Abstract
Introduction:
Particularly in the last 2 years, due to the new coronavirus pandemic, people with depression have increasingly sought human connection and relief from depressive symptoms through playing in the world of videogames, and a small yet growing portion of researchers have been investigating the therapeutic potential of that kind of interaction.
Objective:
The objective of this review was to provide an exploration of the current panorama of scientific research with videogames used as therapeutic intervention tools for depression.
Method:
A systematic review was performed for that purpose, with a semantic field of 12 keywords around the terms “depression,” “mental health,” and “video games” narrowed down into a concise syntax—(games OR serious games) AND (depression) AND (treatment)—applied to relevant databases for health research; followed by the execution of a search and screening protocol based on one guiding question; and analysis of results based on four elaborative questions.
Results:
Twenty-six studies met the inclusion criteria and provided a set of both quantitative and qualitative data about demographics, kinds of therapeutic interventions, types of videogames used in the interventions, places, and forms of interaction.
Conclusion:
Important gaps were found in the review, such as a lack of research aimed at the age group most affected by the disorder, who is also the largest consumer of games; and fresh opportunities to expand the understanding of the subject as well as guide developments of game-based therapeutic interventions.
Introduction
Depression is a chronic state of apathy that impairs almost every aspect of a person's life. It is characterized by persistent depressed mood on most days for at least 1 year, accompanied by at least two of the symptoms described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) such as fatigue, low self-esteem, poor concentration, and feelings of hopelessness. 1 The depressive disorder affects ∼280 million people worldwide, being currently one of the leading causes of disability according to the World Health Organization (WHO). 2 The problem escalated significantly in the last 2 years due to the new coronavirus pandemic.
Research has shown that social isolation worsens mental health issues, and even younger age groups have been affected. 3 Many isolated people living with the disorder have been seeking human connection and relief from depressive symptoms through interacting in the virtual worlds of videogames; not coincidentally. The videogames industry has become the second entertainment giant, surpassing the music and the film industries combined with a revenue surge of 20% in 2020 alone. 4 Market experts do not see the numbers declining any time soon. 5 These two contemporary global trends—the widespread advance of depression and the rising of the videogames industry—now meet at a large intersection.
Empirical observation
Players themselves imply the usefulness of videogames to dealing with psychological distress in nonclinical contexts. We observed it is not uncommon to find testimonials on the internet about how games help depressed people; therefore, we decided to conduct a preliminary ethnographic study to explore the therapeutic potential of gaming from the perspective of those who play. A single open access publication on one of the most popular social news and discussion aggregators, entitled “For those using games to help with depression during these times, share what you are playing” (2020),
6
has >400 comments. We highlight the following sample for exemplification of how diverse the relationship of gamers with depression and the hobby of gaming can be:
“Stardew Valley helped me out a lot during a time when I was deeply depressed. The simplicity and tone made it playable when it was hard just getting out of bed. Seeing your daily tasks lead to gradual improvements in my farm was like therapy.” “For me, highly immersive and/or engaging games that can get me away from reality are the best during depressive episodes.” “I don't know if anybody has said it but the Witcher 3 for me. I first played it on the day my best friend committed suicide, and I always come back to it whenever I feel hopeless. Something about helping Geralt find Ciri was therapeutic for me, as if I had to let go but he didn't have to because of me. Anyway, that's my gaming sob story.” “I've thankfully kept my depression locked in a box for the past… yearish? I always recommend these games because they are directly responsible for my change of mood. I love these games, and two out of three I might have never played if I didn't constantly push myself to leave my comfort zone.” “I'm not depressed right now, but I am 90% of the time. I find what helps me most are single player games that have cool companions, make me feel not so alone.” “Delivering packages (having that clear attainable goal), people complimenting you on a good job/giving you positive feedback about being amazing helping out/being a part of something big (things I don't usually get in real life) are helping keeping my mind off of things that usually take me to a… not so good place.” “Reminds me of hanging out with really good friends. That game got me through some tough times last year, highly recommend it to everyone.” “I find some of the best games to alleviate depression and anxiety are the ones that require your complete focus.” “Completing a portion of your factory that you spent a bit of time planning and doing the math for is really satisfying. Being able to walk around your factory and watch it get more and more complex really gives you a sense of accomplishment and productivity.” “I won't pretend I didn't use video games in a similar manner. Just keep in mind that escapism can help coping in the moment but won't solve any underlying issues and delaying to find help can make you even more miserable in the long run. At least that's my experience.”
