2/show/NCT03665415. %M 33988508 %R 10.2196/24566 %U https://formative.jmir.org/2021/5/e24566 %U https://doi.org/10.2196/24566 %U http://www.ncbi.nlm.nih.gov/pubmed/33988508 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e25462 %T Evaluation of the Implementation and Effectiveness of Community-Based Brain-Computer Interface Cognitive Group Training in Healthy Community-Dwelling Older Adults: Randomized Controlled Implementation Trial %A Yeo,Pei Shi %A Nguyen,Tu Ngoc %A Ng,Mary Pei Ern %A Choo,Robin Wai Munn %A Yap,Philip Lin Kiat %A Ng,Tze Pin %A Wee,Shiou Liang %+ Geriatric Education and Research Institute, 2 Yishun Central 2, Tower E, Level 4, Singapore, 768024, Singapore, 65 6592 4606, weeshiouliang@gmail.com %K group-based computerized cognitive training %K cognition %K gait %K community program implementation %K healthy older adults %K cognitive %K community program %K cognitive training %K elderly %K aging %D 2021 %7 27.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Cognitive training can improve cognition in healthy older adults. Objective: The objectives are to evaluate the implementation of community-based computerized cognitive training (CCT) and its effectiveness on cognition, gait, and balance in healthy older adults. Methods: A single-blind randomized controlled trial with baseline and follow-up assessments was conducted at two community centers in Singapore. Healthy community-dwelling adults aged 55 years and older participated in a 10-week CCT program with 2-hour instructor-led group classes twice a week. Participants used a mobile app to play games targeting attention, memory, decision making, visuospatial abilities, and cognitive flexibility. Implementation was assessed at the participant, provider, and community level (eg, reach, implementation, and facilitators and barriers). Effectiveness measures were the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Color Trails Test 2 (CTT-2), Berg Balance Scale, and GAITRite walkway measures (single and dual task gait speed, dual task cost, and single and dual task gait variability index [GVI]). Results: A total of 94 healthy community-dwelling adults participated in the CCT program (mean age 68.8 [SD 6.3] years). Implementation measures revealed high reach (125/155, 80.6%) and moderate adherence but poor penetration of sedentary older adults (43/125, 34.4%). The effectiveness data were based on intention-to-treat (ITT) and per-protocol (PP) analysis. In the ITT analysis, single task GVI increased (b=2.32, P=.02, 95% CI [0.30 to 4.35]) and RBANS list recognition subtest deteriorated (b=–0.57, P=.01, 95% CI [–1.00 to –0.14]) in both groups. In the PP analysis, time taken to complete CTT-2 (b=–13.5, P=.01, 95% CI [–23.95 to –3.14]; Cohen d effect size = 0.285) was faster in the intervention group. Single task gait speed was not statistically significantly maintained in the intervention group (b=5.38, P=.06, 95% CI [–0.30 to 11.36]) and declined in the control group (Cohen d effect size = 0.414). PP analyses also showed interaction terms for RBANS list recall subtest (b=–0.36, P=.08, 95% CI [–0.75 to 0.04]) and visuospatial domain (b=0.46, P=.08, 95% CI [–0.05 to 0.96]) that were not statistically significant. Conclusions: CCT can be implemented in community settings to improve attention and executive function among healthy older adults. Findings help to identify suitable healthy aging programs that can be implemented on a larger scale within communities. Trial Registration: ClinicalTrials.gov NCT04439591; https://clinicaltrials.gov/ct2/show/NCT04439591 %M 33904819 %R 10.2196/25462 %U https://formative.jmir.org/2021/4/e25462 %U https://doi.org/10.2196/25462 %U http://www.ncbi.nlm.nih.gov/pubmed/33904819 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e21115 %T The Moderating Role of Coping Mechanisms and Being an e-Sport Player Between Psychiatric Symptoms and Gaming Disorder: Online Survey %A Bányai,Fanni %A Zsila,Ágnes %A Kökönyei,Gyöngyi %A Griffiths,Mark D %A Demetrovics,Zsolt %A Király,Orsolya %+ Centre of Excellence in Responsible Gaming, University of Gibraltar, Europa Point Campus, Europa Point, Gibraltar, GX111AA, Gibraltar, 36 30 976 1097, zsolt.demetrovics@unigib.edu.gi %K gaming disorder %K esports %K professional gaming %K video games %K coping skills %K psychiatric symptoms %K psychiatry %K mental health %K gaming %D 2021 %7 23.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The emerging popularity of playing video games (gaming) as a hobby and as a professional sport raises awareness about both the benefits and possible downsides of the activity. Although a healthy and passionate hobby for most, a minority of gamers experience addiction-like symptoms and are considered to have gaming disorder (GD). GD has previously been found to be related to aversive conditions, such as depression or anxiety, as well as putatively maladaptive coping strategies. Objective: The aim of this study is twofold: to explore the moderating effect of different coping strategies and type of video game usage (professional [e-sport] or recreational) on the relationship between psychiatric symptoms and GD. Methods: A sample of 3476 gamers (n=3133, 90.13% males; mean age 23.20, SD 6.48 years) was recruited via the website and social networking site of the most popular gaming magazine in Hungary (GameStar). Results: The main effect of psychiatric symptoms was moderate to large in all models, whereas the moderation effects were significant (P<.001) for 4 out of 8 coping strategies (ie, self-blame/self-distraction, denial, emotional/social support, and active coping). However, the explained variance of the models only increased negligibly (from 0.3% to 0.5%) owing to the moderation effect. The direction of the moderations was as expected (ie, putatively maladaptive strategies were associated with more GD symptoms when the level of psychiatric symptoms was high, while putatively adaptive strategies were associated with less). Furthermore, no considerable moderation effect of the player type (recreational vs professional players) was found on the association between psychiatric symptoms and GD (β=.04; P=.02; 0.1% change in the explained variance). Conclusions: Future studies should be designed to better understand coping-related mechanisms in the context of video gaming and GD. %M 33755024 %R 10.2196/21115 %U https://mental.jmir.org/2021/3/e21115 %U https://doi.org/10.2196/21115 %U http://www.ncbi.nlm.nih.gov/pubmed/33755024 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e24078 %T Emotional Bias Modification for Individuals With Attention Deficit Hyperactivity Disorder: Protocol for a Co-Design Study %A Zhang,Melvyn %A Vallabhajosyula,Ranganath %A Fung,Daniel %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Level 18 Family Medicine and Primary Care, Singapore, 308322, Singapore, 65 63892000, melvynzhangweibin@gmail.com %K emotional bias %K cognitive biases %K ADHD %K child psychiatry %D 2020 %7 23.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a worldwide prevalence rate of 5%. Individuals with ADHD often tend to have difficulties with emotional regulation. The advances in experimental psychology have led to the discovery of emotional biases. Targeting emotional biases could potentially help improve the core symptoms of irritability and short-temperedness among these individuals. Emotional biases refer to the preferential allocation of attention toward emotional stimuli. A recent study reported the presence of emotional biases among individuals with ADHD when they compared individuals with ADHD with those without. Gamification technologies have been explored to help diminish the repetitiveness of the task and increase the intrinsic motivation to train. These inconsistent findings of the impact of gaming on the effectiveness of mobile interventions call for further work to better understand the needs of patients (users) and health care professionals. Objective: The aim of this research study is to collate health care professionals’ perspectives on the limitations of the existing task, and to determine if gamification elements could be incorporated, to refine the conventional intervention. Methods: A qualitative research approach, that of a focus group, will be used. Health care professionals from the Department of Development Psychiatry, Institute of Mental Health, Singapore will be invited to participate in this qualitative research. During the focus group, participants are to comment on the limitations of the existing emotional bias intervention; recommend strategies to improve the intervention; and provide their perspectives pertaining to the use of gamification to improve the intervention. Results: We expect that the study will be completed in 12 months from the publication of this protocol. Conclusions: To our best knowledge, this is perhaps one of the only few studies that have attempted to explore emotional biases among adolescents with ADHD. International Registered Report Identifier (IRRID): PRR1-10.2196/24078 %M 33355536 %R 10.2196/24078 %U http://www.researchprotocols.org/2020/12/e24078/ %U https://doi.org/10.2196/24078 %U http://www.ncbi.nlm.nih.gov/pubmed/33355536 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e20889 %T Evidence on Virtual Reality–Based Therapies for Psychiatric Disorders: Meta-Review of Meta-Analyses %A Dellazizzo,Laura %A Potvin,Stéphane %A Luigi,Mimosa %A Dumais,Alexandre %+ Research Center of the Institut Universitaire en Santé Mentale de Montréal, 7331 Hochelaga, Montreal, QC, H1N 3V2, Canada, 1 514 251 4000 ext 3925, alexandre.dumais@umontreal.ca %K systematic review %K virtual reality %K therapy %K mental disorders %K meta-analysis %D 2020 %7 19.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Among all diseases globally, mental illnesses are one of the major causes of burden. As many people are resistant to conventional evidence-based treatments, there is an unmet need for the implementation of novel mental health treatments. Efforts to increase the effectiveness and benefits of evidence-based psychotherapy in psychiatry have led to the emergence of virtual reality (VR)–based interventions. These interventions have shown a wide range of advantages over conventional psychotherapies. Currently, VR-based interventions have been developed mainly for anxiety-related disorders; however, they are also used for developmental disorders, severe mental disorders, and neurocognitive disorders. Objective: This meta-review aims to summarize the current state of evidence on the efficacy of VR-based interventions for various psychiatric disorders by evaluating the quality of evidence provided by meta-analytical studies. Methods: A systematic search was performed using the following electronic databases: PubMed, PsycINFO, Web of Science, and Google Scholar (any time until February 2020). Meta-analyses were included as long as they quantitatively examined the efficacy of VR-based interventions for symptoms of a psychiatric disorder. To avoid overlap among meta-analyses, for each subanalysis included within this meta-review, only one analysis provided from one meta-analysis was selected based on the best quality of evidence. Results: The search retrieved 11 eligible meta-analyses. The quality of evidence varied from very low to moderate quality. Several reasons account for the lower quality evidence, such as a limited number of randomized controlled trials, lack of follow-up analysis or control group, and the presence of heterogeneity and publication bias. Nonetheless, evidence has shown that VR-based interventions for anxiety-related disorders display