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Asociación Española
de Psicología Clínica
y Psicopatología
Revista de Psicopatología y Psicología Clínica Vol. 19, N.º 3, pp. 227-242, 2014
www.aepcp.net ISSN 1136-5420/14
DOI: http://dx.doi.org/10.5944/rppc.vol.19.num.3.2014.13904
SERIOUS GAMES FOR THE TREATMENT OR PREVENTION
OF DEPRESSION: A SYSTEMATIC REVIEW
THERESA M. FLEMING1,2, COLLEEN CHEEK3, SALLY N. MERRY1, HIRAN THABREW1,
HEATHER BRIDGMAN4, KAROLINA STASIAK1, MATTHEW SHEPHERD5, YAEL PERRY6,
AND SARAH HETRICK7
1 Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
2 Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
3 University of Tasmania Rural Clinical School, Burnie, TAS 7320, Australia
4 University of Tasmania Centre for Rural Health, Launceston, TAS 7250, Australia
5School of Counselling, Human Services and Social Work Faculty of Education, University of Auckland,
Auckland, New Zealand
6 Black Dog Institute, University of New South Wales, Hospital Rd, Randwick NSW 2031 Australia
7 Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Parkville,
Victoria 3052, Australia.
Abstract: Serious games (computerised interventions which utilise gaming for serious purposes)
have been shown to support improved outcomes in several health conditions. We aimed to review
evidence regarding serious games for depression. We undertook electronic searches of PsycInfo,
EMBASE and Medline, using terms relevant to computer games and depression. We included full-
text articles published in English in peer-reviewed literature since 2000, where the intervention was
designed to treat or prevent depression and which included pre-and post-intervention measurement
of depression. Nine studies relating to a total of six interventions met inclusion criteria. Most
studies were small and were carried out by the developers of the programs. All were tested with
young people (ages between 9 and 25 years). Most reported promising results with some positive
impact on depression although one universal program had mixed results. Serious gaming interven-
tions show promise for depression, however evidence is currently very limited.
Keywords: Depression; adolescents; computerised CBT; serious gaming; e-therapy.
Juegos serios para el tratamiento o la prevención de la depresión: una revisión sistemática
Resumen: Se ha demostrado que los juegos serios (intervenciones computarizadas que utilizan
juegos) mejoran los resultados en diferentes problemas de salud. Pretendemos examinar las eviden-
cias de estos juegos para la depresión. Se realizaron búsquedas electrónicas en PsycINFO, EMBA-
SE y Medline usando términos relacionados con juegos de ordenador y depresión. Se incluyeron
artículos publicados desde el año 2000, donde se diseñó la intervención para tratar o prevenir la
depresión incluyendo medidas pre- y post-intervención. Nueve estudios sobre un total de seis in-
tervenciones cumplieron los criterios de inclusión. La mayoría de estos fueron pequeños y los lle-
varon a cabo los desarrolladores de los programas. Todos incluían población joven (9 - 25 años).
La mayoría presentan resultados prometedores con un impacto positivo sobre la depresión aunque
un programa universal tuvo resultados mixtos. Se concluye que las intervenciones basadas en jue-
gos serios son prometedoras para la depresión, aunque la evidencia es todavía muy limitada.
Palabras clave: Depresión; adolescentes; TCC informatizada; juegos serios; e-terapia.
Received: June 17, 2014; accepted: July 3, 2014.
Correspondence: Theresa Fleming (PhD), Senior Lectu-
rer, Department of Psychological Medicine and Depart-
ment of Paediatrics: Child and Youth Health, University
of Auckland, Private Bag 92019, Auckland, New Zealand.
E-mail: t.fl eming@auckland.ac.nz
Disclosures: The intellectual property for SPARX is held
by UniServices. UniServices has licensed SPARX to a third
party for the territories of the USA, Canada and Mexico and,
as the result of a revenue-sharing agreement between Uni-
Services and S. Merry, K. Stasiak, T. Fleming, M. Shepherd
and M. Lucassen stand to gain fi nancially from any revenue
received from this license. K. Stasiak developed The Journey
and S. Merry was PhD supervisor on this project.
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228 T. M. Fleming. et al.
Revista de Psicopatología y Psicología Clínica 2014, Vol. 19 (3), 217-242 © Asociación Española de Psicología Clínica y Psicopatología
INTRODUCTION
Depression and sub-threshold depression
cause serious harm and are leading causes of
disability (Ustun, Ayuso-Mateos, Chatterji, Ma-
thers, & Murray, 2004). Although evi-
dence-based treatments exist, most people do
not receive treatment and expanding clinical
services to address these unmet needs would
require substantial funding (Wittchen, & Jaco-
bi, 2005). In addition, available services may be
inconvenient, costly, or not appealing to some
of those who might benefi t from them (Fleming,
Dixon, & Merry, 2012). Partly in response to
these issues, computerised therapies, mainly
computerised cognitive behavioural therapies
(CCBT), have been developed.
There are some computerised therapies for
depression that are widely available such as
MoodGYM (Christensen, Griffi ths, & Jorm,
2004), and Beating the Blues (Proudfoot et al.,
2003). Systematic reviews have found CCBT
programs to be promising or effective for the
treatment of depression (Hedman, Ljotsson, &
Lindefors, 2012; Newman, Szkodny, Llera, &
Przeworski, 2011; Richards, & Richardson,
2012) and acceptable to the adult population
(Gun, Titov, & Andrews, 2011). While less re-
search has focused on children and adolescents,
growing evidence suggests that CCBT pro-
grams can be effective at reducing symptoms
of depression and anxiety for young people
(Calear, & Christensen, 2010; Richardson, Stal-
lard, & Velleman, 2010). The National Institute
for Clinical Excellence (NICE) guidelines cur-
rently recommend the use of CCBT for anxiety
and depression as part of a stepped-care ap-
proach (NICE, 2009).
