ChapterPDF Available

A Review of Indie Games for Serious Mental Health Game Design

Authors:
Chapter

A Review of Indie Games for Serious Mental Health Game Design

Abstract

Mental health disorders present a global challenge being the largest contributor to non-fatal burden of disease. In fact, those who are experiencing symptoms of mental illness often wait ten years before seeking help. This is frequently due to help-seeking barriers such as stigma and cost. One way to combat help-seeking barriers is through increasing the mental health literacy of the public. This has been achieved successfully through digital delivery of mental health information and services, including serious games. Early research suggests that serious games are an effective tool for improving mental health literacy. However, factors such as poor-quality game design and research studies mean that developers face challenges when designing, developing, and analyzing serious games. To address these challenges this paper will provide an analysis of indie games that feature topics of mental health, trauma, and grief. Indie games share similarities to research environments, often being created by small teams on a limited budget. Even with these limitations they can tell impactful and emotional stories, making them a valuable source of inspiration for developers of serious mental health games.
AReviewofIndieGamesforSeriousMental
Health Game Design
Myfanwy King(B), Tim Marsh, and Zeynep Akcay
Griffith Film School, Griffith University, Brisbane, Australia
myfanwy.king@griffithuni.edu.au, {t.marsh,
z.akcay}@griffith.edu.au
Abstract. Mental health disorders present a global challenge being the largest
contributor to non-fatal burden of disease. In fact, those who are experiencing
symptoms of mental illness often wait ten years before seeking help. This is
frequently due to help-seeking barriers such as stigma and cost. One way to combat
help-seeking barriers is through increasing the mental health literacy of the public.
This has been achieved successfully through digital delivery of mental health
information and services, including serious games. Early research suggests that
serious games are an effective tool for improving mental health literacy. However,
factors such as poor-quality game design and research studies mean that developers
face challenges when designing, developing, and analyzing serious games. To
address these challenges this paper will provide an analysis of indie games that
feature topics of mental health, trauma, and grief. Indie games share similarities
to research environments, often being created by small teams on a limited budget.
Even with these limitations they can tell impactful and emotional stories, making
them a valuable source of inspiration for developers of serious mental health
games.
Keywords: Serious games ·Mental health ·Mental health literacy ·Indie
games ·Independent games
1 Introduction
Mental health disorders are the greatest contributors to non-fatal burden of disease
(18.3% as of 2016) and account for eight million deaths per year [13]. Mental ill-
ness symptoms can affect a person’s mental, physical, and social wellbeing and reduce
their ability to manage everyday life, for example their ability to attend work or school,
go on social outings or care for themselves [3]. Despite the personal cost of these symp-
toms, it can take up to ten years for a person to seek treatment for a mental illness leading
to more severe illness at presentation [4]. This is often due to treatment barriers such as
stigma or cost, where stigma is the main reason reported for not seeking help [511].
Therefore, reducing stigma and improving the treatment, identification and management
of mental health disorders is an imperative global challenge that relies on governments
and communities working together.
© Springer Nature Switzerland AG 2021
B. Fletcher et al. (Eds.): JCSG 2021, LNCS 12945, pp. 138–152, 2021.
https://doi.org/10.1007/978-3-030-88272-3_11
A Review of Indie Games for Serious Mental Health Game Design 139
One way to increase awareness in communities is through digital interventions that
aim to increase mental health literacy (MHL). MHL, first coined by Jorm et al., is a term
derived from health literacy and refers to the knowledge of mental health, wellbeing,
symptoms, treatment, care, and services [9,12,13]. This includes initiatives that reduce
stigma and prejudice toward mental health disorders [9,12,13]. Digital initiatives such
as Beyond Blue aim to do this by providing resources and support to communities [14].
The Beyond Blue initiative has been credited by Jorm, Christensen and Griffiths in help-
ing to increase the publics MHL in Australia [12]. Other interventions aim at augmenting
treatment or improving wellbeing. For example, moodgym, an online cognitive behav-
ioral therapy-based course, has been shown to be effective in improving outcomes for
those with early symptoms of mental illness when compared to patients on a waitlist
[15,16]. Suggesting that digital interventions are a promising direction for improving
MHL. Additionally, there are many mobile application interventions including mood
trackers, mindfulness, and meditation applications [17]. Like other digital interventions,
serious games present another promising avenue for the delivery of mental health literacy
content.
This paper will provide a brief overview of serious games for mental health. Addi-
tionally, it will provide an analysis of indie games that explore stories of mental health
and mental illness. Through this analysis, suggestions will be provided on ways indie
games can inform serious games design. This paper is structured as follows. Section 2
will outline serious game’s role in mental health treatment and education. Section 3
explores indie games that provide an insight into the thoughts associated with mental
illness and offer a creative look into the design of serious games for mental health.
Section 4will provide a discussion and conclusion to the topics covered in this paper.
2 A Brief Overview of Serious Games for Mental Health
Serious games have been defined by Michael and Chen as games that primarily focus on
education, without principally being entertaining [18]. However, they are now further
defined to exist on a continuum of gameplay mechanics, narrative, and styles – widening
the scope for what is classified as a serious game [19]. Boyle et al. finding articles covering
a broad field of topics such as science, health, and business, across several game genres
(e.g., simulation and role-playing) in their serious game meta-analysis [20]. Additionally,
they found that the benefits of serious game can include but are not limited to behavior
change, real world skills development and knowledge acquisition [20]. In fact, both
Boyle et al. and Qian and Clark suggest that serious games are ideal for teaching 21st
century skills such as communication, problem solving and scientific reasoning [20,21].
Indeed, MHL should be considered a 21st century skill and is therefore an appro-
priate field for development of serious games. However, there are challenges in the
development of both digital interventions and serious games that utilize mental health
literacy. As stated earlier, moodgym is targeted to those who have early signs of mental
illness, because it was less effective to those with more severe symptoms of mental
illness [15,16,22]. Additionally, while there are many mobile applications for mental
health, most mobile applications lack research-based examination, may not be backed by
current evidence and/or may present damaging information [17]. Moreover, these types
140 M. King et al.
of interventions have challenges such as having high attrition and dose dependence;
therefore, they are not considered suitable for primary treatment [15,2325]. Serious
games present a similar challenge to developers in the area of mental health literacy.