overall medium-to-large effects when compared with inactive controls but no significant difference when compared with standard evidence-based approaches. Preliminary data have highlighted that such effects appear to be sustained in time, and subjects may fare better than active controls. Neurocognitive disorders also appear to improve with VR-based approaches, with small effects being found for various clinical outcomes (eg, cognition, emotion). Finally, there are insufficient data to classify VR-based interventions as an evidence-based practice for social skills training in neurodevelopmental disorders and compliance among patients with schizophrenia. Conclusions: VR provides unlimited opportunities by tailoring approaches to specific complex problems and individualizing the intervention. However, VR-based interventions have not shown superiority compared with usual evidence-based treatments. Future VR-based interventions should focus on developing innovative approaches for complex and treatment-resistant symptoms that are difficult to address with traditional treatments. Future research should also aim to gain a better understanding of the potential factors that may mediate VR outcomes to improve treatment. %M 32812889 %R 10.2196/20889 %U http://www.jmir.org/2020/8/e20889/ %U https://doi.org/10.2196/20889 %U http://www.ncbi.nlm.nih.gov/pubmed/32812889 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18644 %T The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis %A Vermeir,Julie F %A White,Melanie J %A Johnson,Daniel %A Crombez,Geert %A Van Ryckeghem,Dimitri M L %+ School of Psychology and Counselling, Institute of Health and Biomedical Innovation, Queensland University of Technology, 170 Victoria Park Road, Brisbane, 4059, Australia, 61 731384714, julie.vermeir@hdr.qut.edu.au %K gamification %K cognition %K health %K systematic review %K meta-analysis %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X 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. %M 32773374 %R 10.2196/18644 %U https://games.jmir.org/2020/3/e18644 %U https://doi.org/10.2196/18644 %U http://www.ncbi.nlm.nih.gov/pubmed/32773374 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18687 %T Mapping Behavioral Health Serious Game Interventions for Adults With Chronic Illness: Scoping Review %A Thomas,Teresa Hagan %A Sivakumar,Varshini %A Babichenko,Dmitriy %A Grieve,Victoria L B %A Klem,Mary Lou %+ School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, United States, 1 4126243799, t.thomas@pitt.edu %K review %K chronic disease %K behavioral sciences %K video games %D 2020 %7 30.7.2020 %9 Review %J JMIR Serious Games %G English %X Background: Serious games for health are increasingly being used to address health outcomes in patients with chronic illnesses. These studies vary in their study designs, patient populations, frameworks, outcome variables, and degree of specificity of the serious game intervention. Objective: This scoping review aims to clarify the conceptual features of the existing research related to serious games designed to improve cognitive and behavioral outcomes in adults with chronic illness. Methods: We applied the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for scoping reviews (PRISMA-ScR) methodology, including an a priori research question. We searched 4 electronic databases to identify articles published through November 2019. Inclusion criteria encompassed (1) adults 18 years or older; (2) patients with a diagnosis of chronic illness; (3) a serious game intervention; and (4) defined patient outcomes that assess patients’ behavioral, cognitive, or health outcomes. Results: Of the 3305 articles identified, 38 were included in the review. We charted and analyzed the theoretical frameworks, key concepts, and outcome variables of these studies with summaries of features across articles. The majority of studies used a randomized controlled trial design (23/38, 61%), included a custom serious game intervention (22/38, 58%), and lacked a theoretical framework (25/38, 66%). Common outcome variables included quality of life (16/38, 42%), mood (15/38, 39%), cognitive function (13/38, 34%), symptoms (12/38, 32%), and physical activity (9/38, 24%). Key differences between studies included whether or not serious games aimed to train versus teach patients, be widely accessible versus tailored interventions, or replace versus complement current treatments. Conclusions: This scoping review defines the current landscape of research in serious games for health research targeting behavioral and cognitive outcomes in adults with chronic disease. Studies have addressed a variety of patient populations and diverse patient outcomes. Researchers wanting to build on the current research should integrate theoretical frameworks into the design of the intervention and trial to more clearly articulate the active ingredients and mechanisms of serious games. %M 32729836 %R 10.2196/18687 %U http://games.jmir.org/2020/3/e18687/ %U https://doi.org/10.2196/18687 %U http://www.ncbi.nlm.nih.gov/pubmed/32729836 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14958 %T An Integrative Model for the Effectiveness of Biofeedback Interventions for Anxiety Regulation: Viewpoint %A Weerdmeester,Joanneke %A van Rooij,Marieke MJW %A Engels,Rutger CME %A Granic,Isabela %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 243612076, j.weerdmeester@psych.ru.nl %K biofeedback %K neurofeedback %K anxiety %K appraisal %K mechanisms %K mental health %K eHealth %K video games %K wearable technology %K review %K mobile phone %D 2020 %7 23.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Biofeedback has shown to be a promising tool for the treatment of anxiety; however, several theoretical as well as practical limitations have prevented widespread adaptation until now. With current technological advances and the increasing interest in the use of self-monitoring technology to improve mental health, we argue that this is an ideal time to launch a new wave of biofeedback training. In this viewpoint paper, we reflect on the current state of biofeedback training, including the more traditional techniques and mechanisms that have been thought to explain the effectiveness of biofeedback such as the integration of operant learning and meditation techniques, and the changes in interoceptive awareness and physiology. Subsequently, we propose an integrative model that includes a set of cognitive appraisals as potential determinants of adaptive trajectories within biofeedback training such as growth mindset, self-efficacy, locus of control, and threat-challenge appraisals. Finally, we present a set of detailed guidelines based on the integration of our model with the mechanics and mechanisms offered by emerging interactive technology to encourage a new phase of research and implementation using biofeedback. There is a great deal of promise for future biofeedback interventions that harness the power of wearables and video games, and that adopt a user-centered approach to help people regulate their anxiety in a way that feels engaging, personal, and meaningful. %M 32706654 %R 10.2196/14958 %U https://www.jmir.org/2020/7/e14958 %U https://doi.org/10.2196/14958 %U http://www.ncbi.nlm.nih.gov/pubmed/32706654 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14865 %T Habits and Attitudes of Video Gaming and Information Technology Use in People with Schizophrenia: Cross-Sectional Survey %A Choi,William TH %A Yu,Dan KS %A Wong,Terry %A Lantta,Tella %A Yang,Min %A Välimäki,Maritta %+ Department of Nursing Science, Faculty of Medicine, University of Turku, ICT-City, A-wing, 5th floor, Joukahaisenkatu 3–5, Turku, 20520, Finland, 358 29 450 236, maritta.valimaki@polyu.edu.hk %K video gaming %K internet %K information technology %K schizophrenia %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information technology and video gaming have potential advantages in the treatment of schizophrenia. However, information regarding the habits and attitudes related to internet use and video gaming in people with schizophrenia is limited. Objective: The aim of this study was to explore the habits and attitudes regarding video gaming and information technology usage and their associated factors in people with schizophrenia in Hong Kong. Methods: In this cross-sectional survey, service users with schizophrenia were recruited from 6 halfway hostels and 7 integrated centers for mental wellness in Hong Kong. A 79-item self-report questionnaire was utilized to explore the habits of internet use and video gaming in these people with schizophrenia. The attitude toward video gaming was assessed using the Gaming Attitudes, Motivations, and Experiences Scales. Of the 148 individuals in a convenience sample who were invited to participate in this study, 110 willingly participated (a response rate of 74.3%). The data were analyzed using descriptive statistics, a two-tailed independent t test, Pearson correlation, and principal analysis with 3 methods of rotation (varimax, equimax, and promax). Results: Most participants (100/110, 90.9%) had access to the internet and half of them (54/110, 49.1%) used the internet daily mostly to watch videos (66/110, 60.0%) or read news or books, etc (42/110, 38.2%). One-third of the participants (36/110, 32.7%) used the internet to play web-based games, and most of them (88/110, 80.0%) had played a video game in the past year. The most favorable gaming platforms were cellular phones (43/88, 49%) followed by computers (19/88, 22%) and arcade cabinets (6/88, 7%). The most favorable game genre was action games (34/145, 23.4%). Those who had a bachelor’s degree or higher scored lower in social interaction than those with a lower education level (P=.03). Those who played video games daily scored higher in the category of story than those who did not play daily (t86=2.03, P=.05). The most popular gaming category was autonomy and the least popular categories were violent catharsis and violent reward. Two motives, “social playing” and “evasive playing,” were formed to describe the characteristics of playing video games. Conclusions: Our data showed a high internet utilization rate among people with schizophrenia in Hong Kong. Only a few of them used the internet to search for health-related information. Our study also exemplified the unique habits of gaming among the participants. Health care professionals could utilize video games to engage people with schizophrenia and promote coping with stress and provide social skills training to such people with schizophrenia. Identification of the gaming attitudes can contribute to the development of serious games for the schizophrenic population. Further investigation is vital for the promotion of mental health through web-based platforms. %M 32459646 %R 10.2196/14865 %U http://www.jmir.org/2020/7/e14865/ %U https://doi.org/10.2196/14865 %U http://www.ncbi.nlm.nih.gov/pubmed/32459646 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e13834 %T Digital Game Interventions for Youth Mental Health Services (Gaming My Way to Recovery): Protocol for a Scoping Review %A Ferrari,Manuela %A McIlwaine,Sarah V %A Reynolds,Jennifer Ann %A Archie,Suzanne %A Boydell,Katherine %A Lal,Shalini %A Shah,Jai L %A Henderson,Joanna %A Alvarez-Jimenez,Mario %A Andersson,Neil %A Boruff,Jill %A Nielsen,Rune Kristian Lundedal %A Iyer,Srividya N %+ Douglas Mental Health University Institute, 6875 Boulevard LaSalle, Perry C3 E-3102, Montreal, QC, H4H 1R3, Canada, 1 514 761 6131 ext 3445, manuela.ferrari@douglas.mcgill.ca %K mental health %K mental disorders %K biomedical technology %K video games %K virtual reality %K mental health services %D 2020 %7 24.