Maximising the impact of computerised
therapies is challenging. It has been proposed
that computerised therapies may help to ad-
dress unmet needs for large numbers of people;
however dramatic uptake rates which might
reduce population rates of depression have not
been reported. Attrition (non-completion) rates
have been shown to range from 2 to 83% (Mel-
ville, Casey, & Kavanagh, 2010;Richards et
al., 2012;So et al., 2013). Such rates may not
be dissimilar to face-to-face therapy, and con-
cepts of dose may require reassessment
(Donkin et al., 2013), but these fi ndings are
disappointing.
Understanding optimal design features and
implementation processes for computerised
therapies will be an important step in increasing
their impact. Although some computerised ther-
apies (Coyle, McGlade, Doherty, & O’Reilly,
2011; Stallard, Richardson, Velleman, & At-
twood, 2011) are designed to be used with a
therapist, most offer little or no personalised
support; this is of interest in several ways. First-
ly, a therapeutic relationship appears to be a
critical ‘active ingredient’ in face-to-face mod-
els of therapy (Weisz, McCarty, & Valeri, 2006)
and yet many computerised therapies are effec-
tive while offering little human contact. This
raises questions about how computerised ther-
apies work, and if the active ingredients might
in some way differ from those offered in face-
to-face models (Cavanagh, & Millings 2013).
Secondly, increased human contact in conjunc-
tion with an online intervention has been the
main change proposed to increase adherence
(Christensen, Reynolds, & Griffi ths, 2011; New-
man et al., 2011; Richards et al., 2012). Howev-
er, if CCBT is a different experience from face-
to-face therapy as young people have suggested
it is (Fleming et al, manuscript in preparation),
then alternative elements such as gaming or
telepresence might also be important. In the
view of the authors, computerised therapies for
depression have yet to maximise the immersive,
experiential and user-centred potential of online
experiences.
As the focus shifts to increasing participa-
tion and engagement with online interventions,
recent research (Merry et al., 2012; Shandley,
Austin, Klein, & Kyrios, 2010) has begun to
explore the potential contribution of gaming in
mental health interventions. Once the domain
of predominantly young western males, com-
puter game-play is a now worldwide phenome-
non with a diverse participant base. Well-de-
signed computer games have been shown to
have multiple benefi ts including increased mo-
tivation for learning, improved attention and
problem solving, and increased social engage-
ment (Connolly, Boyle, MacArthur, Hainey, &
Boyle, 2012; Papastergiou, 2009) ‘Serious
games’ are games or programs with gaming
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Serious gaming for depression 229
© Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2014, Vol. 19 (3), 217-242
features which utilise these features for purpos-
es such as learning or health (Arnab et al.,
2014). Serious games have been effective for
improving knowledge and adherence to treat-
ment in conditions such as asthma, diabetes and
cancer (Murray, Burns, See, Lai, & Nazareth,
2005; Stinson, Wilson, Gill, Yamada, & Holt,
2009). There are a number of features of serious
games that may align well with treatment. The
combination of a narrative within games, to-
gether with clear learning objectives can facil-
itate deep learning (Dondlinger, 2007). Visual
imagery and immersion may promote under-
standing of abstract concepts and improve re-
tention (Andrews, 2011; Salzman, Dede, &
Loftin, 1999). Social Learning Theory describes
the importance of learning from others who are
credible and likeable (Baranowski, Buday,
Thompson, & Baranowski, 2008) which, in a
gaming world, can be achieved through interac-
tions with virtual characters. Participants who
may be particularly sensitive to criticism or
rejection are able to acquire and rehearse skills
in a non-threatening context where choices are
associated with clear outcomes (Read, & Short-
ell, 2011). This rehearsal and feedback can be
an effective tool for behaviour change (Read et
al., 2011) and has been shown to enhance locus
of control and self-effi cacy (Goh, Ang, & Tan,
2008). In these ways, features of serious gaming
might offer opportunities to increase the impact
of computerised therapies for depression.
Serious gaming might also offer opportuni-
ties to increase the appeal of computerised ther-
apies for depression, at least for some users.
People playing popular games fi nd it hard to tear
themselves away, unlike users of mental health
computer-based interventions, where motivat-
ing people to complete the intervention has
been troublesome.
Connolly et al. (2012) reviewed empirical
evidence on serious games and Primack et al.
(2012) reviewed video games for health-related
outcomes, however neither identifi ed any games
for depression. In this paper we aim to review
evidence-based serious games for depressive
symptoms and consider clinical and research
implications. For the purposes of this paper, we
focus on online digital or computerised inter-
ventions which are designed to reduce, treat or
prevent depression, and which utilise elements
of gaming (Prensky, 2001) as an integral and
primary method for achieving their purpose.
Defi ning serious gaming
There is no one defi nition of serious gaming.
Indeed, ‘gaming’ itself does not have a single
defi nition. Prensky (2001) defi ned gaming as
having six structural elements: rules, goals and
objectives; outcomes and feedback; confl ict,
competition, challenge or opposition; interac-
tion and representation or story. However, not
all of these elements are present in every game
(Marsh, 2011). We propose gaming is a poly-
thetic concept as described by Wittgenstein
(Wittgenstein, & Anscombe, 2009), i.e. some-
thing which is discussed as if it is connected by
one underlying essential factor but is instead
connected by a series of overlapping similarities
(or ‘family resemblances’), where no single
factor is necessarily common to all. Secondly,
we propose that serious games are not so much
a category as a continuum, from those in which
gaming is the primary purpose, to those which
incorporate elements of gaming but which
would be unlikely to appeal to those who did
not aspire to their more serious goal. For the
purposes of this analysis, we defi ned ‘serious
games’ as interventions which are games or
utilise elements of gaming (Prensky, 2001) as
an integral and primary method for achieving
their purpose.
Virtual reality can offer simulation of real
life experiences for training or rehabilitation
purposes and/or offer gaming in virtual envi-
ronments (Designing Digitally Incorporated,
n.d.). We propose that virtual reality interven-
tions are not inherently games, unless they in-
clude signifi cant features of gaming.
