Many of us play video games, whether it’s a full-blown role-player like Witcher 3 or a casual quick game of Candy Crush. In fact, in 2017, 32.4 million people played games in the UK (UKIE report, 2016); that’s half of the UK population (who are admitting to it). The average gamer is not an 18-year-old boy who hasn’t seen daylight for weeks, but is actually 35 years old. Adult women represent a greater portion of the video game playing population (31%) than boys under age 18 (18%). So why do people play video games? In short, because they’re fun! We’re motivated to play because they’re fun and engaging.

Research has long been interested in whether it’s possible to use therapeutic games to motivate people to improve health related outcomes. Such games are known as serious games or “games that do not have entertainment, enjoyment or fun as their primary purpose” (Michael & Chen, 2005). The primary purpose of serious games can be, but are not limited to, education, training, human resource management and health improvement. Serious games may make learning more meaningful, engaging, and challenging than traditional teaching by using the interactive, visual, and immersive characteristics available in video games. Although serious games have started to emerge over the last decade, little is known about their effectiveness, especially for mental health.

Lau and colleagues conducted a systematic review and meta-analysis to assess the effectiveness of serious games for symptoms related to mental health conditions. Previous research suggests that serious games have been widely introduced to physical health care. For example, the successful serious game Re-Mission, which was developed to actively involve young people with cancer in their treatment, by educating them about cancer and the different treatment options.

In recent years, the potential use of serious games in mental health care has also been explored, but not in a systematic way. Previous reviews either focused on serious games for one disorder like depression, or were conducted a long time ago (considering more and more serious games emerge every year), or looked at more than just randomised controlled trials (RCTs). Lau et al argue that the potential impact of serious games for common mental disorders is yet to be robustly explored. This is also the first meta-analysis in the field of serious video games for mental health.

Methods

• Systematic review followed recommended PRISMA guidelines
• 3 databases were searched (PubMed, PsychINFO and Embase)
• Included only RCTs
• Extracted game and study characteristics
• The meta-analysis looked at whether participants in the serious game conditions improved over the control conditions
• Secondly, a meta-analysis was conducted per disorder using a similar approach (ASD, PTSD and cognitive functioning)
• Funnel plot was conducted to detect publication bias.

Results

10 studies were included in the review and 9 in the meta-analysis. Game characteristics included name of the game, genre, serious game type and purpose. For a more detailed description of the game, read the full paper (it’s open access).

Meta-analysis

• A total of 674 participants were included in the meta-analysis (380 in the experimental group and 294 in the control group)
• The included RCTs targeted different conditions:
  • Depression (n=2)
  • ADHD (n=1)
  • Alcohol Use Disorder (n=1)
  • PTSD (n=2)
  • Cognitive functioning (n=2)
  • Autism Spectrum Disorder (n=2)
• The included RCTs had different comparison groups
  • Compared serious games to no intervention (n=6)
  • Compared serious games to active controls (n=3)
  • Compared serious games to treatment as usual (n=1)
• The overall outcome of the nine studies showed a moderately significant effect size of g = 0.55 (P < 0.001) for improvement on mental disorder symptoms (serious games condition vs control)
• Subgroup analysis by age
  • The group targeting youth (≤18) was shown to have a moderate effect size g = 0.70,
  • differing non-significantly from the adult group (18+) g = 0.53
• Subgroup analysis by participant type
  • The group targeting clinical participants (with diagnosed mental disorder) showed a moderate effect size of g = 0.59,
  • differing non-significantly from the non-clinical group g = 0.68
• A funnel plot identified a possible risk of publication bias.

Conclusion

The reviewers concluded that serious games are moderately effective in reducing psychiatric disorder-related symptoms. There is potential for games having a positive impact on various age groups and both clinical and non-clinical populations. The results are in-line with previously conducted systematic reviews on serious games (e.g. this review focusing on depression: Fleming et al, 2014).

The effect size in this review is comparable to other digital interventions for mental illness in youth or adults, e.g. internet-based or computer-based interventions.

Strengths

• This claims to be the first systematic review with a meta-analysis, which systematically evaluates the effectiveness of serious games on psychiatric-related symptoms

• It uses the standard PRISMA methodology

• The methodological quality of the papers was assessed

• The reviewers accounted for publication bias

• The decision to include only RCTs (and not observational studies) gives a less biased estimate of treatment effects.

Limitations

• There was a high heterogeneity across the included studies, which is bad for a meta-analysis (comparing apples with oranges)

• The publication bias found may mean that negative studies have remained unpublished, which means that these results are possibly an over-estimate of the true effectiveness of serious games
• There was a moderate risk of bias in some of the included RCTs
• There was no clear definition of a serious video game, which means that it’s potentially hard to reproduce these results
• Overall, a small number of studies were available for the meta-analysis.

Summary

This was a first attempt to summarise all RCTs out there, that looked at serious games and mental health-related symptoms. In conclusion, there is a potential for therapeutic serious games in the mental health domain. However, we must not get over-excited and remember that this is only a “potential” right now. More high-quality trials are needed so that we can establish concrete evidence for efficacy and safety.

Links

Primary paper

Lau HM, Smit JH, Fleming TM, Riper H. (2016) Serious Games for Mental Health: Are They Accessible, Feasible, and Effective? A Systematic Review and Meta-analysis. Frontiers in Psychiatry. 2016;7:209. doi:10.3389/fpsyt.2016.00209.

Other references

The UK Interactive Entertainment Association: research page. https://ukie.org.uk/research

Michael DR, Chen SL. (2005) Serious Games: Games That Educate, Train, and Inform. Education. (2005). p. 1–95. Available from: http://portal.acm.org/citation.cfm?id=1051239

Fleming T, Cheek C, Merry S, Thabrew H, Bridgman H, Stasiak K, et al. (2014) Serious games for the treatment or prevention of depression: a systematic review. Revista de Psicopatología y Psicología Clínica 2014, 19(3):227–42.10.5944/rppc.vol.19.num.3.2014.13904

Interesting links

Serious Game SPARX (depression) https://www.sparx.org.nz/

Serious Game Playmancer (eating disorders and other impulse disorders, not included in this systematic review) https://www.youtube.com/watch?v=osmo9EAClv8

Serious Game Re-mission http://www.re-mission.net/

Photo credits

• Photo by Matt Wildbore on Unsplash
• JD Hancock CC BY 2.0