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Digital or video games are played by millions of adolescents and young adults around the world and are one of the technologies used by youths to access mental health services. Youths with mental health problems strongly endorse the use of technologies, including mobile and online platforms, to receive information, support their treatment journeys (eg, decision-making tools), and facilitate recovery. A growing body of literature explores the advantages of playing digital games for improving attention span and memory, managing emotions, promoting behavior change, and supporting treatment for mental illness (eg, anxiety, depression, or posttraumatic stress disorder). The research field has also focused on the negative impact of video games, describing potential harms related to aggression, addiction, and depression. To promote clarity on this matter, there is a great need for knowledge synthesis offering recommendations on how video games can be safely and effectively adopted and integrated into youth mental health services. Objective: The Gaming My Way to Recovery scoping review project assesses existing evidence on the use of digital game interventions within the context of mental health services for youths (aged 11-29 years) using the stepped care model as the conceptual framework. The research question is as follows: For which youth mental health conditions have digital games been used and what broad objectives (eg, prevention, treatment) have they addressed? Methods: Using the methodology proposed by Arksey and O’Malley, this scoping review will map the available evidence on the use of digital games for youths between 11 and 29 years old with mental health or substance use problems, or both. Results: The review will bring together evidence-based knowledge to assist mental health providers and policymakers in evaluating the potential benefits and risks of these interventions. Following funding of the project in September 2018, we completed the search in November 2018, and carried out data screening and stakeholder engagement activities during preparation of the protocol. We will conduct a knowledge synthesis based on specific disorders, treatment level and modality, type of service, population, settings, ethical practices, and user engagement and offer recommendations concerning the integration of video game technologies and programs, future research and practice, and knowledge dissemination. Conclusions: Digital game interventions employ unique, experiential, and interactive features that potentially improve skills and facilitate learning among players. Digital games may also provide a new treatment platform for youths with mental health conditions. Assessing current knowledge on video game technology and interventions may potentially improve the range of interventions offered by youth mental health services while supporting prevention, intervention, and treatment. International Registered Report Identifier (IRRID): PRR1-10.2196/13834 %M 32579117 %R 10.2196/13834 %U http://www.researchprotocols.org/2020/6/e13834/ %U https://doi.org/10.2196/13834 %U http://www.ncbi.nlm.nih.gov/pubmed/32579117 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17121 %T Age-Associated Capacity to Progress When Playing Cognitive Mobile Games: Ecological Retrospective Observational Study %A Bonnechère,Bruno %A Bier,Jean-Christophe %A Van Hove,Olivier %A Sheldon,Sally %A Samadoulougou,Sékou %A Kirakoya-Samadoulougou,Fati %A Klass,Malgorzata %+ Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Lennik street 808, Brussels, 1070, Belgium, 32 5554013, bbonnech@ulb.ac.be %K cognitive performance %K brain training %K cognitive monitoring %K mobile games %K aging %K serious games %D 2020 %7 12.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The decline of cognitive function is an important issue related to aging. Over the last few years, numerous mobile apps have been developed to challenge the brain with cognitive exercises; however, little is currently known about how age influences capacity for performance improvement when playing cognitive mobile games. Objective: The objective of this study was to analyze the score data of cognitive mobile games over a period of 100 gaming sessions to determine age-related learning ability for new cognitive tasks by measuring the level of score improvement achieved by participants of different ages. Methods: Scores from 9000 individuals of different ages for 7 cognitive mobile games over 100 gaming sessions were analyzed. Scores from the first session were compared between age groups using one-way analysis of variance. Mixed models were subsequently used to investigate the progression of scores over 100 sessions. Results: Statistically significant differences were found between age groups for the initial scores of 6 of the 7 games (linear trend, P<.001). Cognitive mobile game scores increased for all participants (P<.001) suggesting that all participants were able to improve their performance. The rate of improvement was, however, strongly influenced by the age of the participant with slower progression for older participants (P<.001). Conclusions: This study provides evidence to support two interesting insights—cognitive mobile game scores appear to be sensitive to the changes in cognitive ability that occur with advancing age; therefore, these games could be a convenient way to monitor cognitive function over long-term follow-up, and users who train with the cognitive mobile games improve regardless of age. %M 32530432 %R 10.2196/17121 %U http://games.jmir.org/2020/2/e17121/ %U https://doi.org/10.2196/17121 %U http://www.ncbi.nlm.nih.gov/pubmed/32530432 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14369 %T Can Social Communication Skills for Children Diagnosed With Autism Spectrum Disorder Rehearsed Inside the Video Game Environment of Minecraft Generalize to the Real World? %A Cadieux,Lee %A Keenan,Mickey %+ School of Arts and Humanities, Ulster University, MA205 Magee Campus, Northland Road, Londonderry, BT48 7JL, United Kingdom, 44 2871675025, l.cadieux@ulster.ac.uk %K autism %K behavior analysis %K serious games %K social skills %K gamification %K Lego %K neurodiversity %K Minecraft %K virtual worlds %K virtual reality %D 2020 %7 12.5.2020 %9 Viewpoint %J JMIR Serious Games %G English %X In this paper, we outline opportunities within the video game environment for building skills applicable to real-world issues faced by some children. The game Minecraft is extremely popular and of particular interest to children diagnosed with autism spectrum disorder. Although the game has been used by support communities to facilitate the social interaction of children and peer support for their parents, little has been done to examine how social skills developed within the game environment generalize to the real world. Social Craft aims to establish a framework in which key social communication skills would be rehearsed in-game with a view to facilitating their replication in a similarly contained real-world environment. Central to this approach is an understanding of the basic principles of behavior and the engagement of a sound methodology for the collection of data inside and outside the respective environments. %M 32396129 %R 10.2196/14369 %U http://games.jmir.org/2020/2/e14369/ %U https://doi.org/10.2196/14369 %U http://www.ncbi.nlm.nih.gov/pubmed/32396129 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e15164 %T Gamified Mobile Computerized Cognitive Behavioral Therapy for Japanese University Students With Depressive Symptoms: Protocol for a Randomized Controlled Trial %A Yokomitsu,Kengo %A Irie,Tomonari %A Sekiguchi,Mayu %A Shimizu,Ayako %A Matsuoka,Hirofumi %A Merry,Sally Nicola %A Stasiak,Karolina %+ College of Comprehensive Psychology, Ritsumeikan University, 2-150 Iwakura-cho, Ibaraki, Osaka, 567-8570, Japan, 81 72 665 2490, k-yoko@fc.ritsumei.ac.jp %K SPARX %K Japan %K university students %K depressive symptoms %D 2020 %7 7.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Evidence shows that computerized self-help interventions are effective for reducing symptoms of depression. One such intervention, SPARX, is a gamified mobile computerized cognitive behavioral therapy (cCBT) developed for adolescents in New Zealand, which was shown to be as effective as usual care for young people with mild-to-moderate symptoms of depression. However, gamified cCBT has not yet been tested in Japan. Objective: This trial is designed to investigate whether a Japanese-adapted version of SPARX improves depressive symptoms in Japanese university students with mild-to-moderate depressive symptoms. Methods: In this 7-week, multicenter, stratified, parallel-group, superiority randomized trial, participants will be allocated to either a treatment condition (SPARX) or a wait-list control condition. SPARX is a fully automated program, which will be delivered to the mobile phone or tablet device of the participants. SPARX is designed as an interactive fantasy game to guide the user through seven modules that teach key CBT strategies. All participants will be recruited from universities via advertisements on online bulletin boards, the campus newspaper, and posters. Participants in the treatment condition will use the SPARX program weekly. The primary outcome is the reduction of depressive symptoms (using Patient Health Questionnaires-9) measured at baseline and weekly: once after the 7-week intervention and once at a 1-month follow-up. Secondary outcomes include satisfaction with the program and satisfaction with life, measured by the Satisfaction With Life Scale; positive and negative moods, measured by the Profile of Mood States Second Edition; social functioning, measured by the EuroQol Instrument; rumination, measured by the Ruminative Responses Scale; and coping, measured by the Brief Coping Orientation to Problem Experienced Inventory. Results: This study received funding from The Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, and obtained institutional review board approval in September 2019. Data collection began in April 2019. Conclusions: Results of this trial may provide further evidence for the efficacy of gamified cCBT for the treatment of depression and, specifically, provide support for using SPARX with Japanese university students. Trial Registration: Japan Primary Registries Network UMIN000034354; https://tinyurl.com/uu7xd77 International Registered Report Identifier (IRRID): DERR1-10.2196/15164 %M 32254045 %R 10.2196/15164 %U https://www.researchprotocols.org/2020/4/e15164 %U https://doi.org/10.2196/15164 %U http://www.ncbi.nlm.nih.gov/pubmed/32254045 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e16066 %T Efficacy of a Virtual Reality Biofeedback Game (DEEP) to Reduce Anxiety and Disruptive Classroom Behavior: Single-Case Study %A Bossenbroek,Rineke %A Wols,Aniek %A Weerdmeester,Joanneke %A Lichtwarck-Aschoff,Anna %A Granic,Isabela %A van Rooij,Marieke M J W %+ Behavioural Science Institute, Radboud University, PO Box 9104, Nijmegen, 6500 HE, Netherlands, 31 243612638, r.bossenbroek@pwo.ru.nl %K anxiety %K disruptive behavior %K single-case study %K applied game %K serious games %K special education %K attention-deficit/hyperactivity disorder (ADHD) %K autism spectrum disorder (ASD) %K adolescents %D 2020 %7 24.