METHODS
We aimed to review serious gaming inter-
ventions for depression. Studies were eligible
for inclusion if they were English language
peer-reviewed articles, published after the year
2000 (given that reviews in the last 10 years had
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230 T. M. Fleming. et al.
Revista de Psicopatología y Psicología Clínica 2014, Vol. 19 (3), 217-242 © Asociación Española de Psicología Clínica y Psicopatología
identifi ed no serious games for depression).
Given that this is an emerging fi eld, we includ-
ed any study design (randomised controlled
trials (RCTs), controlled clinical trials (CCTs)
or single group designs (open trials)).
The intervention had to be delivered online
and/or via digital technology, including via a
CD-ROM, a tablet, the internet, computer,
smart phone, Nintendo or any other computer-
ised device.
We defined serious gaming as outlined
above. For the purposes of this analysis, we
included interventions which utilise elements
of gaming (Prensky, 2001) as an integral and
primary method for achieving their purpose.
We included trials where the purpose of the
serious game was to treat or prevent depression.
We included programs where stated aims were
to reduce emotional/mental distress, anxiety or
promoting emotional wellbeing where this ap-
peared to include depression or depressive
symptoms. This somewhat complex criterion
was required as programs did not utilize stand-
ard ways of describing their purpose. For exam-
ple, one study described an intervention as be-
ing for depression and anxiety (Stallard et al.,
2011), while another study by the same group
described the same program as being for emo-
tional health issues (Attwood, Meadows, Stal-
lard, & Richardson, 2012). Interventions that
were primarily for a physical health issue (e.g.
cancer) or to deal with symptoms such as audi-
tory hallucinations, PTSD, phobias, specifi c
phobia or anxiety diagnoses, or cognitive de-
cline were excluded, as even if these have an
impact on low mood, they would not normally
be disseminated for general use to treat depres-
sion.
Table 1. General characteristics of included studies
Study ID Program Study Design Size Age (years) Nature of participants
Attwood,
et al., 2012
Think Feel Do Open Trial +
CCT (vs AP)
RCT: 22
Open trial: 12
10 to 12 Recruited from school with mode-
rately severe emotional problems
Stallard, et
al., 2011
Think Feel Do RCT (vs WL) RCT: 20 11 to 16 Referred population with anxiety or
mild to moderate depression
Merry et
al., 2012
SPARX RCT (vs TAU) 187 12 to 19 Recruited from primary healthcare
sites with significant depressive
symptoms
Fleming et
al., 2012
SPARX RCT (vs WL) 32 13 to 16 Recruited from alternative educa-
tion schools (for those excluded
from mainstream education) with
possible or probably depression
Lucassen
et al., 2013
SPARX-Rainbow Open Trial 21 13 to 19 Recruited from youth organisation
and schools with significant de-
pressive symptoms
Stasiak et
al., 2012
The Journey RCT (vs AP) 34 13 to 18 Self-referred to school counsellor
with significant depression symp-
toms
Knox et
al., 2011
The Journey to
the Wild Divine;
Freeze Framer
CCT (vs WL) 30 9 to 17 Referred population with a range of
psychological/emotional problems
Coyle et
al., 2011 gNats Island 2 Open Trials Trial 1: 6
Trial 2: 15 11 to 16 Referred population with a range of
psychological/emotional problems
Shandley
et al., 2010 ReachOutCentral Open trial
266 (154
completed
post scores)
18 to 25
Unselected population of volun-
teers but aimed to prevent alcohol
misuse, psychological distress, co-
ping skills, resilience
Note: RCT: Randomised Controlled Trial; CCT: Controlled Clinical Trial; WL: Waitlist; TAU: Treatment as Usual; AP: Attention Placebo
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Serious gaming for depression 231
© Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2014, Vol. 19 (3), 217-242
To be included trials had to report pre- and
post-intervention measurement of depression,
including continuous measures of depression
symptom severity based on validated standard-
ised symptom self-report or observer-adminis-
tered scales or dichotomous measures of the
presence or absence of depressive disorder in-
cluding structured clinical interviews or a
pre-designated cut-off point on a continuous
measure of depression. For the purposes of this
paper we also examined any other outcomes
reported in our included studies.
Search strategy and key words
We undertook electronic searches of PsycIn-
fo, Medline and EMBASE (from inception to
21 June 2014) using a combination of terms
relevant to online computer games (e.g. com-
puter, online, web, internet or digital, with
game/gaming, serious game/gaming, video
game/gaming, electronic game/gaming, virtual,
play, avatar or fantasy) and depression (e.g.
Depressive Disorder, Affective symptoms, De-
pression, Dysthymic Disorder, subclinical/
threshold depression) (contact the fi rst author
for details). Titles and abstracts were searched
by one of three authors to exclude studies that
obviously did not meet the inclusion criteria.
Full text articles of studies that appeared rele-
vant or possibly relevant for inclusion were
requested and inspected independently by two
of six authors with disagreements resolved by
discussion. In addition, we searched references
of key reviews of online or gaming interven-
tions undertaken in the last 10 years as well as
the reference lists of full text articles that ap-
peared relevant or possibly relevant for inclu-
sion. Finally, we carried out a search of Google
using key gaming terms and known program
names and their authors.
Data extraction
Six authors extracted data into a data extrac-
tion form that had been piloted with one paper.
Data relevant to the characteristics of the trial
and outcome data (see Tables 1 and 2) and the
nature of the interventions with regard to the
gaming elements (see Table 3) were extracted.
A seventh author (SH) checked this data extrac-
tion and resolved any anomalies, inconsisten-
cies or queries with regard to this information
with the other authors.
RESULTS
Results of the search
We retrieved 2.137 publications; 274 were
deleted due to being published before the year
2000, and a further 1831 were excluded based
on title and abstract. We retrieved 32 publica-
tions for full inspection. Ancestry searching of
reviews and possibly relevant studies resulted
in retrieval of a further eight studies for inspec-
tion and the Google search resulted in a further
three studies for inspection. Of the 43 studies
interrogated for inclusion, 9 studies relating to
six different interventions were eligible for in-
clusion.