Serious games for mental health are a promising, yet emerging field of research.
Using them for improving mental health literacy, more specifically for treatment, man-
agement, and education, are effective [26,27]. One example of a serious game for
improving mental health literacy in adolescents is SPARX [28]. SPARX is a game and
e-health therapy developed for youth that is currently only available in New Zealand
[28]. It is divided into several levels, each focused-on learning different skills (e.g., cop-
ing with emotions and problems) [29]. SPARX has been shown to significantly improve
depression, anxiety, and quality of life with results persisting through to a three-month
time point [29]. Results from this study are promising and show the potential of a serious
game directed towards youth mental health. However, another study using a variant of
SPARX (SPARX-R) that focused on depression, found that there were no significant
changes in mental wellbeing or coping [30]. This result was likely affected by high
dropout rates and small sample size but touches on a problem with targeting digital
interventions to those with mental illness [30].
Targeting young people and teaching them resilience through video games is a natural
fit as video games make up a large part of modern culture due to their wide availability
over different technologies. However, all the digital initiatives discussed this far fail
to address a larger concern and that is offering help and support to those with severe
mental illness. In a review on treatment of those experiencing severe mental illness (for
example, schizophrenia and psychosis) Fitzgerald and Ratcliffe found that the games
were effective and generally accepted by players [26]. However, they also found that
factors such as poor design, lack of challenge, lack of contextualization and poor narrative
led to users losing motivation and interest in playing the games [26]. In addition, a person
experiencing a mental illness, especially a severe one, may have an impaired ability to
function or ask for help [26,31].
Serious games are an emerging field and there are limited examples of research-based
games for mental health. In their review, Fitzgerald and Ratcliffe found that research
games, existing games and card games were being used in research studies, which is
mirrored in an earlier review by Fleming et al. [26,27]. Interestingly Fitzgerald and
Ratcliffe noted that better designed games were more interesting to players, stating that
“[h]aving a choice and variety of options, appropriate levels of challenge, easy-to-follow
instructions, and familiar, intuitive control devices corresponded to player enjoyment,
confidence that they can play the game, and successful delivery of interventionoutcomes”
[26]. To address the challenge of quality and design in serious games it is important to
draw on previous examples. One avenue of investigation for serious games about mental
illness are indie games.
3 Indie Games
Video games, by their nature, are a broad and varied field and can be hard to define and
indie games are no exception to this [32]. Indie or independent games were originally
defined as games that were made on low budgets by small teams who published outside
A Review of Indie Games for Serious Mental Health Game Design 141
more mainstream channels used by larger companies [32,33]. As such, for this paper
the term indie will refer to games made by one person or small teams that have a limited
budget including those that were funded by platforms like Kickstarter. They differ from
Triple-A games which are produced by larger companies with larger budgets.
Triple-A games, despite the increase in available platforms for indie games, are an
industry standard offering high end aesthetics, grand heroic stories and stunning visuals
to players. They are made over many years, have huge budgets, and rely on large teams of
people to produce them. However, many of these games utilize formulaic “cookie cutter”
gameplay and rely heavily on heroic adventures rather then creating deep and meaningful
stories. Indie games on the other hand, tend to be made by one person or smaller teams
and are limited by budget. However, they are praised for their innovation, creativity,
deep personal stories, authored experiences, and appealing nature. Of course, there are
exceptions to these rules, for example The Last of Us is a Triple-A game that focuses
on story driven gameplay [34]. An indie game example is Hellblade: Senua’s Sacrifice,
which tells a deep story about a character with psychosis using detailed graphics and
gameplay that could be found in a Triple-A title [35].
3.1 Indie Games and Mental Illness
Indie games may seem to be more restrictive than larger Triple-A games, but they have
a freedom to explore topics that bigger game companies might avoid. These stories can
include characters who have a mental illness and/or are LGTBQ+. For example, Coming
Out Simulator is based on the personal experiences of the developer coming out as gay
[36]. This freedom means there are more examples of indie games that explore topics of
mental health, mental illness, and trauma. These stories offering a rich narrative world
that takes a deeper look at the impact mental illness and trauma can have on those who
either experience mental illness or those around them. There are a few exceptions to
this, but many popular Triple-A games use trauma as a catalyst for heroic endeavors. For
example, The Last of Us explores an emotional story of loss and trauma, while games
like Assassins Creed Origin focus on the hero’s journey, where trauma is a catalyst for
a heroic adventure rather then the focus of the game [34,37].
Meaning indie games analyzed in this paper provide insight into the creation of short
impactful games that have been created by smaller teams on a limited budget. Drawing
on factors such as visual style, storytelling, and gameplay of indie games can help to
improve the quality and longevity of serious games. Additionally, these games often
provide an example of both positive and negative representation of mental illness that
can be used to inform character design. Of course, developers are not limited to video
games, additional sources can be found in film, books, and comics. However, the focus
of this review is to highlight indie games, which may be overlooked, for use as examples
when developing serious mental health games. An overview of these games can be seen
in Table 1.
Florence. Florence is a touching and beautifully executed game that explores the begin-
ning and end of a romantic relationship [38]. Regarding mental health, it addresses the
feelings of grief and sadness associated with the loss of a relationship and unfulfillment
of life goals. Grief itself is not a mental illness as it is a normal response to loss; however,
142 M. King et al.
it can affect a person’s mental health and wellbeing [14]. Florence is a predominantly
visual game that uses minimalistic design and straightforward mechanics coupled with
both graphic and visual metaphor to tell the games story. For example, as the relation-
ship grows communication is shown visually through a speech bubble puzzle [38]. The
puzzle becoming less complicated over time, as the couple gets to know each other.