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many adolescents in special education are affected by anxiety in addition to their behavioral problems. Anxiety leads to substantial long-term problems and may underlie disruptive behaviors in the classroom as a result of the individual’s inability to tolerate anxiety-provoking situations. Thus, interventions in special needs schools that help adolescents cope with anxiety and, in turn, diminish disruptive classroom behaviors are needed. Objective: This study aimed to evaluate the effect of a virtual reality biofeedback game, DEEP, on daily levels of state-anxiety and disruptive classroom behavior in a clinical sample. In addition, the study also aimed to examine the duration of the calm or relaxed state after playing DEEP. Methods: A total of 8 adolescents attending a special secondary school for students with behavioral and psychiatric problems participated in a single-case experimental ABAB study. Over a 4-week period, participants completed 6 DEEP sessions. In addition, momentary assessments (ie, 3 times a day) of self-reported state-anxiety and teacher-reported classroom behavior were collected throughout all A and B phases. Results: From analyzing the individual profiles, it was found that 6 participants showed reductions in anxiety, and 5 participants showed reductions in disruptive classroom behaviors after the introduction of DEEP. On a group level, results showed a small but significant reduction of anxiety (d=–0.29) and a small, nonsignificant reduction of disruptive classroom behavior (d=−0.16) on days when participants played DEEP. Moreover, it was found that the calm or relaxed state of participants after playing DEEP lasted for about 2 hours on average. Conclusions: This study demonstrates the potential of the game, DEEP, as an intervention for anxiety and disruptive classroom behavior in a special school setting. Future research is needed to fully optimize and personalize DEEP as an intervention for the heterogeneous special school population. %M 32207697 %R 10.2196/16066 %U http://mental.jmir.org/2020/3/e16066/ %U https://doi.org/10.2196/16066 %U http://www.ncbi.nlm.nih.gov/pubmed/32207697 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e15871 %T Co-designing a Mobile Gamified Attention Bias Modification Intervention for Substance Use Disorders: Participatory Research Study %A Zhang,Melvyn %A Heng,Sandor %A Song,Guo %A Fung,Daniel SS %A Smith,Helen E %+ National Addictions Management Service, Institute of Mental Health, 10 Buangkok Green Medical Park, Singapore, 539747, Singapore, 65 63892000, melvynzhangweibin@gmail.com %K attention bias %K cognitive bias %K gamification %K participatory design research %K psychiatry %K apps %K cognitive bias %K mobile intervention %D 2019 %7 3.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Advances in experimental psychology have highlighted the need to modify underlying automatic cognitive biases, such as attentional biases. The effectiveness of bias modification has been well studied for substance use disorders. With recent advances in technology, it is now possible to work outside the laboratory with Web-based and mobile-based attention bias interventions. Gamification technologies might also help diminish the repetitiveness of the task and increase the intrinsic motivation to train. The inconsistent findings of the impact of gaming on the effectiveness of mobile interventions call for further work to better understand the needs of patients (users) and health care professionals. Objective: The aim of this study was to involve patients, together with health care professionals, in the design of a gamified mobile attention bias modification intervention for substance use disorders. Methods: The participatory design research method adopted is that of a user-oriented design approach in the form of a future workshop. In the first phase of the workshop, participants shared their critique of an attention bias modification intervention. In the second phase of the workshop, participants were asked to brainstorm features. Participants were also shown gamification approaches and asked to consider if gaming elements could enhance the existing app. In the last phase, participants were asked to sketch a new prototype. Results: Three co-design workshops were conducted with health care professionals, inpatients, and outpatients. There were 20 participants, consisting of 10 health care professionals and 10 patients. When asked to identify the limitations in the existing app, common issues identified were those of the design, visual probe task, and the included images. Outpatients were also concerned with the safety of administration of the intervention. In the brainstorming sessions, health care professionals made recommendations as to how the stimulus, the mechanism of responding, and the presentation of the scores could be enhanced. Inpatient participants recommended the addition of functionalities, such as information on the harms associated with the substance use, and for there to be enhancements in the design, images, and task. Outpatient participants perceived a need to improve the images and presentation of the results and recommended the inclusion of gaming features. There were differences in opinion on the inclusion of gaming features, as only health care professionals endorsed their inclusion. In the last phase of the workshop, participants were tasked with the conceptualization of prototypes, and the commonality in the design was for a gradual shortening of the interval for stimulus/image presentation. Conclusions: The results from this research will guide the development of an app that meets the specific needs of patients and is still based on a pre-existing validated task paradigm.   %M 31584003 %R 10.2196/15871 %U https://mhealth.jmir.org/2019/10/e15871 %U https://doi.org/10.2196/15871 %U http://www.ncbi.nlm.nih.gov/pubmed/31584003 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 7 %P e12853 %T Digital Games and Mindfulness Apps: Comparison of Effects on Post Work Recovery %A Collins,Emily %A Cox,Anna %A Wilcock,Caroline %A Sethu-Jones,Geraint %+ School of Management, University of Bath, Claverton Down, Bath, BA2 7AY, United Kingdom, 44 01225 388388, e.i.m.collins@bath.ac.uk %K play %K occupational health %K mindfulness %D 2019 %7 18.07.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Engagement in activities that promote the dissipation of work stress is essential for post work recovery and consequently for well-being. Previous research suggests that activities that are immersive, active, and engaging are especially effective at promoting recovery. Therefore, digital games may be able to promote recovery, but little is known about how they compare with other popular mobile activities, such as mindfulness apps that are specifically designed to support well-being. Objective: The aim of this study was to investigate and compare the effectiveness of a digital game and mindfulness app in promoting post work recovery, first in a laboratory setting and then in a field study. Methods: Study 1 was a laboratory experiment (n=45) in which participants’ need for recovery was induced by a work task, before undertaking 1 of 3 interventions: a digital game (Block! Hexa Puzzle), a mindfulness app (Headspace), or a nonmedia control with a fidget spinner (a physical toy). Recovery in the form of how energized participants felt (energetic arousal) was compared before and after the intervention and how recovered participants felt (recovery experience) was compared across the conditions. Study 2 was a field study with working professionals (n=20), for which participants either played the digital game or used the mindfulness app once they arrived home after work for a period of 5 working days. Measures of energetic arousal were taken before and after the intervention, and the recovery experience was measured after the intervention along with measures of enjoyment and job strain. Results: A 3×2 mixed analysis of variance identified that, in study 1, the digital game condition increased energetic arousal (indicative of improved recovery) whereas the other 2 conditions decreased energetic arousal (F2,42=3.76; P=.03). However, there were no differences between the conditions in recovery experience (F2,42=.01; P=.99). In study 2, multilevel model comparisons identified that neither the intervention nor day of the week had a significant main effect on how energized participants felt. However, for those in the digital game condition, daily recovery experience increased during the course of the study, whereas for those in the mindfulness condition, it decreased (F1,18=9.97; P=.01). Follow-up interviews with participants identified 3 core themes: detachment and restoration, fluctuations and differences, and routine and scheduling. Conclusions: This study suggests that digital games may be effective in promoting post work recovery in laboratory contexts (study 1) and in the real world, although the effect in this case may be cumulative rather than instant (study 2). %M 31322125 %R 10.2196/12853 %U http://mental.jmir.org/2019/7/e12853/ %U https://doi.org/10.2196/12853 %U http://www.ncbi.nlm.nih.gov/pubmed/31322125 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e13717 %T Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review %A Cheng,Vanessa Wan Sze %A Davenport,Tracey %A Johnson,Daniel %A Vella,Kellie %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, Sydney,, Australia, 61 286276941, vanessa.cheng@sydney.edu.au %K well-being %K video games %K gamification %K mental health %K health behavior %K systematic review %K eHealth %K mHealth %K health informatics %D 2019 %7 26.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 31244479 %R 10.2196/13717 %U http://mental.jmir.org/2019/6/e13717/ %U https://doi.org/10.2196/13717 %U http://www.ncbi.nlm.nih.gov/pubmed/31244479 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e12430 %T Using Computer Games to Support Mental Health Interventions: Naturalistic Deployment Study %A van der Meulen,Hidde %A McCashin,Darragh %A O'Reilly,Gary %A Coyle,David %+ University College Dublin, School of Computer Science, Belfield, Dublin, 4, Ireland, 353 17162818, d.coyle@ucd.ie %K mental health %K eHealth %K mHealth %K adolescents %K children %K computer game %K treatment %K cognitive behavioral therapy %D 2019 %7 09.