For the majority of possibly relevant studies
that were excluded, the reason for exclusion was
that the intervention was exclusively a Virtual
Reality simulation that did not incorporate gam-
ing as an integral or primary strategy or was an
intervention that was aimed at other conditions.
For example, many were interventions aimed to
increase exercise in various populations, were
aimed to reduce cognitive impairment in the
elderly, or were for specifi c conditions such as
ADHD, or accident-related trauma. Other pro-
grams did not include pre- and post-interven-
tion measures of depression.
Two studies required particular considera-
tion for inclusion or exclusion. Coyle et al.
(2011) were marginal on the pre- and post-in-
tervention measurement of depression criteria.
They utilised the Child Behaviour Checklist
(CBCL); Youth Self Report (YSR) and reported
that young people improved on these measures,
but they do not report the data. This study was
included given the early state of the fi eld of
serious gaming for depression. A second study
(Alvarez, Sotres, Leon, Estrella, & Sosa, 2008),
was aimed at people with depression and in-
cluded number sequencing games. However, the
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232 T. M. Fleming. et al.
Revista de Psicopatología y Psicología Clínica 2014, Vol. 19 (3), 217-242 © Asociación Española de Psicología Clínica y Psicopatología
Table 2. Depression results
Study ID Program Depression measure Result
Attwood et
al., 2012
Think Feel Do Study 1 (CCT): none
Study 2 Open Trial: Adolescent we-
llbeing scale
Study 1: NA
Study 2: Statistically significant pre to post inter-
vention improvements in the group who received
‘Think Feel Do’ (Z=-2.09, p<.05)
Stallard et
al., 2011
Think Feel Do Adolescent wellbeing scale Statistically significant pre to post intervention
improvements in the group who received ‘Think
Feel Do’ T(5)=2.49, p<.05
Merry et
al., 2012
SPARX Children’s Depression Rating Sca-
le-Revised (CRDS-R)
Reynolds Adolescent Depression
Scale-Second Edition (RADS-II)
Mood and Feelings Questionnaire
(MFQ)
Remission
CDRS-R: Per protocol mean difference 2.73
(Confidence Interval -0.31 to 5.77, p=.079)
RADS-II: Per protocol mean difference 3.65
(Confidence Interval -0.15 to 7.45, p=.060)
MFQ: Per protocol mean difference 3.74 (Confi-
dence Interval 0.33 to 7.16, p=.032)
Remission: Per protocol remission rates were
significantly higher in the SPARX group (43.7%)
compared to treatment as usual (26.4%) (p=.030)
Fleming et
al., 2012
SPARX Children’s Depression Rating Sca-
le-Revised (CDRS-R)
Reynolds Adolescent Depression
Scale-Second Edition (RADS-II)
Remission
CDRS-R: Significantly greater reductions in de-
pression for those using SPARX (F=18.11,
p=.000)
Significantly greater reductions in depression for
those using SPARX (F=4.13, p=.052)
Remission: Remission rates were significantly
higher in the SPARX group (78.9%) compared
to waitlist (36.4%) (p=.004)
Lucassen
et al., 2013
SPARX-Rain-
bow
Children’s Depression Rating Sca-
le-Revised (CRDS-R)
Reynolds Adolescent Depression
Scale-Second Edition (RADS-II)
Mood and Feelings Questionnaire
(MFQ)
CDRS-R: Statistically significant pre to post in-
tervention improvements in the group who recei-
ved SPARX (mean change -7.43; Confidence
Interval -10.79 to -4.07, p<.0001)
RADS-II: Statistically significant pre to post
intervention improvements in the group who re-
ceived SPARX (mean change -7.90; Confidence
Interval -12.17 to -3.64, p=.001)
MFQ: Statistically significant pre to post inter-
vention improvements in the group who received
SPARX (mean change -6.19; Confidence Interval
-11.13 to -1.25, p=.02)
Stasiak et
al., 2012
The Journey Children’s Depression Rating Sca-
le-Revised (CRDS-R)
Reynolds Adolescent Depression
Scale-Second Edition (RADS-II)
CDRS-R: Significantly greater reductions in de-
pression for those using The Journey (mean chan-
ge intervention group = 17.6, CI = 14.13 to 21.00;
attention placebo group = 6.06,CI = 2.01 to
10.02; F(1,27)=20.6; p< .001)
RADS-II: Greater reductions in depression for
those using The Journey but not statistically sig-
nificantly different from attention placebo group
(mean change intervention group = 13.3, CI =
7.46 to 19.15; attention placebo group = 5.19,CI
= -1.40 to 11.77; F(1,27)=3.39; p< .077)
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purpose of the game was to reduce cognitive
impairment, rather than to reduce depression,
hence, after careful review, this paper was ex-
cluded.
Characteristics of included studies
In total, nine studies were included (Table
1). Seven of the studies reported programs test-
ed with children or adolescents with depressive
symptoms or emotional problems and recruited
via schools, community organisations or health
care providers. These programs included sup-
ported interventions (Think Feel Do, Journey
to the Wild Divine and Freeze Framer and gNAT
Island) and fully self-help interventions
(SPARX, Rainbow SPARX and The Journey).
One paper (Attwood et al., 2012) reported re-
sults from two small studies; in one of the stud-
ies 13 opportunistically recruited students par-
ticipated in a trial of Think Feel Do as universal
intervention and in the other, 12 students with
‘emotional health problems’ participated. One
study reported fi ndings from a wellbeing-fo-
cused intervention tested with young people
recruited online who did not necessary have
clinical symptoms (ReachOutCentral).
Study methods
Study methods varied. One paper included
description of an open trial, as well as a CCT
(Attwood et al., 2012) of ‘Think, Feel Do’. A
study from the same group reported an RCT of
this program (Stallard et al., 2011).