This is also used when the two have an argument, the puzzle pieces changing color and
shape. There are many examples of the use of visual intrigue and clever design dotted
throughout Florence. A minimalist design with thoughtful mechanics can help a designer
explore how to communicate story visually and mechanically, without the need for a
long narrative.
Coming Out Simulator. Coming Out Simulator tells the story of a young man who
struggles with coming out as gay to his parents [36]. It also explores the fear, loss
and loneliness associated with both hiding and coming out as gay and finally, coming
to accept it. A short game, with a minimalist design, it proves that short games and
stories can have an emotional impact. Providing both a visual style that is appealing yet
minimalist and stories told in short sentences. The players choices are limited, leading
to changes in dialogue but not outcome. This can provide inspiration in how to tell small
impactful stories that could be used in serious games design, especially in a research
setting where time and funds may be limited.
Depression Quest. Depression Quest is surrounded by controversy; however, the focus
here will not be on these problems, but on the game itself [39]. Depression Quest is an
interactive fiction with minimal design. It explores a twenty something characters life
as the symptoms of depression begin to manifest and become worse. Choices can lead
to different outcomes, for example getting treatment or taking medication can improve
choices, while avoiding treatment and worsening symptoms of depression can cause
options to be crossed out. Depression Quest provides insight into the field of narrative
design and development for both characters and stories. Additionally, it shows how
mechanics can help communicate ideas in story (i.e., crossing out of options when
symptoms get worse).
That Dragon Cancer. That Dragon Cancer provides a heart wrenching insight into one
family’s emotional journey through diagnosis and treatment of their son’s cancer and the
inescapable death of their son [40]. The game uses metaphors, perspective, and personal
discussions to explore the characters feelings during each stage of their child’s treatment.
They also explore the religious beliefs and how they affect each other’s views on what
their family is going through. For example, while the mother holds fast that god will
save her child, the father is left feeling overwhelmed and alone knowing that their child
is going to die. The sense of loneliness and separation of the two characters as they
deal with grief and acceptance in their own way is palpable. That Dragon Cancer uses a
mixture of metaphor, atmosphere, and personal recollection to tell an emotional story.
It highlights the importance of personal stories in the development of character driven
serious games.
Keep in Mind: Remastered. Keep in Mind: Remastered is a short game that uses
metaphor to explore mental illness and substance use disorder [41]. Players enter an
A Review of Indie Games for Serious Mental Health Game Design 143
alternate dream world where they need to walk around and speak to monsters, each
a metaphorical representation of the symptoms, thoughts and feelings associated with
mental illness. For example, one monster represents his past guilt at the loss of a loved
one, while another represents his struggle with alcoholism. The use of the monster
metaphor is a well-known way a person describes their mental illness, where the experi-
encer sees the mental illness as a shadow, cloud, or a black dog. In the end Keep in Mind:
Remastered is about the acceptance and desire to change and face one’s inner demons.
It provides designers with examples of how metaphor can be used to communicate not
only the symptoms of mental illness, but also the inner fears, thoughts, and feelings of
a person’s experience.
Actual Sunlight. Actual Sunlight is a somewhat brutal look at mental illness that
explores some of the symptoms associated with depression and suicidal ideation [42,43].
The main character works in a thankless job, has lost pleasure in life and is addicted to
video games [42]. You can feel the characters pain, explore his reasoning for suicide and
his experience with the symptoms of mental illness. Most confronting is when he decides
to act on thoughts of suicide. This is not shown directly but through the metaphorical use
of the suns light to express release. This game provides a good example of exploring the
thoughts, feelings, and symptoms of someone experiencing a mental illness, including
the more challenging thoughts of suicide.
Depression. Depression is a short but clever game developed by Martínez and can be
found on the indie game hosting site, itch.io [44]. The developer interviewed participants
and asked them to define their experience with depression and then expressed these
definitions through game mechanics [44,45]. The game mechanics are straightforward,
get your character (a white square) to a goal using the keyboard. Each of the eleven
chapters addresses some aspect of how depression feels. For example, scene two is titled
“Sometimes things are a bit more difficult… like you feel … slower” and when the player
moves the square it begins to get slower and slower until it crawls to the goal [44,45].
The act of moving the square provides a mechanical description of the symptom of being
slowed down by depression. This game strips away complex visuals, and narrative, in
favor of telling a story through mechanics.
3.2 Indie Games, Stigma and Tropes
There are many indie games that explore personal or fictional stories that could be consid-
ered serious games. These games innovative designs, visual storytelling, and insightful
narratives merit further analysis to learn ways to create impactful and emotional serious
games that have longevity. They also provide a portrait of different characters experi-
ences with mental illness to draw from. However, it is essential to be able to recognize
inaccurate information and stigma in indie games that serve to misinform the player.
144 M. King et al.
Fran Bow. Fran Bow is a dark tale that explores a child’s experience of trauma [46].
The game begins in a mental institution where Fran Bow is being stalked by a shadowy
monster and must escape to find her cat Mr. Midnight. Depicting mental institutions
is a common and often problematic trope seen in the horror genre that does not reflect
modern mental health care practices [46,47]. Fran Bow also depicts common stereotypes
of mental illness where treatment is seen as dangerous, the doctors and staff are viewed
as incompetent, and children are being depicted as lobotomized and experimented on
[4648]. While some of the depictions in this game are problematic it must be taken in
the context of the game developers lived experiences.
The developer Figueroa using game development as a cathartic experience, stating in
an interview “the game itself is a kind of screaming out what I been experienced through
my childhood and teenager years. From childhood I have being experiencing traumatic
events, from being witness to family violence to unfair personal treatment outside home.
And as a teenager being sentenced to be part of a religious sect, being kind of a guinea
pig for research with all medicine’s doctors gave me to try to cure the mental illness
that life was giving me” [49]. In this light, the metaphors of monsters, being trapped
in an institution, trying to escape one’s past and losing family are brought into context.