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Recent research has highlighted naturalistic uptake as a key barrier to maximizing the impact of mental health technologies. Although there is increasing evidence regarding the efficacy of digital interventions for mental health, as demonstrated through randomized controlled trials, there is also evidence that technologies do not succeed as expected when deployed in real-world settings. Objective: This paper describes the naturalistic deployment of Pesky gNATs, a computer game designed to support cognitive behavioral therapy (CBT) for children experiencing anxiety or low mood. The objective of this deployment study was to identify how therapists use Pesky gNATs in real-world settings and to discover positive and negative factors. On the basis of this, we aimed to derive generalizable recommendations for the development of mental health technologies that can have greater impact in real-world settings. Methods: Pesky gNATs has been made available through a not-for-profit organization. After 18 months of use, we collected usage and user experience data from therapists who used the game. Data were collected through an online survey and semistructured interviews addressing the expectations and experiences of both therapists and young people. Thematic analysis was used to identify key themes in the interview and survey data. Results: A total of 21 therapists, who used Pesky gNATs with 95 young people, completed the online survey. Furthermore, 5 therapists participated in the follow-up interview. Confirming previous assessments, data suggest that the game can be helpful in delivering therapy and that young people generally liked the approach. Therapists shared diverse opinions regarding the young people for whom they deemed the game appropriate. The following 3 themes were identified: (1) stages of use, (2) impact on the delivery of therapy, and (3) customization. We discuss therapists’ reflections on the game with regard to their work practices and consider the question of customization, including the delicate balance of adaptable interaction versus the need for fidelity to a therapeutic model. Conclusions: This study provides further evidence that therapeutic games can support the delivery of CBT for young people in real-world settings. It also shows that deployment studies can provide a valuable means of understanding how technologies integrate with the overall mental health ecosystem and become a part of therapists' toolbox. Variability in use should be expected in real-world settings. Effective training, support for therapist autonomy, careful consideration of different approaches to customization, the reporting of deployment data, and support for communities of practice can play an important role in supporting variable, but effective, use. %M 31094346 %R 10.2196/12430 %U https://mental.jmir.org/2019/5/e12430/ %U https://doi.org/10.2196/12430 %U http://www.ncbi.nlm.nih.gov/pubmed/31094346 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e12656 %T The Importance of User Segmentation for Designing Digital Therapy for Adolescent Mental Health: Findings From Scoping Processes %A Fleming,Theresa %A Merry,Sally %A Stasiak,Karolina %A Hopkins,Sarah %A Patolo,Tony %A Ruru,Stacey %A Latu,Manusiu %A Shepherd,Matthew %A Christie,Grant %A Goodyear-Smith,Felicity %+ Department of Psychological Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand, 64 9 923 5025, t.fleming@auckland.ac.nz %K gamification %K computerized therapy %K mental health %K adolescent %K mobile apps %K internet %D 2019 %7 08.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: New Zealand youth, especially those of Māori and Pacific descent, have high rates of depression, anxiety, and self-harm, but have low rates of help-seeking from mental health professionals. Apps, computerized therapy, and other digital tools can be effective, highly scalable treatments for anxiety and depression. Co-design processes are often used to foster engagement with end users, but this does not always lead to high levels of engagement. Objective: We aimed to carry out preliminary scoping to understand adolescents’ current internet use and diversity of preferences to inform a planned co-design process for creating digital mental health tools for teenagers. Methods: Interactive workshops and focus groups were held with young people. Data were analyzed using a general inductive approach. Results: Participants (N=58) engaged in 2 whānau (extended family) focus groups (n=4 and n=5), 2 school- or community-based focus groups (n=9 each), and 2 workshops (n=11 and n=20). The authors identified 3 overarching themes: (1) Digital mental health tools are unlikely to be successful if they rely solely on youth help-seeking. (2) A single approach is unlikely to appeal to all. Participants had diverse, noncompatible preferences in terms of look or feel of an app or digital tool. The authors identified 4 user groups players or gamers, engagers, sceptics, and straight-talkers. These groups differed by age and degree of current mental health need and preferred gamified or fun approaches, were open to a range of approaches, were generally disinterested, or preferred direct-to-the-point, serious approaches, respectively. (3) Digital mental health tools should provide an immediate response to a range of different issues and challenges that a young person may face. Conclusions: Defining the preferences of different groups of users may be important for increasing engagement with digital therapies even within specific population and mental health–need groups. This study demonstrates the importance of scoping possible user needs to inform design processes. %M 31066705 %R 10.2196/12656 %U https://mental.jmir.org/2019/5/e12656/ %U https://doi.org/10.2196/12656 %U http://www.ncbi.nlm.nih.gov/pubmed/31066705 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e13242 %T An Interactive Mobile App Game to Address Aggression (RegnaTales): Pilot Quantitative Study %A Ong,Jeffrey G %A Lim-Ashworth,Nikki S %A Ooi,Yoon P %A Boon,Jillian S %A Ang,Rebecca P %A Goh,Dion H %A Ong,Say H %A Fung,Daniel S %+ Department of Developmental Psychiatry, Institute of Mental Health, Health Promotion Board Building, 3 Second Hospital Avenue #03-01, Singapore, 168937, Singapore, 65 64353251, jeffrey_gx_ong@imh.com.sg %K video games %K mental health %K anger management %K mobile app %D 2019 %7 08.05.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: The rapid advancement in media technology has radically changed the way we learn and interact with one another. Games, with their engaging and interactive approach, hold promise in the delivery of knowledge and building of skills. This has potential in child and adolescent mental health work, where the lack of insight and motivation for therapy are major barriers to treatment. However, research on the use of serious games in mental health interventions for children and adolescents is still in its infancy. Objective: This study adds to the research on serious games in mental health interventions through the development and evaluation of RegnaTales, a series of 6 mobile apps designed to help children and adolescents manage anger. We examined the usability and playability of RegnaTales, as well as children’s aggression levels before and after the game play. Methods: A total of 72 children aged between 6 and 12 years were recruited for the study. Thirty-five participants had a clinical diagnosis of disruptive behavior disorders (DBD), whereas 37 were typically developing (TD) children. Each child played 1 of the 6 RegnaTales apps for approximately 50 min before completing the Playability and Usability Questionnaire. The Reactive-Proactive Aggression Questionnaire was completed before and after the game play. Results: The overall results showed high levels of enjoyment and playability. TD children and children with DBD had similar experienced fun and perceived playability scores on all 6 mobile apps. All 6 mobile apps garnered comparable experienced fun and perceived playability scores. Furthermore, 42% (5/12) to 67% (8/12) of the children indicated that they would like to play the games again. Importantly, children felt that they acquired skills in anger management, were motivated to use them in their daily lives, and felt confident that the skills would help them better manage their anger. Children reported significantly lower reactive aggression after playing the mobile apps Rage Raver (P=.001), Abaddon (P=.008), and RegnaTools (P=.03). These apps focused on the psychoeducation of the link between thoughts and emotions, as well as equipping the participants with various emotion regulation strategies such as relaxation and cognitive restructuring. Conclusions: This study presents evidence to support RegnaTales as a feasible serious game. The preliminary findings associated with reduction in reactive aggression, coupled with future research to further establish its efficacy, could warrant RegnaTales as a potential intervention for anger issues among clinical and community populations. %M 31066682 %R 10.2196/13242 %U http://games.jmir.org/2019/2/e13242/ %U https://doi.org/10.2196/13242 %U http://www.ncbi.nlm.nih.gov/pubmed/31066682 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e12432 %T Framing Mental Health Within Digital Games: An Exploratory Case Study of Hellblade %A Fordham,Joseph %A Ball,Christopher %+ Department of Media and Information, Michigan State University, 404 Wilson Road, Michigan State University, East Lansing, MI, 48824, United States, 1 517 618 1235, fordham4@msu.edu %K video games %K electronic gaming %K psychosis %K stigma %D 2019 %7 18.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Researchers and therapists have increasingly turned to digital games for new forms of treatments and interventions for people suffering from a variety of mental health issues. Yet, the depiction of mental illness within digital games typically promotes stigmatized versions of those with mental health concerns. Recently, more games have attempted to implement more realistic and respectful depictions of mental health conditions. Objective: This paper presents an exploratory analysis of a contemporary game that has the potential to change the way researchers, practitioners, and game designers approach topics of mental health within the context of gaming. Methods: A case study of Hellblade: Senua's Sacrifice was conducted using frame analysis to show how key design choices for this game present the potential for new ways of approaching games and mental health. Results: A case study of Hellblade’s development shows how research-informed collaborative design with mental health practitioners, scientists, and individuals with mental health problems can lead to a realistic depiction of mental illness in games. Furthermore, the use of frame analysis demonstrates how to harness narrative, mechanics, and technology to create embodied experiences of mental health, which has the potential to promote empathetic understanding. Conclusions: This paper highlights an exemplary case of collaborative commercial game design for entertainment purposes in relation to mental health. Understanding the success of Hellblade's depiction of psychosis can improve serious games research and design. Further research must continue to provide deeper analysis of not only games that depict mental illness, but also the design process behind them. %M 30998224 %R 10.2196/12432 %U http://mental.jmir.org/2019/4/e12432/ %U https://doi.org/10.2196/12432 %U http://www.ncbi.nlm.nih.gov/pubmed/30998224 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e12003 %T A Digital Game and School-Based Intervention for Students in Hong Kong: Quasi-Experimental Design %A Shum,Angie KY %A Lai,Eliza SY %A Leung,Wing Gi %A Cheng,Mabel NS %A Wong,Ho Kit %A So,Sam WK %A Law,Yik Wa %A Yip,Paul SF %+ The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, 2/F, The Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong,, China (Hong Kong), 852 28315232, sfpyip@hku.hk %K digital game-based learning %K school-based learning %K mental health %K schools %K students %K child welfare %K health promotion %K follow-up studies %K internet access %K public health %K non-randomized controlled trials %D 2019 %7 05.