Two of the included studies (Fleming, Dix-
on, Frampton, & Merry, 2012; Merry et al.,
2012) described RCTs of SPARX. A further
study from the same group described an open
trial of an adapted version of SPARX for young
people attracted to the same sex, both sex, or
questioning their sexuality (Lucassen et al.,
2013). One study described an RCT of The
Journey, a program which preceded and infl u-
enced the development of SPARX (Stasiak et
al., 2012).
One study described a CCT that tested the
effectiveness of a game-based biofeedback de-
livered via two games called Journey to the
Wild Divine and Freeze Framer (Knox et al.,
2011). The fi nal two studies each described an
open trial: gNat Island (Coyle et al., 2011) and
ReachOutCentral (Shandley et al., 2010).
The RCTs employed various control groups:
Think, Feel Do was compared with a waitlist
control (Stallard et al., 2011); SPARX has been
Study ID Program Depression measure Result
Knox et
al., 2011
The Journey
to the Wild
Divine; Freeze
Framer
Children’s Depression Inventory
(CDI)
Significantly greater reductions in depression for
those using The Journey to the Wild Divine and
Freeze-Framer (Post-intervention mean scores
intervention group=49.00 (SD 11.75) vs Wait-
list=54.83 (SD14.88); F(2,23)=9.39, p=.001)
Coyle et
al., 2011
gNats Island Study 1: Child Behaviour Checklist
(CBCL); Youth Self Report (YSR)
Study 2 : No outcome measurement
described
No data reported; discussion states that CBCL
indicated improvement while YSR symptom sco-
res were less conclusive
Discussion states gNats Island had a positive
impact on participants
Shandley
et al., 2010
ReachOut-
Central
Kessler Psychological Distress Sca-
le (K10)
Resiliency Short Form (RS)
K10: Report only a significant gender effect
(F(1,264)=11.89, p=0.00) with females having a
higher levels of distress than males. Means scores
pre to post-intervention = Females: 28.31 to
27.74; Males 24.14 to 23.76.
RS: Mean scores showed no changes for males;
whereas resiliency improved for females at fo-
llow-up F(1,177)=15.51, p=0.00)
Table 2. Depression results (continuation)
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234 T. M. Fleming. et al.
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compared with treatment as usual (Merry et al.,
2012) and a waitlist control (Fleming et al.,
2012); The Journey has been compared to an
attention placebo control group. The CCTs test-
ed the effectiveness of Journey to the Wild Di-
vine and Freeze Framer compared with a wait-
list control group (Knox et al., 2011) and Think
Feel Do with an attention placebo control group
(Attwood et al., 2012).
Participants
The RCTs and CCTs were generally small;
fi ve had a sample size less than 34; one RCT of
SPARX (Merry et al., 2012) included a sample
size of 187. Similarly, the open trials were
small, all with fewer than 21 participants except
in the open trial of ReachOutCentral (Shandley
et al., 2010), which enrolled 266 participants
and obtained outcome data for 154 of these.
Eight studies focused on children and or
adolescents (aged 9 to 19 years); while
ReachOutCentral was tested with 18 to 25 year
olds.
Participants were recruited via schools or
school guidance counsellors in three studies,
(Attwood et al., 2012; Lucassen et al., 2013;
Stasiak et al., 2012), via alternative high schools
in one study (Fleming et al., 2012), and via
school counsellors or primary health care in one
study (Merry et al., 2012). Participants were
recruited via primary health care, hospital or
mental health services in a further four studies
(Knox et al., 2011; Stallard et al., 2011; Stasiak
et al., 2012) and were recruited via a website in
the remaining study (Shandley et al., 2010).
The aims of programs were to reduce de-
pression or improve mental health or emotional
wellbeing and most described participants as
having depression, depressive symptoms (Flem-
ing et al., 2012; Lucassen et al., 2013; Merry et
al., 2012; Stasiak et al., 2012) or depression and
anxiety (Stallard et al., 2011). One study de-
scribed participants as having emotional or psy-
chological problems (Coyle et al., 2011); one
described participants as having symptoms or
a diagnosis of anxiety (Knox et al., 2011); one
paper included a non selected sample and a
group with ‘emotional health problems’ includ-
ing anxiety or low mood (Attwood et al., 2012);
and one study recruited volunteers with no re-
strictions on inclusion (Shandley et al., 2010).
Program features
Gaming aspects of included studies are sum-
marised in Table 3. These descriptions are de-
rived to the best of our ability from the limited
information describing each program.
Think, Feel, Do is a CBT-based program
comprised of six 30 to 45-minute sessions, de-
livered via a computer or CD-ROM. It is deliv-
ered with a facilitator who discusses the pro-
gram content, provides support and refl ects on
the lessons being taught in the program with the
young person. The user interface is two-dimen-
sional with three cartoon heads (Tom, the think-
er; Becky, the feeler; and Izzy the doer) guiding
the user through each session. Users choose
another cartoon character to represent them-
selves, who is superimposed into various video
vignettes of everyday situations, with users se-
lecting from a range of possible thoughts or
feelings that might arise in these situations. In
later sessions these selections infl uence what
happens next in the videos so that users become
aware of the consequences, and can select dif-
ferent options thus learning how different types
of thoughts and feelings can lead to positive or
negative outcomes. This program was included,
although with the information available, it was
challenging to determine whether or not it met
serious gaming inclusion criterion of utilizing
elements of gaming as an integral and primary
method for achieving its purpose.
SPARX is a CBT-based program comprised
of seven approximately 30-minute sessions,
delivered via a computer on a CD-ROM. There
is no therapist or other facilitator involvement.