Fran Bow reminds us firstly that understanding the developers’ views can help frame
the context of stigmatized depictions. Secondly, having knowledge of these stigmatized
depictions allows us to recognize them and know they are not the norm.
The Suicide of Rachel Foster. The Suicide of Rachel Foster is a mystery horror game
that follows Nicole as she returns to her parent’s hotel years after the suicide of Rachel
[50]. The start of the mystery is quite interesting and builds a creepy atmosphere as
you walk around the hotel learning about the main characters and the tragedy that
unfolded. As Nicole walks around, she discusses the story to an emergency services
worker and Rachels brother, Irving. This game deals with several sensitive topics poorly
(e.g., Nicole’s father having a relationship with Rachel), but the focus here will be on its
use of suicide.
Suicide is used as a plot point several times in game, the most confronting of these
occurs when the player finds themselves in a car as it fills with exhaust [50]. The player
has the choice to stay in the car and die or remain at the hotel forever. Placing the player
directly in the role of someone who is acting on thoughts of suicide, with no viable
alternative or chance to get help. Several non-research game reviews cover the ending
of the game and its use of suicide as a plot point [5153]. The game does well to build
atmosphere; however, its use of suicide as a plot device for shock value detracts from a
game that had the potential to tell an emotional story. One that explores the emotional
experience of those who have a shared trauma.
A Review of Indie Games for Serious Mental Health Game Design 145
Table 1. An overview of indie games that explore mental health topics including their design,
core mechanics, advantages, and limitations.
Title Florence [38]
Overview Tells the story of the beginning and end of a relationship. Showing both the
happiness of new love, breaking down of a relationship and the grief that comes
at the end of it. Additionally, it shows the personal growth that can come out of
grief and loss
Design A minimalist design with a beautiful art style consisting of muted tones and
bright colors highlighted by lines. Backgrounds tend to be sparsely designed
when the focus is on the character but detailed when establishing environment
Mechanics Initially designed for mobile, the game uses straightforward swipe or mouse
gestures to browse through the comic panels and complete puzzles
Advantages Well-designed gameplay and visuals
Communicates story through gameplay without dialogue
Explores grief, overcoming it and moving on
Good use of emotional gameplay
Limitations No text or dialogue used for communication
Title Coming Out Simulator [36]
Overview Tells the story of a young man’s experiences with hiding and coming out as gay
and its effect it has on his personal relationships. The ending of the game is more
positive, with the character coming to accept who he is and finding a community
to help him overcome these challenges
Design The visual design uses two or three tone colors with line art and faceless
characters. Dialogue is shown in colored text boxes that are overlayed above the
background and characters. Choices are given at the bottom of the screen in a
small grey area that blends will with the other visuals
Mechanics Players read dialogue through text boxes and make choices by clicking on text
below
Advantages Straight-forward design
Interesting use of the graphical user interface (GUI)
Tells short but emotional story
Positive and personal representation of LGBTQ+ characters
Limitations Characters have no faces, therefore do not show emotions visually
Title Depression Quest [39]
Overview Depression Quest follows the story of a young person as they develop the signs
and symptoms of depression. It shows how symptoms of depression can affect
everyday life
Design Depression Quest was made using Twine and therefore consist of text, a basic
textured grey background, and hyperlinked choices. The side bar contains a title
and some information about the game. Above the text is a single image reflecting
actions or places in the story. Below the main text and choices is a tracking
system consisting of text on top of grey boxes with an animated background
(continued)
146 M. King et al.
Table 1. (continued )
Mechanics Depression Quest uses interactive fiction mechanics where the player can make
choices that affect story and characters, with multiple possible endings reached
based on these choices. A tracking system down the bottom of the page shows the
level of depression and if the character is receiving treatment. The tracking
system is linked to choices, with some being crossed out dependent on the level
of symptoms and current treatment
Advantages Story told from main characters perspective
Clearly shows how symptoms can affect everyday decisions
Inspired by personal experiences with mental illness
Characters and partners gender are open to players interpretation
Limitations Large amount of text to read, players might lose interest
There are mixed reviews despite the fact the game has won awards
Subjectively, not as emotional as other games on this list
Title That Dragon Cancer [40]
Overview That Dragon Cancer follows a family’s journey through the diagnosis of cancer,
treatment, and death of their young son, Joel. Exploring the thoughts and feelings
of Joel’s parents and how they each coped with learning that their son was going
to die
Design The design uses a mixture of bright colors and low poly models for most scenes.
Dark pulsating tumorous cells are dotted throughout the game and represent
Joel’s cancer. Additionally, the game uses a variety of colors and metaphors to
explore very emotional themes (e.g., drowning under water when feeling alone
and overwhelmed). Each chapter of the game plays like a living story book
telling different parts of the overall journey
Mechanics That Dragon Cancer is primarily a walking simulator where you explore the
world through movement and interaction. There are several points in the game
where mechanics are changed to create unique moments within the story. For
instance, there is an arcade style game where you need to defeat a dragon
Advantages Great example of emotional story telling
Communicates deep emotions and create atmosphere for players
Explores concepts of loss and grief
Might help players who are going through the same experience
Limitations Emotional content can be overwhelming
May not be suitable if players have recently experienced loss
Title Keep in Mind: Remastered [41]
Overview The players follow Jonas into a nightmare world where he encounters
representations of his mental illness, fears, and grief. He must visit each one and
come to terms with them before he can escape
Design Colors are a mixture of black, red, and white in the dream world, except for Jonas
who is in color. It uses a sparse pixel aesthetic, with real-world scenes being more
detailed than those in the dream world
Mechanics The game is a 2D walking simulator that uses top-down mechanics. The player
controls the characters direction and can interact with NPC’s
(continued)
A Review of Indie Games for Serious Mental Health Game Design 147
Table 1. (continued )
Advantages Metaphorical look at anxiety, grief, and substance use disorder
Uses the monster metaphor to explore symptoms of mental illness
Uses sound to enhance some visual metaphors
Limitations Easy to get lost trying to find characters in the game
Subjectively, not as emotionally impactful as some of the other games explored
Title Actual Sunlight [42]
Overview Actual Sunlight follows Evan Winters, a thirty something year old man, who is
experiencing symptoms of depression and game addiction. Players explore his
everyday life, struggle with thoughts of suicide and the reasons why he decides to
act on those thoughts
Design Actual Sunlight was built in RPG Maker. It has a pixel aesthetic, interspersed
with hand drawn images of story moments. It does not use color or metaphor in
the same way the other games do, except for the metaphor of sunlight and release
to represent suicide
Mechanics Players discover story elements through interaction with characters and objects.