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In Hong Kong, with an increasing number of children experiencing mental health issues, there is a need to not only develop innovative interventions but also develop comprehensive prevention interventions so as to reduce their anxiety symptoms and enhance their emotional management and interpersonal relationships. Objective: The aim of this study was to determine the effectiveness of The Adventures of DoReMiFa, an integration model of the cognitive-behavioral approach and positive psychology by using digital game–based and school-based mental health enhancement intervention to magnify the social and emotional health and well-being of the school children in Hong Kong aged 9 to 11 years. Methods: A quasi-experimental design method was used to evaluate this digital game and school-based intervention. The Adventures of DoReMiFa was piloted in 4 primary schools where students were allocated to either an intervention or a control group. The participants were assessed at pre- and postintervention with a 6-month follow-up measuring their mental health knowledge, levels of anxiety symptoms, positive and negative thinking, perspective-taking, and self-esteem. Results: A total of 459 primary school students from 4 primary schools participated in the study. The response rate on the questionnaires answered on the Web was up to 85.1% (391/459). Compared with the control group, the intervention group was found to have significant association with improved mental health knowledge at the time immediately after the intervention (beta=.46; P=.01) and in the 6-month postintervention period (beta=.66; P<.001); for perspective-taking, the intervention group had exhibited a significant improvement 6 months after the completion of the universal program (beta=1.50; P=.03). The intervention, however, was found not to be effective in reducing the rates of anxiety symptoms and negative thinking among the participating students. Conclusions: The Adventures of DoReMiFa, an integration of a digital game–based and school-based mental health enhancement intervention, was shown to be effective in elevating the knowledge of mental health and promoting perspective-taking in the primary school students of Hong Kong. Although there was insufficient evidence to support a reduction in symptoms of anxiety and negative automatic thoughts, the overall results were still encouraging in that a preventive effect was found, indicating that the program has the potential to enhance the mental well-being of schoolchildren. It also suggests that knowledge enhancement may not necessarily lead to behavior change, and more focused effort may be needed to achieve the translation. The implications and limitations of this study and suggestions for future research were also discussed. %M 30950795 %R 10.2196/12003 %U https://www.jmir.org/2019/4/e12003/ %U https://doi.org/10.2196/12003 %U http://www.ncbi.nlm.nih.gov/pubmed/30950795 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 3 %P e11255 %T A Game-Based School Program for Mental Health Literacy and Stigma Regarding Depression (Moving Stories): Protocol for a Randomized Controlled Trial %A Tuijnman,Anouk %A Kleinjan,Marloes %A Hoogendoorn,Evert %A Granic,Isabela %A Engels,Rutger CME %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 24 3612076, a.tuijnman@pwo.ru.nl %K depression %K help-seeking behavior %K helping behavior %K health literacy %K stigma %K video games %K adolescence %K secondary schools %D 2019 %7 14.03.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: The prevalence of elevated depressive symptoms among youth in most western societies is high. Yet, most adolescents who are experiencing depressive symptoms do not seek help. Low mental health literacy, high stigma, and low social support have been shown to hinder help-seeking. A small number of interventions has been developed to target mental health literacy and stigma, but few focus on actual help-seeking and first aid behavior. We have developed a game-based school program called Moving Stories that targets mental health literacy, including knowledge and behavior, and stigma among adolescents, in regard to depression specifically. Objective: Our aim is to describe the protocol for a study that will test the effectiveness of the program Moving Stories in a Dutch adolescent sample. We hypothesize that adolescents who participate in the program Moving Stories will have better mental health literacy and less stigma regarding depression compared to adolescents in the nonintervention control group at posttest and at 3- and 6-months follow-up. We also expect a positive change in actual help-seeking and first aid behavior at 3- and 6-months follow-up. Methods: Moving Stories has been developed by a professional game design company in collaboration with researchers and relevant stakeholders. The effectiveness of Moving Stories will be tested through a randomized controlled trial with two conditions: Moving Stories versus control. Participants will fill in questionnaires at pretest, posttest, and 3- and 6-months follow-up. Our power analysis showed a required sample size of 180 adolescents. Results: Four high schools have agreed to participate with a total of 10 classes. A total of 185 adolescents filled in the pretest questionnaire. The last of the follow-up data was collected in December 2018. Conclusions: If Moving Stories proves to be effective, it could be implemented as a school-based program to target mental health literacy and stigma regarding depression; this could, in turn, improve early help-seeking in adolescents suffering from depression. Trial Registration: Nederlands Trial Register NTR7033; https://www.trialregister.nl/trial/6855 International Registered Report Identifier (IRRID): DERR1-10.2196/11255 %M 30869652 %R 10.2196/11255 %U https://www.researchprotocols.org/2019/3/e11255/ %U https://doi.org/10.2196/11255 %U http://www.ncbi.nlm.nih.gov/pubmed/30869652 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11528 %T Use of the Principles of Design Thinking to Address Limitations of Digital Mental Health Interventions for Youth: Viewpoint %A Scholten,Hanneke %A Granic,Isabela %+ Behavioural Science Institute, Radboud University, PO Box 9104, Nijmegen, 6500 HE, Netherlands, 31 24 3612527, h.scholten@bsi.ru.nl %K anxiety %K depression %K design thinking %K e-mental health %K youth %D 2019 %7 14.01.2019 %9 Viewpoint %J J Med Internet Res %G English %X Numerous reviews and meta-analyses have indicated the enormous potential of technology to improve the appeal, effectiveness, cost, and reach of mental health interventions. However, the promise of digital mental health interventions for youth has not yet been realized. Significant challenges have been repeatedly identified, including engagement, fidelity, and the lack of personalization. We introduce the main tenets of design thinking and explain how they can specifically address these challenges, with an entirely new toolbox of mindsets and practices. In addition, we provide examples of a new wave of digital interventions to demonstrate the applicability of design thinking to a wide range of intervention goals. In the future, it will be critical for scientists and clinicians to implement their scientific standards, methods, and review outlets to evaluate the contribution of design thinking to the next iteration of digital mental health interventions for youth. %M 31344671 %R 10.2196/11528 %U https://www.jmir.org/2019/1/e11528/ %U https://doi.org/10.2196/11528 %U http://www.ncbi.nlm.nih.gov/pubmed/31344671 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11068 %T An App That Incorporates Gamification, Mini-Games, and Social Connection to Improve Men's Mental Health and Well-Being (MindMax): Participatory Design Process %A Cheng,Vanessa Wan Sze %A Davenport,Tracey A %A Johnson,Daniel %A Vella,Kellie %A Mitchell,Jo %A Hickie,Ian B %+ Brain and Mind Centre, The University of Sydney, 94 Mallett Street, Camperdown, Sydney, NSW 2050, Australia, 61 286276941, vanessa.cheng@sydney.edu.au %K football %K mental health %K well-being %K video games %K adolescent %K young adult %K cell phone %K gamification %K sport %K men’s health %K social connection %D 2018 %7 19.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Men have different mental health needs as compared with women, and women make up the primary audience of most digital mental health interventions. An Australian football-themed (specifically Australian Football League, AFL) app named MindMax incorporating psychoeducation, gamification, mini-games, and social connection was developed in an effort to address this issue. Objective: The aim of this study was to identify the best way to structure and present MindMax, an app that aims to deliver psychoeducational modules, and create a Web-based community centering on well-being, AFL, and video games for men aged 16 to 35 years who are interested in AFL or video games. Methods: We conducted 6 participatory design (PD) workshops with people aged 16 to 35 years in 3 cities in Australia, to identify the best way to present MindMax, and contracted a digital development agency to develop MindMax. We then iteratively tested MindMax prototypes with 15 user experience testing interviews across 3 separate time points: 2 before app launch and 1 after app launch. Results: A total of 40 individuals (25 male and 15 female) participated in the PD workshops, and a total of 15 individuals (10 male and 5 female) participated in user experience interviews. Broadly, participants expressed a preference for activities requiring active engagement that practiced useful skills. They were also sensitive to how content was presented and wanted the ability to customize their own app experience. Although participants agreed that social motivations were important for engagement with an app, they recommended not to mimic existing social networks. Conclusions: In basing itself strongly within the AFL subculture and by incorporating gamification as well as mini-games, MindMax aimed to tackle mental health help-seeking barriers for people who enjoy AFL or video games, with a particular emphasis on men, and to provide psychoeducation on strategies to increase mental health and well-being. If MindMax is successful, this would indicate that generalizing this approach to other traditional sporting codes and even competitive video gaming leagues (esports) would be fruitful. %M 30455165 %R 10.2196/11068 %U http://mental.jmir.org/2018/4/e11068/ %U https://doi.org/10.2196/11068 %U http://www.ncbi.nlm.nih.gov/pubmed/30455165 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11640 %T Gamified Cognitive Bias Modification Interventions for Psychiatric Disorders: Review %A Zhang,Melvyn %A Ying,Jiangbo %A Song,Guo %A Fung,Daniel SS %A Smith,Helen %+ National Addiction Management Service, Institute of Mental Health, 10 Buangkok Green Medical Park, Singapore,, Singapore, 65 6389 2504, melvynzhangweibin@gmail.com %K attention bias %K cognitive bias %K gamification %K psychiatry %D 2018 %7 25.10.2018 %9 Review %J JMIR Ment Health %G English %X Background: Automatic biases, such as attentional biases and avoidance and interpretative biases, have been purported to be responsible for several psychiatric disorders. Gamification has been considered for cognitive bias modification, mainly to address the core issues of diminishing motivation to train over time, as bias modification intervention tasks tend to be highly repetitive. While a prior review has suggested how gamification strategies could be applied to such tasks, there remains a lack of systematic evaluation of gamified cognitive bias modification interventions in the literature. Objective: The objective of this review is to understand the overall effectiveness of a gamified approach for cognitive bias modification and inform future research that seeks to integrate gamification technologies into existing conventional bias modification interventions. Methods: To identify the relevant articles for our review, the following search terminologies were used: (“cognitive bias” OR “attention bias” OR “interpret* bias” OR “approach bias” OR “avoidance bias”) AND (“training” OR “modification” OR “practice” OR “therapy”) AND (“gamification” OR “game elements” OR “game” OR “gaming” OR “game mechanics”). PubMed, MEDLINE, PsycINFO, and Scopus databases were searched systematically for articles published after 2000. Articles were included if they described a gamified cognitive bias modification task and included participants with underlying psychopathological symptoms. Data were systematically extracted from the identified articles, and a qualitative synthesis was performed. Results: Four studies evaluated gamified cognitive bias modification interventions. Two studies included participants with anxiety symptoms, one with affective symptoms, and one with alcohol problems. The conventional visual probe task paradigm was used in 3 studies, and the attentional visual search task paradigm was used in the last study. We found gaming elements incorporated to include that of animations, sounds, feedback, and a point-scoring system for response time and difficulty. Of the 4 identified studies, only 2 reported their gamified interventions to be effective. Conclusions: Our review is the first to systematically synthesize the evidence for gamified cognitive bias modification interventions. The results arising from our review should be considered in the future design and conceptualization of gamified cognitive bias modification interventions. International Registered Report Identifier (IRRID): RR2-10.2196/10154 %M 30361194 %R 10.2196/11640 %U http://mental.jmir.org/2018/4/e11640/ %U https://doi.org/10.2196/11640 %U http://www.ncbi.nlm.nih.gov/pubmed/30361194 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e14 %T Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research %A Jerdan,Shaun W %A Grindle,Mark %A van Woerden,Hugo C %A Kamel Boulos,Maged N %+ Department of Digital Health, Centre for Health Science, University of the Highlands and Islands, Old Perth Road, Inverness, IV2 3JH, United Kingdom, 44 734 298 7169, shaun.jerdan@uhi.ac.uk %K virtual reality %K well-being %K behavior change %D 2018 %7 06.07.2018 %9 Review %J JMIR Serious Games %G English %X Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment. %M 29980500 %R 10.2196/games.9226 %U http://games.jmir.org/2018/3/e14/ %U https://doi.org/10.2196/games.9226 %U http://www.ncbi.nlm.nih.gov/pubmed/29980500 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e9 %T Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial %A Pramana,Gede %A Parmanto,Bambang %A Lomas,James %A Lindhiem,Oliver %A Kendall,Philip C %A Silk,Jennifer %+ Department of Health Information Management, University of Pittsburgh, 6025 Forbes Tower, Pittsburgh, PA, 15260, United States, 1 4123836649, parmanto@pitt.edu %K gamification %K mobile health %K ecological momentary intervention %K cognitive behavioral therapy %K child anxiety treatment %K SmartCAT %K childhood anxiety disorders %D 2018 %7 10.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. %M 29748165 %R 10.2196/games.8902 %U http://games.jmir.org/2018/2/e9/ %U https://doi.org/10.2196/games.8902 %U http://www.ncbi.nlm.nih.gov/pubmed/29748165 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 4 %P e46 %T Evaluation of a Digital Game-Based Learning Program for Enhancing Youth Mental Health: A Structural Equation Modeling of the Program Effectiveness %A Huen,Jenny MY %A Lai,Eliza SY %A Shum,Angie KY %A So,Sam WK %A Chan,Melissa KY %A Wong,Paul WC %A Law,YW %A Yip,Paul SF %+ Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong, China (Hong Kong), 852 39174375, sfpyip@hku.hk %K digital game-based learning %K mental health %K program evaluation %K Internet %D 2016 %7 07.10.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital game-based learning (DGBL) makes use of the entertaining power of digital games for educational purposes. Effectiveness assessment of DGBL programs has been underexplored and no attempt has been made to simultaneously model both important components of DGBL: learning attainment (ie, educational purposes of DGBL) and engagement of users (ie, entertaining power of DGBL) in evaluating program effectiveness. Objective: This study aimed to describe and evaluate an Internet-based DGBL program, Professor Gooley and the Flame of Mind, which promotes mental health to adolescents in a positive youth development approach. In particular, we investigated whether user engagement in the DGBL program could enhance their attainment on each of the learning constructs per DGBL module and subsequently enhance their mental health as measured by psychological well-being. Methods: Users were assessed on their attainment on each learning construct, psychological well-being, and engagement in each of the modules. One structural equation model was constructed for each DGBL module to model the effect of users' engagement and attainment on the learning construct on their psychological well-being. Results: Of the 498 secondary school students that registered and participated from the first module of the DGBL program, 192 completed all 8 modules of the program. Results from structural equation modeling suggested that a higher extent of engagement in the program activities facilitated users’ attainment on the learning constructs on most of the modules and in turn enhanced their psychological well-being after controlling for users’ initial psychological well-being and initial attainment on the constructs. Conclusions: This study provided evidence that Internet intervention for mental health, implemented with the technologies and digital innovations of DGBL, could enhance youth mental health. Structural equation modeling is a promising approach in evaluating the effectiveness of DGBL programs. %M 27717921 %R 10.2196/mental.5656 %U http://mental.jmir.org/2016/4/e46/ %U https://doi.org/10.2196/mental.5656 %U http://www.ncbi.nlm.nih.gov/pubmed/27717921 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e15 %T A Study on the Validity of a Computer-Based Game to Assess Cognitive Processes, Reward Mechanisms, and Time Perception in Children Aged 4-8 Years %A Peijnenborgh,Janneke CAW %A Hurks,Petra PM %A Aldenkamp,Albert P %A van der Spek,Erik D %A Rauterberg,GWM %A Vles,Johan SH %A Hendriksen,Jos GM %+ Center for Neurological Learning Disabilities, Kempenhaeghe, P.O. Box 61, Heeze, 5590 AB, Netherlands, 31 (0)40227923, peijnenborghj@kempenhaeghe.nl %K experimental games %K ADHD %K children %K neuropsychological test %D 2016 %7 22.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: A computer-based game, named Timo’s Adventure, was developed to assess specific cognitive functions (eg, attention, planning, and working memory), time perception, and reward mechanisms in young school-aged children. The game consists of 6 mini-games embedded in a story line and includes fantasy elements to enhance motivation. Objective: The aim of this study was to investigate the validity of Timo’s Adventure in normally developing children and in children with attention-deficit/hyperactivity disorder (ADHD). Methods: A total of 96 normally developing children aged 4-8 years and 40 children with ADHD were assessed using the game. Clinical validity was investigated by examining the effects of age on performances within the normally developing children, as well as performance differences between the healthy controls and the ADHD group. Results: Our analyses in the normally developing children showed developmental effects; that is, older children made fewer inhibition mistakes (r=−.33, P=.001), had faster (and therefore better) reaction times (r=−.49, P<.001), and were able to produce time intervals more accurately than younger children (ρ=.35, P<.001). Discriminant analysis showed that Timo’s Adventure was accurate in most classifications whether a child belonged to the ADHD group or the normally developing group: 78% (76/97) of the children were correctly classified as having ADHD or as being in the normally developing group. The classification results showed that 72% (41/57) children in the control group were correctly classified, and 88% (35/40) of the children in the ADHD group were correctly classified as having ADHD. Sensitivity (0.89) and specificity (0.69) of Timo’s Adventure were satisfying. Conclusions: Computer-based games seem to be a valid tool to assess specific strengths and weaknesses in young children with ADHD. %M 27658428 %R 10.2196/games.5997 %U http://games.jmir.org/2016/2/e15/ %U https://doi.org/10.2196/games.5997 %U http://www.ncbi.nlm.nih.gov/pubmed/27658428 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 3 %P e39 %T Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review %A Brown,Menna %A O'Neill,Noelle %A van Woerden,Hugo %A Eslambolchilar,Parisa %A Jones,Matt %A John,Ann %+ Swansea University, Medical School, ILS2, Singleton Park, Swansea, SA2 8PP, United Kingdom, 44 179260 ext 6312, menna.brown@swansea.ac.uk %K adherence %K Web-based mental health interventions %K well-being %K gamification %K engagement %K dropout %K patient compliance %K patient nonadherence %D 2016 %7 24.08.2016 %9 Review %J JMIR Ment Health %G English %X Background: Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of “active” technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being. Objective: This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being. Methods: A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched. Results: A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration. Conclusions: Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data. %M 27558893 %R 10.2196/mental.5710 %U http://mental.jmir.org/2016/3/e39/ %U https://doi.org/10.2196/mental.5710 %U http://www.ncbi.nlm.nih.gov/pubmed/27558893 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e11 %T Gamification of Cognitive Assessment and Cognitive Training: A Systematic Review of Applications and Efficacy %A Lumsden,Jim %A Edwards,Elizabeth A %A Lawrence,Natalia S %A Coyle,David %A Munafò,Marcus R %+ UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, 12a Priory rd, Bristol, BS8 1TU, United Kingdom, 44 117 92 88450, jim.lumsden@bristol.ac.uk %K gamification %K gamelike %K cognition %K computer games %K review %D 2016 %7 15.07.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive tasks are typically viewed as effortful, frustrating, and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or reduce intervention effects. However, gamification may provide a possible solution. If game design features can be incorporated into cognitive tasks without undermining their scientific value, then data quality, intervention effects, and participant engagement may be improved. Objectives: This systematic review aims to explore and evaluate the ways in which gamification has already been used for cognitive training and assessment purposes. We hope to answer 3 questions: (1) Why have researchers opted to use gamification? (2) What domains has gamification been applied in? (3) How successful has gamification been in cognitive research thus far? Methods: We systematically searched several Web-based databases, searching the titles, abstracts, and keywords of database entries using the search strategy (gamif* OR game OR games) AND (cognit* OR engag* OR behavi* OR health* OR attention OR motiv*). Searches included papers published in English between January 2007 and October 2015. Results: Our review identified 33 relevant studies, covering 31 gamified cognitive tasks used across a range of disorders and cognitive domains. We identified 7 reasons for researchers opting to gamify their cognitive training and testing. We found that working memory and general executive functions were common targets for both gamified assessment and training. Gamified tests were typically validated successfully, although mixed-domain measurement was a problem. Gamified training appears to be highly engaging and does boost participant motivation, but mixed effects of gamification on task performance were reported. Conclusions: Heterogeneous study designs and typically small sample sizes highlight the need for further research in both gamified training and testing. Nevertheless, careful application of gamification can provide a way to develop engaging and yet scientifically valid cognitive assessments, and it is likely worthwhile to continue to develop gamified cognitive tasks in the future. %M 27421244 %R 10.2196/games.5888 %U http://games.jmir.org/2016/2/e11/ %U https://doi.org/10.2196/games.5888 %U http://www.ncbi.nlm.nih.gov/pubmed/27421244 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e7 %T A Serious Game for Clinical Assessment of Cognitive Status: Validation Study %A Tong,Tiffany %A Chignell,Mark %A Tierney,Mary C. %A Lee,Jacques %+ Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, 5 King's College Road, Toronto, ON,, Canada, 1 416 978 7581, tiffany.tong@mail.utoronto.ca %K cognitive assessments %K cognitive screening tools %K computerized assessments %K games %K human computer interaction %K human factors %K neuropsychological tests %K screening %K serious games %K tablet computers %K technology assessment %K usability %K validation studies %K video games %D 2016 %7 27.05.