Such discussions suggest that gaming might be particularly beneficial for coping with depression in times of social isolation. Also, related research supports that videogames' constitutive elements can work both on the objective and subjective dimensions of the depressive disorder. Game mechanics can enhance impaired cognitive functions. 7 Esthetics and narrative themes can break negative thought patterns and promote emotion regulation. 8 Oftentimes, the interactions afforded in secure virtual environments help depressed players to “explore and develop parts of themselves that for whatever reason seem more difficult to be accessed in the physical world,” as noted by psychologist Alexander Kriss in his clinical experience with gamers. 9 Online multiplayer games have been connecting socially distanced people since the COVID-19 outbreak, fulfilling their “desire to socialize.” 10 Another positive feature is that the hobby of gaming is adaptable to each individual's needs and environments, whether isolated or not.
Digital health for depression
This research aims to bridge the gap between empirical and scientific knowledge on the subject of depression and the utilization of gaming therapeutically. In health science, the relatively new term digital health (or eHealth) has been coined for the use of any information and communication technologies to support health practices. “Using the power of digital technologies is essential for us to achieve universal health coverage,” declared the Director-General of the WHO at the time of release of the first guideline on digital health interventions and the creation of the WHO's Department of Digital Health and Innovation. 11 The fields of psychiatry and psychology have benefited from employing videogames as eHealth tools in therapeutic interventions that aid different types of psychotherapy for depression. 12
As gaming has become a ubiquitous element of present-day life, and a largely accessible hobby in the mobile market, 13 its relations to mental health have been increasingly researched. While depression is recognized to be a serious public health problem, videogames still raise several questions in academia concerning its negative or positive effects on mental health. Much of the research on the topic focuses on trying to identify correlations between videogames and mental health damage—for example, gaming disorder.
However, a recent systematic review by Stevens et al 14 noted that although worldwide prevalence of gaming disorder often appears to be “exceedingly high,” most studies lack a deeper examination of the methodological, cultural, and/or demographic factors that might explain the phenomenon beyond gaming itself. Now, a small yet growing portion of researchers have been investigating the potential of gaming's application in therapeutic interventions. To better understand this side of scientific research and compare it with what we have found empirically, we conducted a systematic review of game-based therapeutic interventions in treatments for depression. The methodology of this review consisted of the steps described in the next section.
Method
The objective of this study is to explore the available literature on therapeutic interventions with videogames through the lenses of health and interaction design. For this purpose, it proved necessary the elaboration of a mixed methodological approach combining a systematic review with particularities of a systematic mapping. Mappings allow for greater exploratory freedom as they represent not only the results but also indirectly, the activities related to the results, 15 the experiences of every actor involved in interventions, and the factors that shape their implementations, 16 not limited to practical assessments. This approach was designed mainly for the meta-analysis of results and is further explained in the “Results” section. The search strategy of the review was based on the PRISMA 2020 Checklist. 17
Research question and search strategy
First, a guiding question was defined to delineate the main goal of the review: what does the recent scientific data on the therapeutic use of videogames in interventions for depression inform? We determined a period from 2016 to December 2021 for carrying out the survey. Then, a semantic field of 12 keywords was created around the terms “depression,” “mental health,” and “video games”—games, gaming, game design, serious games, video games, mental health, depression, depressive disorder, psychotherapy, intervention, therapeutic intervention, and treatment. Preliminary searches were performed in databases widely consulted by researchers in the fields of health and technology.
Several tests with different combinations of the keywords were performed in various databases. The most effective strategy for the purpose of this study proved to be narrowing the semantic field into a concise syntax and qualifying the databases. We identified the most efficient syntax to be “(games OR serious games) AND (depression) AND (treatment)” and selected three of the most relevant for health research as the appropriate databases, JMIR, PubMed, and LILACS/BVS, along with one relevant database for serious games, International Journal of Serious Games. Since we are based in Brazil, we have also run searches on the two databases of the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) to ensure that no national study would be missed.
Inclusion and exclusion criteria
Studies would be considered for inclusion if they focused exclusively on interventions for depression with the use of videogames, published in peer-reviewed publications and fully available. The kind of studies accepted for inclusion comprised case studies, clinical trials, dissertations and theses, reviews, research reports, or scientific articles. On account of the specificity of this review's scope—analyze the intersection between the advance of depression and the rise of the videogames industry in the last few years—studies must have been published between 2016 and 2021. Studies would be excluded if they were published in languages other than Portuguese or English, used other types of games rather than just videogames, and treated any other mental disorder than depression.