The player moves the character around from a top-down perspective. This game
is story driven and is like other interactive fiction/walking simulators
Advantages Tells a story about the thoughts and feelings associated with suicide
Tackles a challenging subject well
Limitations Best avoided by those who may be experiencing thoughts of suicide or
struggling with experiences of mental illness
No attempt made to help the character or find solutions
Title Depression [44,45]
Overview Depression is a straightforward game that tells stories of depression through short
text statements and mechanics. The creator interviewed people with depression
and translated those into game mechanics
Design The game is set on a dark textured background and consists of small white
squares for the main character and as obstacles
Mechanics The player controls a white square with the keyboard and the aim is to move the
square toward a goal. Each level creates different obstacles for the player that
represent symptoms or feelings of depression mechanically
Advantages Shows how mechanics can be used to explore symptoms of mental illness
Limitations N/A
Title Fran Bow [46]
Overview Fran Bow is an adventure game that follows a young girl as she escapes a mental
institution to search for her cat Mr. Midnight. The game uses horror elements to
explore mental illness, grief, and past trauma
Design The game design is a mix of cute 2D characters with dark horror elements
inspired by such stories as Alice in Wonderland. It is a very graphic game
depicting for example, dead animals, blood, gore, and murder. Juxtaposing
innocent and sweet with death and gore to explore the mind of a child who is
experiencing symptoms of psychosis
(continued)
148 M. King et al.
Table 1. (continued )
Mechanics Uses adventure game mechanics with the players controlling the character by
clicking the mouse on screen. Objects can be interacted with and can be
combined in the inventory to solve puzzles. Additionally, the player can interact
with different NPCs to have conversations and solve puzzles. The world is
divided between reality and a dark dimension that is accessed when Fran takes a
pill called Duotine
Advantages A metaphorical exploration of trauma and mental illness
Uses tropes and stigma to communicate personal experiences
Explores trauma from the perspective of a child
Limitations Traumatic experiences viewed through the eyes of a child
May be challenging to those who have experienced trauma
Contains some use of tropes and stigmatized views of mental illness
Title The Suicide of Rachel Foster [50]
Overview After the death of her father, the player (Nicole) returns to the family’s hotel and
uncovers the mystery surrounding the death of Rachel Foster
Design The design of the game is three dimensional and played from the characters
perspective. The hotel environment is well designed, and the game builds a
haunting atmosphere through visual, audio and story
Mechanics The game is a walking simulator, where the player can move around the hotel and
interact with objects. The story is told through objects and by talking to Irving
(NPC) on the phone, which provides most of the dialogue
Advantages Good build-up of atmosphere and mystery at the start of the game
Limitations May be challenging to those who have experienced trauma/suicidal ideation
Deals poorly with sensitive topics
Player can participate in suicide
Suicide and past trauma used as plot point and for shock value
4 Conclusion
There are many challenges when developing serious games, including, limited funding,
small teams, a need for broad expertise and limited examples for development of both
games and studies. These challenges lead to issues of quality in both study and game
design. Serious mental health games that target those with mental illness directly face
additional challenges. Those with a mental health disorder often have symptoms that can
affect their ability to engage with content. This means developing mental health serious
games present unique challenges to developers, who must decide how to best address
their intended audience.
Currently, researchers are using both commercial games and purpose-built research
games to target those experiencing mental illness. Each of these methods have shown
promise; however, there are advantages and limitations to both approaches. Research
games have the advantage of being backed by a broad range of knowledge and expertise
and are often examined to determine their effectiveness. Nevertheless, they are limited
A Review of Indie Games for Serious Mental Health Game Design 149
by poor quality research studies and low-quality game design. On the other hand, com-
mercial games have the advantage of being more engaging due to their higher quality
design and focus on entertainment. However, this focus on entertainment means that the
serious objectives identified by researchers may not reach the intended audience.
To address the question of quality in serious games design one source of inspiration
are indie games. Indie games that explore both lived experiences with mental illness and
emotional stories of grief, trauma and loss provide a unique perspective into the portrayal
of complex and relatable characters. Many of these games contain serious content even
though they have been created outside of a research context. The examples above are by
no means perfect in their portrayals of mental illness; however, their stories can help to
inform designers on the creation of characters who are experiencing mental illness that
are realistic, informed, humanized, and relatable.
Stigma often demonizes those with mental illness, portraying them as violent, crazy,
or insane individuals. To counter these views as developers, creating characters that are
well developed, who could be our friends or relatives and who have everyday lives can
help to humanize those with mental illness. This extends not only to game development
but also to our own analysis of videogames, where a clear understanding of stigma and
tropes can help contextualize portrayals. Additionally, an understanding of the symptoms
of mental illness and the feelings and thoughts associated with it can aid in accurate and
sensitive character portrayals. Although minimizing stigmatized portrayals of mental
illness is ideal there are instances where stigma may be appropriate.
When a game explores a creator’s personal experiences, what may seem to be a
problematic portrayal, could help to give a voice to someone who has experienced mental
illness or trauma. These stigmatized views may serve to communicate the experiences
of the creator. Additionally, providing players a chance to assess a stigmatized view
and challenge their own thoughts could provide an educational moment. Ultimately,
developers must consider the role of stigma when designing characters with mental
illness for games. Making the characters relatable, honest, and grounded, might help to
reduce the impact of stigma in video games.