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: We propose the use of serious games to screen for abnormal cognitive status in situations where it may be too costly or impractical to use standard cognitive assessments (eg, emergency departments). If validated, serious games in health care could enable broader availability of efficient and engaging cognitive screening. Objective: The objective of this work is to demonstrate the feasibility of a game-based cognitive assessment delivered on tablet technology to a clinical sample and to conduct preliminary validation against standard mental status tools commonly used in elderly populations. Methods: We carried out a feasibility study in a hospital emergency department to evaluate the use of a serious game by elderly adults (N=146; age: mean 80.59, SD 6.00, range 70-94 years). We correlated game performance against a number of standard assessments, including the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). Results: After a series of modifications, the game could be used by a wide range of elderly patients in the emergency department demonstrating its feasibility for use with these users. Of 146 patients, 141 (96.6%) consented to participate and played our serious game. Refusals to play the game were typically due to concerns of family members rather than unwillingness of the patient to play the game. Performance on the serious game correlated significantly with the MoCA (r=–.339, P <.001) and MMSE (r=–.558, P <.001), and correlated (point-biserial correlation) with the CAM (r=.565, P <.001) and with other cognitive assessments. Conclusions: This research demonstrates the feasibility of using serious games in a clinical setting. Further research is required to demonstrate the validity and reliability of game-based assessments for clinical decision making. %M 27234145 %R 10.2196/games.5006 %U http://games.jmir.org/2016/1/e7/ %U https://doi.org/10.2196/games.5006 %U http://www.ncbi.nlm.nih.gov/pubmed/27234145 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e26 %T Behavioral Outcome Effects of Serious Gaming as an Adjunct to Treatment for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial %A Bul,Kim CM %A Kato,Pamela M %A Van der Oord,Saskia %A Danckaerts,Marina %A Vreeke,Leonie J %A Willems,Annik %A van Oers,Helga JJ %A Van Den Heuvel,Ria %A Birnie,Derk %A Van Amelsvoort,Thérèse AMJ %A Franken,Ingmar HA %A Maras,Athanasios %+ Yulius Academy, Yulius Mental Health Care Organization, Dennenhout 1, Barendrecht, 2994 GC, Netherlands, 31 884056990, k.bul@yulius.nl %K attention deficit-hyperactivity disorder %K ADHD %K serious game %K Internet %K children %K treatment %K randomized controlled trial %D 2016 %7 16.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: The need for accessible and motivating treatment approaches within mental health has led to the development of an Internet-based serious game intervention (called “Plan-It Commander”) as an adjunct to treatment as usual for children with attention-deficit/hyperactivity disorder (ADHD). Objective: The aim was to determine the effects of Plan-It Commander on daily life skills of children with ADHD in a multisite randomized controlled crossover open-label trial. Methods: Participants (N=170) in this 20-week trial had a diagnosis of ADHD and ranged in age from 8 to 12 years (male: 80.6%, 137/170; female: 19.4%, 33/170). They were randomized to a serious game intervention group (group 1; n=88) or a treatment-as-usual crossover group (group 2; n=82). Participants randomized to group 1 received a serious game intervention in addition to treatment as usual for the first 10 weeks and then received treatment as usual for the next 10 weeks. Participants randomized to group 2 received treatment as usual for the first 10 weeks and crossed over to the serious game intervention in addition to treatment as usual for the subsequent 10 weeks. Primary (parent report) and secondary (parent, teacher, and child self-report) outcome measures were administered at baseline, 10 weeks, and 10-week follow-up. Results: After 10 weeks, participants in group 1 compared to group 2 achieved significantly greater improvements on the primary outcome of time management skills (parent-reported; P=.004) and on secondary outcomes of the social skill of responsibility (parent-reported; P=.04), and working memory (parent-reported; P=.02). Parents and teachers reported that total social skills improved over time within groups, whereas effects on total social skills and teacher-reported planning/organizing skills were nonsignificant between groups. Within group 1, positive effects were maintained or further improved in the last 10 weeks of the study. Participants in group 2, who played the serious game during the second period of the study (weeks 10 to 20), improved on comparable domains of daily life functioning over time. Conclusions: Plan-It Commander offers an effective therapeutic approach as an adjunct intervention to traditional therapeutic ADHD approaches that improve functional outcomes in daily life. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 62056259; http://www.controlled-trials.com/ISRCTN62056259 (Archived by WebCite at http://www.webcitation.org/6eNsiTDJV). %M 26883052 %R 10.2196/jmir.5173 %U http://www.jmir.org/2016/2/e26/ %U https://doi.org/10.2196/jmir.5173 %U http://www.ncbi.nlm.nih.gov/pubmed/26883052 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 1 %P e1 %T The Design and Relevance of a Computerized Gamified Depression Therapy Program for Indigenous Māori Adolescents %A Shepherd,Matthew %A Fleming,Theresa %A Lucassen,Mathijs %A Stasiak,Karolina %A Lambie,Ian %A Merry,Sally N %+ School of Counselling, Human Services and Social Work, Department of Education, University of Auckland, 5th floor, N Building, Epsom Campus, Epsom, Auckland, Private Bag 92601, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K computerized cognitive behavioral therapy %K Māori %K indigenous populations %K depression %K consumer opinions %K participatory design %D 2015 %7 03.03.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression. Objective: The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach. Methods: There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data. Results: SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery. Conclusions: SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people. Trial Registration: The New Zealand Northern Y Regional Ethics Committee; http://ethics.health.govt.nz/home; NTY/09/003; (Archived by WebCite at http://www.webcitation/6VYgHXKaR). %M 25736225 %R 10.2196/games.3804 %U http://games.jmir.org/2015/1/e1/ %U https://doi.org/10.2196/games.3804 %U http://www.ncbi.nlm.nih.gov/pubmed/25736225 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e3 %T Views of Young People in Rural Australia on SPARX, a Fantasy World Developed for New Zealand Youth With Depression %A Cheek,Colleen %A Bridgman,Heather %A Fleming,Theresa %A Cummings,Elizabeth %A Ellis,Leonie %A Lucassen,Mathijs FG %A Shepherd,Matthew %A Skinner,Timothy %+ Rural Clinical School, University of Tasmania, Private Bag 3513, Burnie, 7320, Australia, 61 364305922, Colleen.Cheek@utas.edu.au %K mental health %K stigma %K computer games %K youth %K rural health, computerized CBT %D 2014 %7 18.02.2014 %9 Original Paper %J JMIR Serious Games %G English %X Background: A randomized control trial demonstrated that a computerized cognitive behavioral therapy (cCBT) program (Smart, Positive, Active, Realistic, X-factor thoughts [SPARX]) was an appealing and efficacious treatment for depression for adolescents in New Zealand. Little is known about the acceptability of computerized therapy programs for rural Australians and the suitability of computerized programs developed in one cultural context when used in another country. Issues such as accents and local differences in health care access might mean adjustments to programs are required. Objective: This study sought to explore the acceptability of SPARX by youth in rural Australia and to explore whether and how young people would wish to access such a program. Methods: Focus groups and semistructured interviews were conducted with 16 young people attending two youth-focused community services in a small, rural Tasmanian town. An inductive data-driven approach was used to identify themes using the interview transcripts as the primary data source. Interpretation was supported by demographic data, observer notes, and content analysis. Results: Participants reported that young people want help for mental health issues but they have an even stronger need for controlling how they access services. In particular, they considered protecting their privacy in their small community to be paramount. Participants thought computerized therapy was a promising way to increase access to treatment for youth in rural and remote areas if offered with or without therapist support and via settings other than school. The design features of SPARX that were perceived to be useful, included the narrative structure of the program, the use of different characters, the personalization of an avatar, “socialization” with the Guide character, optional journaling, and the use of encouraging feedback. Participants did not consider (New Zealand) accents off-putting. Young people believed the SPARX program would appeal to those who play computer games generally, but may be less appealing for those who do not. Conclusions: The findings suggest that computerized therapy offered in ways that support privacy and choice can improve access to treatment for rural youth. Foreign accents and style may not be off-putting to teenage users when the program uses a playful fantasy genre, as it is consistent with their expectation of fantasy worlds, and it is in a medium with which they already have a level of competence. Rather, issues of engaging design and confidential access appeared to be more important. These findings suggest a proven tool once formally assessed at a local level can be adopted cross-nationally. %M 25659116 %R 10.2196/games.3183 %U http://games.jmir.org/2014/1/e3/ %U https://doi.org/10.2196/games.3183 %U http://www.ncbi.nlm.nih.gov/pubmed/25659116