Improving Mental Health by Sharing Knowledge

Evidence-basedgames for mentalhealth in youth

Rutger Engels

Together with prof. Isabel Granic

Adam Lobel

Elke Schoneveld

Marlou Poppelaars

Lieke Wijnhoven

Angela Schuurmans

Geert Verheijen

And..

And..

Why mental health?

1. High prevalence. One out of 4 adults become depressed in their life (NEMESIS, 2013)

2. High individual costs. Mental health disorders are the leading causes of disability adjusted life years (DALYs) worldwide (WHO, 2011)

3. High costs for employers

Top 3 of causes of # sick days (NEMESIS, 2011):

1. Depression

2. Chronic back pain

3. COPD and asthma

4. High societal costs

Top 3:

1. Depression

2. Childhood disorders (including ADHD and autism) 3. Anxiety

(Veerbeek et al., 2014)

Two major issues:

The importance of games (and gaming) as intervention tools

• Traditional prevention and treatment do work, but:

- High costs

- Not accessible to majority of youth (waiting lists)

- Stigmatizing

- Drop-out as programs are not engaging

Dilemma

• Hardly any games out there for mental health (ADHD as an exception)

• Some games are not engaging and do not hold the quality that kids are used to

Problems

SPARX: 2 studies by original developers: promising results (Merry et al., 2012)

Our own study: decreased depressive symptoms

BUT! teens reported being bored, wouldn’t play on their own, wouldn’t recommend it to others

Our aim:

Set up a framework that will lead to development of theory-based clinically-appropriate, ENGAGING games for depression and anxiety

Clinical Guidelines for Care

• Basis for financing care is inclusion in clinical guidelines

• Based on empirical evidence, so series of randomized controlled trials (experiments)

• Support by clinicians and patient-groups

No empirical evidence

=no funding for implementation and upscaling of serious games in mental health care

3 points to make

1. Rigorous testing

2. Games as a placebo

3. Resistance by professionals

1. Rigorous testing

Experimental designs, in which participants are randomized to control condition or game

Depressive symptoms

50.00

55.00

60.00

65.00

70.00

T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10

OVK

Depressive symptoms

50.00

55.00

60.00

65.00

70.00

T0 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10

Control

OVK

No control group

No interpretation possible

Measure transference to real life

In-game experiences should translate to out-of-game real life settings

Rigorous Designs

GameDesk, LA

Dojo: game to regulate emotions

Effects of Dojo were tested in a sample of 42 adolescents in residential care, referred for behavioral problems (Schuurmans et al., 2014)

Transference: Beneficial impact on anxiety AND behavioral problems

Testing the working mechanisms of the game

Rigorous Designs

MindLight: approx 8-10h game play, oriented on 8-14 year olds

If MindLight leads to lower anxiety, does this happen BECAUSE kids are better in dealing with threat?

Figure 2. the light in the dark

In-game data. Fine-grained data on player patterns

Rigorous Testing

• Testing in subgroups

– As prevention tool for all kids

– For clinically disordered kids

– Age and gender

– Preference for gaming

Rigorous Testing

Subgroups

RCT 1: teens in residential care for behavioral problems

RCT 2: anxious teens in schools

Subgroups

RCT 1: teens in residential care for behavioral problems

RCT 2: anxious teens in schools

Video Game Development

professional game

developers

Research

Outcome analysisComponent analysis

Process analysis

Go back to game development

2. Game as a placebo

Expectancies:

When teens invest time in a game AND are assured it works for them, it might already have an impact!

RCT with two conditions: a game for anxiety (MindLight) and a control condition

N = 140 (8-12 year olds, screened on anxiety, played 5 sessions of 1h)

MindLight lowered anxiety levels in children, even after 3-months follow-up

Magnitude of decline is comparable to a study in which we tested cognitive behavior therapy in group sessions lead by a therapist (van Starrenburget al., 2013; 2014)

Kids who played Max also went down..

Results

? Because they believed in the game, they got something out of it

? Parents supported them

Why

Recommendation:

Be aware of potential placebo effect

Test why a game has effects using data on game processes and mechanics

3. Overcoming resistance by professionals

Message: it does not replace them, but helps them in making therapy more effective and efficient (and perhaps even fun!)

Two perspectives co-exist

Game as intervention tool that replaces part of treatment or is an additive component

Game as a communication tool

Communication tool

• Creating alliance

• Using examples of in-game behavior like success, frustration and anger

• Dynamic assessment of progress– do children improve over course of therapy

Evidence and acceptance by professionals will assure uptake and financial investments by health insurance companies and authorities

Take-home message