Indie games provide a rich and diverse example of the use of narrative, mechanics,
and aesthetics to tell emotional stories about mental illness, trauma, grief, LGTBQ+
experiences and neurodiversity. One of their greatest strengths lying in the building of
honest and relatable characters through narrative design. Indie games are often built on
low budgets and with small teams and are ideal examples for researchers who are often
in similar situations. In short, although indie games that explore serious mental health
topics might fall short of offering an educative outcome, they can provide information on
how to create characters, design impactful narratives and create atmosphere. Improving
the overall quality of serious games will help to increase their longevity, meaning long
term analysis of these games will be much more likely.
150 M. King et al.
References
1. Vos, T., et al.: Global, regional, and national incidence, prevalence, and years lived with
disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis
for the Global Burden of Disease Study 2016. The Lancet 390(10100), 1211–1259 (2017)
2. Walker, E.R., McGee, R.E., Druss, B.G.: Mortality in mental disorders and global disease
burden implications: a systematic reviewand meta-analysis. JAMA Psychiatry 72(4), 334–341
(2015)
3. Depression and other common mental disorders: global health estimates. World Health
Organization, Geneva (2017)
4. Kessler, R., et al.: Lifetime prevalence and age-of-onset distributions of mental disorders in
the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry
6(3), 168–176 (2007)
5. Andrade, L.H., et al.: Barriers to mental health treatment: results from the WHO World Mental
Health surveys. Psychol. Med. 44(6), 1303–1317 (2014)
6. Mechanic, D.: Removing barriers to care among persons with psychiatric symptoms. Health
Aff. 21(3), 137–147 (2002)
7. Dockery, L., et al.: Stigma- and non-stigma-related treatment barriers to mental healthcare
reported by service users and caregivers. Psychiatry Res. 228(3), 612–619 (2015)
8. Clement, S., et al.: What is the impact of mental health-related stigma on help-seeking? A
systematic review of quantitative and qualitative studies. Psychol. Med. 45(1), 11–27 (2015)
9. Kutcher, S., Wei, Y., Coniglio, C.: Mental health literacy: past, present, and future. Can. J.
Psychiatry 61(3), 154–158 (2016)
10. Ezell, J.M., Choi, C.-W., Wall, M.M., Link, B.G.: Measuring recurring stigma in the lives of
individuals with mental illness. Community Ment. Health J. 54(1), 27–32 (2018). https://doi.
org/10.1007/s10597-017-0156-1
11. Fox, A.B., Smith, B.N., Vogt, D.: How and when does mental illness stigma impact treat-
ment seeking? Longitudinal examination of relationships between anticipated and internalized
stigma, symptom severity, and mental health service use. Psychiatry Res. 268, 15–20 (2018)
12. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P.: “Mental
health literacy”: a survey of the public’s ability to recognise mental disorders and their beliefs
about the effectiveness of treatment. Med. J. Aust. 166(4), 182–186 (1997)
13. Jorm, A.F.: Mental health literacy: public knowledge and beliefs about mental disorders. Br.
J. Psychiatry 177(5), 396–401 (2000)
14. Beyond Blue. https://www.beyondblue.org.au. Accessed 31 May 2021
15. Twomey, C., et al.: A randomized controlled trial ofthe computerized CBT programme,
MoodGYM, for public mental health service users waiting for interventions. Br. J. Clin.
Psychol. 53(4), 433–450 (2014)
16. moodgym. https://moodgym.com.au. Accessed 31 May 2021
17. Qu, C.C., Sas, C., Roquet, C.D., Doherty, G.: Functionality of top-rated mobile apps for
depression: systematic search and evaluation. JMIR Ment. Health 7(1), e15321 (2020)
18. Michael, D., Chen, S.: Serious Games: Games That Educate, Train, and Inform, p. 17. Muska
& Lipman/Premier-Trade, Boston (2005)
19. Marsh, T.: Serious games continuum: between games for purpose and experiential environ-
ments for purpose. Entertain. Comput. 2(2), 61–68 (2011)
20. Boyle, E.A., et al.: An update to the systematic literature review of empirical evidence of the
impacts and outcomes of computer games and serious games. Comput. Educ. 94, 178–192
(2016)
21. Qian, M., Clark, K.R.: Game-based learning and 21st century skills: a review of recent
research. Comput. Hum. Behav. 63, 50–58 (2016)
A Review of Indie Games for Serious Mental Health Game Design 151
22. Twomey, C., O’Reilly, G.: Effectiveness of a freely available computerised cognitive
behavioural therapy programme (MoodGYM) for depression: meta-analysis. Aust. N. Z.
J. Psychiatry 51(3), 260–269 (2017)
23. Brijnath, B., Protheroe, J., Mahtani, K., Antoniades, J.: Do web-based mental health literacy
interventions improve the mental health literacy of adult consumers? Results from a systematic
review. J. Med. Internet Res. 18(6), e5463 (2016)
24. Schneider, J., Foroushani, P.S., Grime, P., Thornicroft, G.: Acceptability of online self-help
to people with depression: users’ views of MoodGYM versus informational websites. J. Med.