The content utilises a ‘bicentric frame of refer-
ence’ (Dede, 2009) whereby the user meets a
virtual ‘Guide’ who talks to them directly about
depression and application of skills learned in
the ‘game world’ to their life. Users choose an
avatar to represent themselves and travel into
the ‘game world’ where they explore and take
on a series of challenges, such as shooting
gNats (Gloomy Negative Automatic Thoughts)
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Table 3. Specific gaming elements of each program
Program Rule, goals and
game objectives
Outcomes and
feedback to the
user
Conflict,
competition,
challenge or
opposition
Interaction Representation
or story
Think Feel Do The objective is to
learn thoughts and
actions that lead
to positive out-
comes
The background
music changes on
the basis of the
user’s mood; the
choices of possi-
ble thoughts and
actions determine
what happens next
Users have to con-
nect thoughts and
feelings and dis-
tinguish between
negative and posi-
tive thinking
styles
The three cartoon
heads of Tom, the
thinker, Becky,
the feeler, and
Izzy the doer,
comment on their
own perspectives
throughout the
program. User
chooses another
cartoon to repre-
sent themselves
who is superim-
posed into the
video vignettes.
The user is en-
couraged to keep
a diary of the pos-
itive things that
happen to them
between sessions
There does not ap-
pear to be an over-
arching narrative
represented be-
yond the various
vignettes
SPARX and
SPARX Rainbow
Defeat gNats,
Gather SPARX
and power gems
via tasks to help
restore balance in
a fantasy world
Various challeng-
es are presented,
such as shooting
gNats and finding
gems
Users take on an
avatar and interact
with other charac-
ters presented as
part of the chal-
lenges; the user
also interacts in
the first person
with a guide
Restoration of
balance in a fanta-
sy world
The Journey The objective is to
travel through the
land with the goal
of earning points
for completing
each module
Users are reward-
ed with simple
mini games at the
end of each mod-
ule.
Users have to earn
points. There are
quizzes that are
completed at the
beginning of each
module.
There is no inter-
action with other
characters; inter-
active exercises
are mentioned but
no description is
given
The Journey is
embedded in a
fantasy game-like
environment and
follows a narra-
tive of a quest
through magical
lands
The Journey to
the Wild Divine
and Freeze-Fram-
er
The objective is to
complete the vari-
ous tasks and ad-
vance through in-
creasing level of
difficulty
Completion of ac-
tivity is only pos-
sible on the basis
of the user slow-
ing their breathing
and decreasing
tension so that
they have imme-
diate feedback
with regard to this
The challenge is
to maintain a state
of calm while
completing in-
creasingly stress-
ful activities
There is no inter-
action with other
characters
Journey to the
Wild Divine has
user enter a fanta-
sy world and un-
dertake a journey
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236 T. M. Fleming. et al.
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and solving problems to fi nd the ‘gems of pow-
er’ and restore balance in the game world. At
the end of each level, the users return to the
Guide to refl ect on the lessons learnt and how
these lessons may apply in their lives.
The Journey is a two-dimensional CBT-
based program comprised of seven 25 to
30-minute sessions, delivered via a CD-ROM
with no therapist or other facilitator involve-
ment. It uses elements of gaming to engage the
user with the program: users select a character
that represents them and are tasked with a mis-
sion to travel to their homeland through a fan-
tasy world comprised of seven ‘magical lands’.
To move between the lands, the user completes
a series of lessons and quizzes. The users earn
points as they complete tasks and are rewarded
with mini games that they can play as part of
The Journey.
One intervention includes two games: Jour-
ney to the Wild Divine and Freeze-Framer 2.0.
These are delivered along with psychoeducation
about the effect of stress on the mind and body
and in conjunction with face-to-face therapy in
eight sessions. Journey to the Wild Divine in-
volves activities such as making a fi re, building
a wall, building a bridge, all in a fantasy world
and Freeze Framer 2.0 involves activities such
as colouring a meadow, making a rainbow and
fl oating in a hot air balloon. Completion of each
activity is only possible if the user slows their
breathing and evidences decreased tension
based on heart-rate variability and skin-con-
ductance levels. Activities include guided im-
agery and sound to aid relaxation. Players pro-
gress through levels of increasing diffi culty to
practice remaining calm during more ‘re-
al-world’ stress-inducing events.
GNats Island is a CBT-based program deliv-
ered over two to four sessions in conjunction
with face-to-face therapy, although it is unclear
how much time in each session is dedicated to
Program Rule, goals and
game objectives
Outcomes and
feedback to the
user
Conflict,
competition,
challenge or
opposition
Interaction Representation
or story
gNats Island The objective is to
travel through a
tropical island
Being stung by a
gNat (a creature
that represents
negative automat-
ic thoughts) re-
sults in a range of
negative thoughts
Opposition is rep-
resented by gNats
that can sting peo-
ple, this causes
negative thinking
Players have dis-
cussions with the
characters they
meet. Throughout
the game players
carry an in-game
notebook, in
which they answer
characters’ ques-
tions and record
new ideas
The user has to
visits a tropical
island and meets a
team of wild life
explorers
ReachOut Central The objective is
successfully inte-
grate and settle
into a new town
Users have a
mood meter that
can be manipulat-
ed by the player
on the basis of the
activities that they
engage in and
their mood im-
pacts on conversa-
tions and interac-
tions and their
progress through
the game
Interpersonal
challenges are
presented and us-
ers have to prob-
lem solve; users
have to engage in
activities that im-
prove their mood
in order to pro-
gress through the
game
Users interact
with a range of
characters; they
also have a coach
from whom they
can seek help at
any stage
The user is new to
a town and has to
work out how to
settle in, make
friends and find
their way around
Table 3. Specific gaming elements of each program (continuation)
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Serious gaming for depression 237
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the game. The user has to fi nd their way through
a fantasy world where little creatures (Negative
Automatic Thoughts – gNats) can sting people
causing negative automatic thoughts. The user
meets a range of characters who introduce strat-
egies for dealing with negative thoughts and
beliefs. The user carries a notebook where they
can record new ideas or answer questions from
these characters throughout the game.