Screening protocol
The aforementioned search strategy was applied to the selected databases, and as a result, 531 studies published until December 2021 were found. These were filtered by the information contained in titles, keywords, and abstracts, and then the full texts were analyzed when the preliminary information was not sufficient to determine if the study truly met the criteria. After this process, we obtained 57 records related to therapeutic interventions with the use of videogames—47 single studies and 10 systematic reviews. First, the systematic reviews were further screened to check if they contained nonrepeated studies that met the criteria and could be extracted and analyzed, three were eligible. Second, from the single studies, those that did not meet the inclusion criteria were eliminated. Finally, 23 single studies met the inclusion criteria and were considered eligible for analysis. Figure 1 shows a diagram of the review process.
Flow diagram of the review process.
Twenty-six studies met the inclusion criteria, and thus were found to be relevant to the purpose of this review. The main information gathered for this article pertains to the kinds of interventions and types of videogames that have been used to treat depression; to whom these interventions with videogames have been directed in the last few years; and the contexts in which the interventions have been conducted. In the next section, we provide a panorama of the current state of scientific research with videogames as therapeutic intervention tools for depression.
Results
We defined four elaborative questions (EQ) for the detailing and meta-analyses of the results. The EQs enabled us to identify the research variables and allowed for the cross-checking of data. They also supported a discussion on trends, gaps, and unexplored opportunities for the therapeutic use of videogames to treat depression.
EQ1—In what kinds of therapeutic interventions were videogames used?
EQ2—To whom were the therapeutic interventions with videogames directed?
EQ3—What types of videogames were used, common games for entertainment or serious games?
EQ4—In which places and ways were videogames used in the therapeutic interventions?
The following topics synthesize the main information extracted from the analyses, answering to EQ1 (Table 1), EQ2 (Table 2), EQ3 (Table 3), and EQ4. Table 4 presents a summary of the reviewed studies.
Kinds of Therapeutic Interventions with Videogames
Demographics of Therapeutic Interventions with Videogames
Types of Videogames Used in Therapeutic Interventions
Summary of the Reviewed Studies
Therapeutic interventions
Of the 26 included studies, 13 tested the direct use of videogames as a form of intervention for preventing or reducing physical and cognitive symptoms of depression. Four studies associated videogames with traditional cognitive therapies: for instance, van der Meulen et al 35 deployed a computer game designed to facilitate and support the delivery of cognitive behavioral therapy (CBT) for children in real-world settings; for individuals with late-life depression, Anguera et al 36 compared problem solving therapy with a digital game designed to enhance cognitive faculties; Kuosmanen et al 37 examined the feasibility of delivering a computerized form of CBT using a serious game designed for young people; and Poppelaars et al 38 compared that same form of computerized CBT with a school-based CBT prevention program for adolescents.
Other four studies used videogames in workshops to assess side effects of the disorder (such as social impairment) or to include the users' participation in the design process of serious games for depression. Three used videogames as psychological support tools to aid hospitalized patients and people with chronic diseases, who became depressed because of their conditions. And one study tested a videogame as complementary treatment in replacement of the introduction of a second drug to deal with resistant depressive symptoms.
Demographics
Most of the studies, 13, were aimed at children and adolescents; only 1 study was found for adults between 18 and 40 years old; 3 for adults between 40 and 60 years old; and 9 for seniors. In terms of sex, 19 mixed studies were found; 6 aimed at females; and there were none aimed at males. There were two studies aimed specifically at the LGBTQIA+ community: Lucassen et al 18 for intersex adolescents and Lucassen et al 19 for trans youth.
Types of videogames
The review indicates an increase in the use of common games (designed for the entertainment market) in the last couple of years, yet serious games (designed for therapeutic purposes) are still more used in general as therapeutic tools; 11 studies employed the first type in therapeutic interventions and 15 used serious games developed in academia.
Discussion
Comparison of our data with data from older reviews 44 showed that there has not been substantial advance around scientific research with videogames in treatments for depression in the last 5 years, most notably considering the significant popularization of the videogame industry in the same period. We have found an average of five studies published per year in different countries, mostly across Europe and North America, the majority of which focused on prevention or reduction of depressive symptoms. Demographics through the years remained balanced regarding sex, most of the studies mixed female and male participants, yet still lacked the LGBTQIA+ community in view of gender identity, and psychosocial or cultural factors. Also, very few studies were aimed at ethnic minorities and their specific needs. In terms of the age groups targeted, although, an interesting shift has occurred.