Internet Res. 16, e90 (2014)
25. Neary, M., Schueller, S.M.: State of the field of mental health apps. Cogn. Behav. Pract. 25(4),
531–537 (2018)
26. Fitzgerald, M., Ratcliffe, G.: Serious games, gamification, and serious mental illness: a
scoping review. Psychiatr. Serv. 71, 170–183 (2020)
27. Fleming, T., et al.: Serious games and gamification for mental health: current status and
promising directions. Front. Psychiatry 7, 215 (2017)
28. SPARX. https://www.sparx.org.nz/home. Accessed 31 May 2021
29. Merry, S.N., Stasiak, K., Shepherd, M., Frampton, C., Fleming, T., Lucassen, M.F.G.: The
effectiveness of SPARX, a computerised self help intervention for adolescents seeking help
for depression: randomised controlled non-inferiority trial. BMJ 344, e2598 (2012)
30. Kuosmanen, T., Fleming, T.M., Newell, J., Barry, M.M.: A pilot evaluation of the SPARX-R
gaming intervention for preventing depression and improving wellbeing among adolescents
in alternative education. Internet Interv. 8, 40–47 (2017)
31. Kitchener, B.A., Jorm A.F., Kelly, C.: Mental Health First Aid Manual. Mental Health First
Aid, Melbourne (2017)
32. Ruberg, B.: Queering Indie: how LGBTQ experiences challenge dominant narratives of
independent games. In: Ruffino, P. (ed.) Independent Videogames : Cultures, Networks,
Techniques and Politics. Taylor & Francis Group, Milton (2020)
33. Iuppa, N., Borst, T.: End-To-End Game Development : Creating Independent Serious Games
and Simulations from Start to Finish. Focal Press, Waltham (2010)
34. The Last of Us. Sony Computer Entertainment, Naughty Dog, PlayStation (2013)
35. Hellblade: Senua’s Sacrifice. Ninja Theory, PlayStation 4 (2017)
36. Case, N.: Coming Out Simulator. Online (2014)
37. Assassin’s Creed Origins. Ubisoft, PlayStation 4 (2017)
38. Florence. Mountains, Annapuma Interactive, Steam (2018)
39. Quinn, Z., Lindsey, P., Schankler, I.: Depression Quest. Online (2013)
40. That Dragon, Cancer. Numinous Games, Steam (2016)
41. Melinn, I., Lima, C.: Keep in Mind: Remastered. Little Moth Games, Akupara Games, Steam
(2018)
42. O’Neill, W.: Actual Sunlight. WZO Games Inc., Steam (2014)
43. Rock Paper Shotgun. https://www.rockpapershotgun.com/2013/02/11/thoughts-on-actual-
sunlight. Accessed 21 June 2019
44. Martínez, M.A.C.: Depression. itch.io
45. https://manuacruz.itch.io/depression. Accessed 27 June 2021
46. Figueroa, N., Martinsson, I.: Fran Bow. Killmonday Games, Steam (2015)
47. Ferrari, M., McIlwaine, S.V., Jordan, G., Shah, J.L., Lal, S., Iyer, S.N.: Gaming with stigma:
analysis of messages about mental illnesses in video games. JMIR Ment. Health 6(5), e12418
(2019)
48. CheckPoint. https://checkpointorg.com/mental-health-representation. Accessed 31 Mar 2020
49. Figueroa, N.: Interview: Killmonday on fran bow, mental health, beauty. In: Walker, J. (ed.).
Rock Paper Shotgun Online (2013)
152 M. King et al.
50. The Suicide of Rachel Foster. One-On-One Games, Daedalic Entertainment, Steam (2020)
51. Watts, R.: The Suicide of Rachel Foster. PC Gamer (2020). https://www.pcgamer.com/the-
suicide-of-rachel-foster-review
52. Evans-Thirlwell, E.: The Suicide of Rachel Fosterreview - a Shining-esque riff on Gone Home
that doesn’t quite dazzle. Eurogamer (2020). https://www.eurogamer.net/articles/2020-02-16-
the-suicide-of-rachel-foster-review-shining-esque-hotel-adventure-doesnt-quite-dazzle
53. Gardner, M.: Review: ‘The Suicide Of Rachel Foster’ Is A Rollercoaster Ride That Plummets
At The End. Forbes. https://www.forbes.com/sites/mattgardner1/2020/02/26/review-the-sui
cide-of-rachel-foster-is-a-rollercoaster-ride-that-plummets-at-the-end
Thesis
Full-text available
In the theoretical part of the master thesis titled "Being a Child Again Through Gameplay" playable child perspectives for adult players in existing games are explored and means to a relatable child perspective are contemplated. As practical thesis part, the game prototype BackSeat was developed. It's development is discussed in the thesis appendix. (BackSeat game prototype impressions: https://youtu.be/ndL8G9hlvBg)
Article
Full-text available
Background: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016. Methods: We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings: Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million (25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million (23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862–11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018–19 228). Interpretation: The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.
Article
Full-text available
We present an exploratory factor analysis of the 8-item Daily Indignities of Mental Illness (DIMI) scale, created to measure the detection and perceptions of recurring stigma among individuals with recent psychiatric hospitalizations. Structured in-person interviews were conducted with individuals with recent psychiatric hospitalizations in metropolitan New York. The 8-item DIMI scale's internal consistency for the sample (n = 65), measured by Cronbach's alpha, was 0.869. Statistically significantly higher DIMI scale scores were observed among individuals with more than 2 psychotic episodes and those reporting seeing relatives less often after hospitalization. The DIMI scale possesses good internal consistency for research contextualizing perceptions around the occurrence or recurrence of mental illness-related stigma among individuals with recent psychiatric hospitalizations.
Article
Full-text available
Aim: The use of computerized mental health programs with vulnerable youth, such as early school leavers, remains relatively unstudied. This pilot study examined the feasibility of delivering a computerized cognitive behavioral therapy (cCBT) gaming intervention (SPARX-R) for young people (age 15–20 years) who have left school early and are attending Youthreach, an alternative education (AE) program in Ireland. Method: Students (n = 146) from twenty-one Youthreach Centers were randomized to SPARX-R and no-intervention control. All students within the group were included in the study whether or not they were exhibiting heightened levels of depression. Program impact was examined on both negative and positive indicators of mental health, including depression (primary outcome), generalized anxiety, general mental wellbeing, coping and emotion regulation. Assessments were conducted at baseline and post-intervention (7 weeks). Participants that provided data at post-assessment (n = 66) were included in the analysis. Results: The participants completed on average 5.3 modules of SPARX-R with 30% (n = 9) completing the entire program. A significant improvement in emotion regulation strategies was detected, with expressive suppression decreasing significantly in the SPARX-R group in comparison to the control (−2.97, 95% CI −5.48 to −0.46, p = 0.03). Conclusions: Findings suggest that SPARX-R has a positive impact on emotion regulation. The lack of significant findings on other outcome measures may be attributed to inadequate sample size, and therefore, further research with larger samples are required to establish the effectiveness of the program in reducing depression and anxiety and improving psychological wellbeing among young people attending AE.