ReachOutCentral is not modularised; the
game can be played for as much or as little time
as the user wishes. It utilises principles of CBT
and is delivered online. Users take on the role
of a character who is new in town. The user
must work out how to settle in, make new
friends and fi nd their way around. Users interact
with a range of characters in the game and have
a coach, or narrator, who acts as a guide and
mentor throughout situations and can be called
upon for help at any stage. Users have a mood
meter that can be manipulated through their
engagement in different activities such as doing
homework, sleeping or conversing. The user’s
mood in turn has an effect on conversation and
social interactions (e.g. if mood is low, making
friends is more diffi cult). Consequently, the user
is encouraged to perform various game actions
that can improve their mood meter (e.g. physical
activity, giving up drugs) in order to more eas-
ily progress in the game.
Outcomes
A summary of the depression measures used
and outcome data for these measures is present-
ed in Table 2.
In the open trial of Think Feel Do reported
by Attwood et al. (2012), participants demon-
strated signifi cant improvements in depression
on the self-rated Adolescent Wellbeing Scale,
the generalized anxiety subscale on the self-rat-
ed Spence Children’s Anxiety Scale and in
self-esteem on the Rosenberg Self Esteem
Scale. In the CCT reported in this study, Think
Feel Do was tested as a universal intervention
with a group of boys. Differences between those
who received the intervention and those who
received an attention placebo were not reported.
Depression was not measured. Those who re-
ceived the intervention had signifi cantly im-
proved scores on the total anxiety score of the
self-rated Spence Children’s Anxiety Scale, as
well as on social phobia and generalised anxi-
ety subscales but no signifi cant improvements
on parent-rated anxiety or on the parent-rated
Strengths and Diffi culties Questionnaire (At-
twood et al., 2012). In the RCT by Stallard et
al. (2011), while young people were randomised
to Think Feel Do or a waitlist control, only with-
in-group analyses were undertaken so it is not
clear if there were signifi cant differences be-
tween groups across the outcome measures.
Those who received the intervention did demon-
strate signifi cant improvements in depression
measured on the self-rated Adolescent Wellbe-
ing Scale, as well as in three of the fi ve sub-
scales of the Strengths and Diffi culties Ques-
tionnaire (parent-rated), one out of six subscales
on the self-rated Spence Children’s Anxiety
Scale (social phobia), self-esteem on the Rosen-
berg Self Esteem Scale and on cognitive sche-
mas (Schema Questionnaire for Children) (Stal-
lard et al., 2011).
In the largest RCT included in this review,
SPARX was shown to be as effective as treat-
ment as usual in reducing clinician-rated de-
pression on the Children’s Depression Rating
Scale-Revised (CDRS-R), on self-report de-
pression symptoms measured on the Reynolds
Adolescent Depression Scale-Revised Edition
(RADS-II) and on the Moods and Feelings
Questionnaire (MFQ), with signifi cantly higher
remission rates for those who received the in-
tervention compared with those who received
treatment as usual (Merry et al., 2012). Those
who received the intervention also had signifi -
cantly greater reductions on self-reported anx-
iety on the Spence Children’s Anxiety Scale.
When compared with a waitlist control in stu-
dents in alternative education settings, SPARX
resulted in signifi cantly greater reductions in
depression on the CDRS-R, and on RADS-II,
as well as signifi cantly higher rates of remis-
sion. However, there were no signifi cant differ-
ences between groups on anxiety or other meas-
ures of psychological functioning (Fleming et
al., 2012). In the open trial of Rainbow SPARX
there were significant reductions on the
CDRS-R, RADS-II and the MFQ, as well as
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anxiety on the self-rated Spence Children’s
Anxiety Scale from pre- to post-intervention
(Lucassen et al., 2013).
The Journey was compared with a psy-
cho-educational computer program in an RCT
and those who received the intervention had
signifi cantly greater reductions in clinician-rat-
ed depression on the CDRS-R but not on
self-report depression symptoms measured on
the RADS-II (Stasiak et al., 2012).
In the CCT of Journey to the Wild Divine
and Freeze Framer, there were significant
post-intervention differences between those
who received the intervention and those who
were in the waitlist control group on depression
measured on the self-report Children’s Depres-
sion Inventory as well as on anxiety measured
by the self-report Multidimensional Anxiety
Scale for Children (Knox et al., 2011).
The remainder of the studies were open
trials, which are limited in terms of their abil-
ity to answer questions about effectiveness and
few outcome data were reported. Coyle et al.
(2011), reported no outcome data but stated
that in study one there were some improve-
ments in Child Behaviour Checklist (CBCL)
scores but not Youth Self Report (YSR) scores
and in study two that gNat Island had a positive
impact but no outcome measurement is de-
scribed (Coyle et al., 2011). In the trial of
ReachOutCentral (Shandley et al., 2010), de-
pression symptoms were only captured with
the Kessler Psychological Distress Scale
(which also includes items relevant to stress
and anxiety) and there were no signifi cant im-
provements from pre- to post-intervention. The
authors did report that there were signifi cant
improvements in resiliency for females, but not
for males.
Adherence and satisfaction
In terms of clinician or facilitator support-
ed interventions, 85% of participants in the
RCT of Think Feel Do completed all modules
(Stallard). Study drop-outs but not adherence
data were reported in the studies of gNats Is-
land Journey to the Wild Divine and Freeze
Framer.
In terms of the fully self-help interventions
(SPARX, SPARX-Rainbow, The Journey and
ReachOutCentral); between 60% and 90% of
participants completed all 7 modules of SPARX
(Fleming et al., 2012, Lucassen et al., 2013,
Merry et al., 2012) and 94% completed all mod-
ules of the Journey (Stasiak et al., 2012). On
average females spent a total of 91 minutes over
1.6 sessions on ReachOutCentral and males
spent 69 minutes over 1.5 sessions (Shandley et
al., 2010).
All of the studies had some measure of sat-
isfaction, with at least moderate ratings for all
the programs. Most studies did not include anal-
ysis of program content or detailed user feed-
back on program design.