Li et al 44 pondered back in 2014 that there was “clearly a research demand for future studies on the development and evaluation of digital game-based interventions tailored specifically to address elderly depression,” having found only 2 out of 19 studies focused on that age group. In our review, while the majority of research still aimed at young people with 14 studies, 9 out of the 26 total studies were tailored to the elderly. This is an academic shift that intersects directly with a major shift in the games industry: differently from most gaming consoles, the Xbox+Kinect bundle (2010), the Nintendo Wii (2011), and subsequently the Nintendo Wii U (2012) were heavily marketed as “family entertainment” since their launch.
Not surprisingly, most interventions for elderly depression used either of these devices. What could also be linked to this marketing shift was an increase in the number of participants in the studies in the last decade. We expected to find some increase in the number of studies itself in the last couple of years due to the pandemic, which has brought with it circumstances that aggravate the problem of depression, but that did not occur.
Nonetheless, researchers do seem to have paid more attention to the potential of casual videogames (CVGs) to treat depression; from 2020, the number of interventions with those games surpassed that of interventions with serious games. Older studies by Russoniello et al,45,46 as far back as 2009, had already shown promising results on CVGs used as interventions. They proved prescient, highlighting “the need for effective interventions that are low cost and help ensure compliance is high” 45 and positing that “clinicians should consider these low-cost CVGs as a possible intervention to address psychological and somatic symptoms associated with depression” 46 —cost and effectiveness are still large barriers for many depressive people who seek treatment.
Contextually, most research targets the objective aspects of depression (e.g., cognitive impairments) without integrating more subjective needs of depressive players. Interventions usually take place at clinics, day care centers, hospitals, nursing homes and schools, and within controlled conditions involving conventional interactions—a mental health professional establishes a predetermined form of intervention with a chosen game, the patient follows their directives individually for a fixed period of time and symptomatology assessments are made at the end. Very few studies have been conducted among groups, for example, taking advantage of videogames with multiplayer features or the potentiality of gaming itself to foster interpersonal connections. The review indicated that science on the use of videogames as therapeutic intervention tools for depression is still limited in scope, it has not caught up with social trends.
Conclusion
The most recent studies on the use of videogames as therapeutic tools for depression demonstrate that the field has relevant gaps, markedly a generational abyss. There is a striking lack of research aimed at the age group who, in addition to being the most affected by the disorder, is the biggest consumer of videogames nowadays—adults between 18 and 40 years old. 47 Taking into consideration that people in depressive states tend to isolate themselves, there are valuable underexplored opportunities such as the unique ability of gaming to connect people, which could be employed in forms of group therapy. 48 Also, a more holistic approach—a look at the person as a whole and their subjective relationship to gaming, not only their mental condition—could be beneficial to treatments for depression.
The “game world” offers a Winnicottian 49 potential space in the convergence of the real and the virtual during the act of play, enabling players to focus their energy on engaging, pleasurable tasks that attend to different physical and emotional needs for different people. In the words of McGonigal, 50 gameplay is the direct opposite of depression. Our systematic review aims to provide an informative, timely set of both quantitative and qualitative data on trends, gaps, and opportunities concerning current game-based therapeutic interventions. With it, we wish to shine a light on the topic. Hopefully this information can be useful to eHealth and mental health researchers looking into person-centered, fresh developments with videogames as aiding tools in treatments for depression—one of the most urgent issues of our time.
Footnotes
Authors' Contributions
Both authors conceived and designed the study. R.G. performed the implementation of the research, acquisition of data, and conducted the first steps of the screening protocol along with a preliminary analysis of the results. R.G. then conducted further screenings under supervision of T.B.P.S. The retrieved studies were analyzed by both the authors, who assessed their eligibility according to a consensus on the inclusion and exclusion criteria. No discrepancy was found between the authors regarding the retrieved studies. R.G. reviewed all the eligible studies under supervision of T.B.P.S. Both the authors then analyzed and discussed the results, and commented on the article drafted by R.G. The final version to be submitted was also written by R.G, T.B.P.S. supervised the work. Both the authors agree to be accountable for all aspects related to the accuracy or integrity of any part of the work.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The research received financial support from the Dean of Graduate Studies of the University of Brasília (UnB), public notice DPG/UnB No. 001/2022.