Article
Objective: The use of serious games and gamification to promote learning has a long history. More recently, serious games and gamification have been used in clinical settings to promote treatment and recovery. Yet there is little evidence to support their use with populations that experience serious mental illness. Methods: A scoping review was used to answer the following research question, What is the current state of knowledge about how games and gamification are used to promote treatment of serious mental illness? Scoping reviews clarify, define, and develop conceptual boundaries within a topic area. Twenty studies were identified and reviewed by using thematic content analysis. Results: A range of game types, formats, and technology were assessed. Six themes emerged from analysis. Serious games and the use of gamification to promote treatment have potential to engage persons with serious mental illness in game content and promote treatment outcomes. Game design that supported clear instruction, a coherent narrative, a smooth interface between mechanics and play, and service user involvement early in the process of game design were important for the successful promotion of engagement and learning. Games reviewed offered the opportunity for problem solving, collaboration, and goal-oriented activity that supported the delivery of therapeutic outcomes. Conclusions: The use of serious games and gamification to promote treatment of serious mental illness had high levels of feasibility and acceptability among both users and providers. The potential treatment value of games, however, is dependent on key features related to the games' design, operation, and rationale.
Article
Background: Video game playing is a daily activity for many youths that replaces other media forms (eg, television); it serves as an important source of knowledge and can potentially impact their attitudes and behaviors. Researchers are, thus, concerned with the impact of video gaming on youth (eg, for promoting prosocial or antisocial behavior). Studies have also begun to explore players' experience of gameplay and video game messages about violence, sexism, and racism; however, little is known about the impact of commercial video games in the sharing and shaping of knowledge, and messages about mental illness. Objective: The aim of this review was to identify how mental illness, especially psychosis, is portrayed in commercial video games. Methods: We performed keyword searches on games made available between January 2016 and June 2017 on Steam (a popular personal computer gaming platform). A total of 789 games were identified and reviewed to assess whether their game content was related to mental illness. At the end of the screening phase, a total of 100 games were retained. Results: We used a game elements framework (characters, game environment/atmosphere, goals, etc) to describe and unpack messages about mental health and illness in video games. The majority of the games we reviewed (97%, 97/100) portrayed mental illness in negative, misleading, and problematic ways (associating it with violence, fear, insanity, hopelessness, etc). Furthermore, some games portrayed mental illness as manifestations or consequences of supernatural phenomena or paranormal experiences. Mental illness was associated with mystery, the unpredictable, and as an obscure illness; its treatment was also associated with uncertainties, as game characters with mental illness had to undergo experimental treatment to get better. Unfortunately, little or no hope for recovery was present in the identified video games, where mental illness was often presented as an ongoing struggle and an endless battle with the mind and oneself. Conclusions: The game elements of the identified commercial video games included mental illness, about which many perpetuated well-known stereotypes and prejudices. We discuss the key findings in relation to current evidence on the impact of media portrayals of mental illness and stigma. Furthermore, we reflect on the ability of serious video games to promote alternative messages about mental illness and clinical practices. Future research is needed to investigate the impact that such messages have on players and to explore the role that video games can play in fostering alternative messages to reduce the stigma associated with mental illness.
Book
You’re part of a new venture, an independent gaming company, and you are about to undertake your first development project. The client wants a serious game, one with instructional goals and assessment metrics. Or you may be in a position to green light such a project yourself, believing that it can advance your organization’s mission and goals. This book provides a proven process to take an independent game project from start to finish. In order to build a successful game, you need to wear many hats. There are graphic artists, software engineers, designers, producers, marketers - all take part in the process at various (coordinated) stages, and the end result is hopefully a successful game. Veteran game producers and writers (Iuppa and Borst) cover all of these areas for you, with step by step instructions and checklists to get the work done. The final section of the book offers a series of case studies from REAL indy games that have been developed and launched succesfully, and show exactly how the principles outlined in the book can be applied to real world products. The book’s associated author web site offers ancillary materials & references as well as serious game demos and presentations.
Article
Although mental illness stigma has been identified as an important barrier to mental health treatment, there is little consensus regarding how and when mental illness stigma negatively impacts treatment seeking. The relationship between mental illness stigma and treatment seeking may depend on the particular stigma mechanism under investigation, as well as an individual's symptom severity. In the present study, we examined relationships between anticipated and internalized stigma, depressive symptom severity, and mental health service use using data from a two-wave longitudinal survey study of U.S. post-9/11 veterans. Mediated and moderated relationships were tested using PROCESS. Mediation analyses revealed that higher anticipated stigma led to higher levels of internalized stigma, which was associated with decreased treatment seeking. Moderation analyses revealed that anticipated stigma was only associated with treatment seeking when depressive symptoms were severe. The central role observed for internalized stigma highlights the value of stigma reduction efforts that focus on this stigma mechanism, whereas the finding that only those individuals with more severe symptoms are vulnerable to the negative effects of anticipated stigma underscores the importance of more targeted anti-stigma interventions.
Article
Mental health apps offer unique opportunities for self-management of mental health and well-being in mobile, cost-effective ways. There is an abundance of apps available to consumers, but selecting a useful one presents a challenge. Most available apps are not supported by empirical evidence and thus consumers have access to a range of untested apps, the benefits of which are not known or supported. While user ratings exist, and are likely to be considered by consumers when selecting an app, they do not actually yield information on app suitability. A possible alternative way for consumers to choose an app would be to use an app review platform. A number of attempts have been made to construct such a platform, and this paper introduces PsyberGuide, which offers a step towards providing objective and actionable information for publicly available mental health apps.