DISCUSSION
In this systematic review, we have identifi ed
nine studies of six computerised interventions
for depression which utilise gaming as a key
component. Eight of the studies investigate the
use of a tool for children or adolescents with
depression or current symptoms. In most of
these cases, the game is played on a computer
and involves a fantasy world in which the user
undertakes a virtual journey as they learn real
life skills. Overall there were promising fi nd-
ings in terms of adherence (when reported) and
in terms of impact on symptoms. However, all
have been carried out by persons involved in the
development of the intervention and all but one
(Merry et al., 2012) are small trials. The remain-
ing study is of ReachOutCentral (Shandley et
al., 2010), an online program where users play
the part of a new young person in town.
ReachOutCentral was tested with an unselected
sample (participants did not need to have symp-
toms), the average player used it for one to two
sessions and there were few notable changes in
outcomes. The lack of defi nitive detail and the
limited nature of the trials does not allow me-
ta-analysis at this time. That said, there is suffi -
cient evidence to demonstrate that it is possible
to develop game-based interventions to deal
with the serious issue of depression; it appears
that young people are willing to try these, the
programs aimed at those with symptoms appear
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to be likely to reduce symptoms of depression,
and users report favourably on them.
Existing literature has demonstrated that
computerised interventions for depression can
be effective and that adherence is enhanced with
therapist or paraprofessional support (Spek et
al., 2007; Richards et al., 2012). Most of the
computerised therapies use text, reading, video,
diagrams and quizzes. Many incorporate social
learning via videos or text and most include
programming logic that allows feedback on user
input. Serious gaming can add features of play,
mystery and narrative (Klopfer, Osterweil, &
Salen, 2009). Serious gaming may be valuable
in increasing immersion and can allow the use
of visual metaphor and egocentric as well as
exocentric learning perspectives (Dede, 2009;
Dondlinger, 2007). Whether serious gaming
might increase uptake of computerised thera-
pies or increase adherence to them has not yet
been tested. Whether serious gaming might also
have negative effects is also unknown. It is fea-
sible that serious gaming programs could re-
duce face validity to some users and might de-
crease appeal to some groups.
Existing evidence shows that serious games
can lead to improvements in diverse social,
behavioural and clinical outcomes (Murray et
al., 2005; Spek et al., 2007; Stinson et al., 2009).
However the fi eld is relatively new, and there
has been little investigation of important ques-
tions such as the effects of serious gaming in-
terventions on existing consumer-therapist re-
lationships, health service utilisation, equity of
access to care and consumer perspectives (Mur-
ray et al., 2005; Stinson et al., 2009). This re-
view indicates that serious gaming might also
be of use for depression, however at present this
literature is very limited. Larger and more in-
dependent trials are required. Further, optimal
gaming components and design elements have
yet to be explored. Most studies provided very
little program description and programs cannot
be accessed easily for review. It is important
that program content and design is reported to
allow learning from previous research.
All included interventions focused on chil-
dren, adolescents or young people (aged 9 to 25
years). This limitation does not refl ect the di-
verse population of game users. While young
people have led the uptake of computerised
games, games are now popular among many age
groups. Computer gaming programs have been
used for cognitive decline among older persons
(Lim, & Chun, 2013) and the Playmancer pro-
ject has developed physical fi tness and move-
ment based programs for older people (Kalap-
anidas et al., 2010). Expansion of serious
gaming for depression into other age groups is
also worthy of exploration.
The fi nding that many of the included inter-
ventions are delivered via technology such as
CD-ROM highlights the important issue of
time-lag from program development to pub-
lished peer-reviewed fi ndings and dissemina-
tion. The CD-ROM is rapidly dating and cannot
be utilised on many devices. No programs were
smartphone-based, even though a large and
increasing proportion of internet access is via
smartphones. Many of the programs described
(with the exception of ReachOutCentral, and,
to those with New Zealand IP addresses,
SPARX) are not available outside of research
settings. In contrast, there are many mental
health apps and online programs which are pub-
lically available and which have been reported
any impact on depression in peer-reviewed lit-
erature. Examples include games designed to
enhance mood or to educate about depression,
gratitude diaries and mood monitoring apps.
The public deserve to know if these are safe and
effective. Furthermore, the evidence-based clin-
ically-validated sector should avoid lagging
behind the rapid prototyping of the commercial
sector. A more rapid development, testing and
dissemination cycle of evidence-based mental
health interventions is required. Models for
such systems have been proposed (Glasgow,
Phillips, & Sanchez, 2013).
Strengths and limitations
The literature regarding serious gaming is at
an early stage. Inconsistent terms used to de-
scribe the aims or purpose of computerised
programs targeting users with depression and
the lack of a consistent nomenclature for serious
gaming added complexity in defi ning included
and excluded studies for this review. We have
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endeavored to make thoughtful judgments about
inclusion criteria and have been explicit about
these. Studies are generally small and interven-
tions are heterogeneous. These limitations pre-
clude meaningful data synthesis at this time. It
has been diffi cult to fi nd out much information
about the content of the interventions. Ideally
we would have been able to complete each one,
and an in-depth analysis of the type of game
play would be worthwhile as this fi eld develops.
These various limitations mean that we can only
make very tentative conclusions about the pos-
sible appeal and impact of serious games for
depression.
We have explored only peer-reviewed liter-
ature regarding serious games for depression.
Consideration of non peer-reviewed interven-
tions and review of serious games for other
aspects of mental health would also be worth-
while.
CONCLUSIONS
As the medium by which we can communi-
cate broadens, it is likely that there is no uni-
versal method that will suit all problems and
goals of treatment, or the all ways that people
wish to access help. Rather, there needs to be a
range of well-designed, proven tools which
practitioners and users can choose from to suit
the diversity of human circumstance and pref-
erence.
We are at the beginning of exploring how
serious games might impact on depression. The
current data suggest that it is possible to devel-
op serious games for depression and that young
people are willing to try them. Available data
regarding adherence and impact is very limited
but is promising. Given the potential gains in
terms of increasing access globally, and meeting
the needs of those reluctant to seek help through
current methods, this is an area ripe for future
development and testing.
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