Serious Games, Gamification, and Serious Mental Illness: A Scoping Review
Abstract
Objective:
Methods:
Results:
Conclusions:
Basic Concepts and Theories
Methods
Stage 1: Identifying the Initial Review Questions
Stage 2: Identifying Relevant Studies
Criterion | Inclusion | Exclusion |
---|---|---|
Language | Published in the English language | Non-English articles |
Time period | January 2000–January 2019 | Articles published outside this time frame |
Population focus | Adults experiencing serious mental illness (schizophrenia, schizophreniform disorder, and bipolar disorder) | Participants experiencing other conditions (e.g., depression, stroke, heart rehabilitation, and autism); adolescents. |
Study focus | Use of serious games and gamification within a gaming context that supports engagement and the delivery of therapeutic interventions | Studies not primarily focused on serious games and gamification, (e.g., virtual reality, fitness, and education) or studies that utilized TV or radio technology |
Literature focus | Review articles including systematic reviews, meta-analyses, meta-syntheses, narrative reviews, rapid reviews, critical reviews, integrative reviews, and the gray literature—such as blogs, commercial Web sites, opinion articles, commentaries, and information sites | Articles with only a passing focus or reference to serious games and gamification or articles about studies that used games as a control condition or for diagnostic purposes. |
Stage 3: Study Selection
Stage 4: Charting the Data
Stage 5: Collating, Summarizing, and Reporting Results
Results
Author | Location | Intervention | Study design and sample | Outcome |
---|---|---|---|---|
Physical activity game | ||||
Leutwyler et al., 2018 (57) | USA | Described the effectiveness of Kinect video game for Xbox 360 game system on walking speed of adults with schizophrenia. Participants allocated to active game (intervention) or sedentary video game (control) for 30 minutes once a week for 6 weeks. | Randomized controlled trial (RCT). N=28. Outpatients, patients in transitional residential and locked inpatient wards. Assessed pre- and postintervention. Schizophrenia or schizoaffective disorder | Walking speed on the Short Physical Performance Battery. Intervention group, increase in walking speed of .08 meters per second. Control group, increase in walking speed of .03 meters per second. Difference not statistically significant but clinically significant. Video game–based physical activity program provided clinically meaningful improvement in walking speed. |
Shimizu et al., 2017 (64) | Japan | Investigated effects of an interactive sports video game (IVG) (Nintendo Wii) on frontal lobe function of patients. IVG played once a week for 60 minutes for 3 months | Single blind crossover study. Schizophrenia. N=6. Pre- and postintervention assessment. Diagnosis of schizophrenia, score of ≥40 on the Global Assessment of Functioning (GAF) | Frontal lobe blood flow volume assessed with functional near-infrared spectroscopy (fNIRS). Functional changes assessed by Frontal Assessment Battery and Health-Related Quality of Life scales. Physical functioning, behaviorally assessed with physical functioning tests. fNIRS performance significantly increased in the IVG period compared with control group. Intervention-related improvement in health-related quality of life. No significant difference in behaviorally assessed physical functioning. Conclusion: IVG may provide high-quality, low-cost rehabilitation for those experiencing schizophrenia |
Campos et al., 2015 (67) | Portugal | Evaluated the feasibility and acceptability of an exergame intervention as a tool to promote physical activity. Playing Microsoft Kinect for 20 minutes twice a week for 8 weeks. Difficulty levels were adjusted to match participant’s individual skills. | Quasi-experimental trial, N=32. Schizophrenia, outpatients. Pretest/posttest feasibility study. Treatment group, N=16; completed treatment, N=13. Treatment as usual, N=16 | Positive and Negative Syndrome Scale (PANSS)total score was not significantly correlated with number of completed game levels. Sustained use was related to good game functioning, and poor game functioning was related to frustration and reduced use. Assessments: feasibility, attendance; acceptability, adapted 28-item self-report questionnaire; functional mobility, Timed Up and Go test; habitual physical activity, Baecke Modified Physical Activity Questionnaire; functional fitness performance, Senior Fitness Test; motor neurological soft signs, brief motor scale; hand grip strength, digital dynamometer; static balance, force plate; speed of processing, Trail making test; and schizophrenia-related symptoms, PANSS. High acceptability. No significant difference between groups at baseline. No significant difference between groups postintervention |
Kimhy et al., 2015 (68) | USA | Characterized the feasibility, acceptability, safety, and adherence associated with using active play video games as part of an aerobic exercise (AE) training program. Xbox 360 with Kinect motion sensing with motion-sensing devices and traditional exercise equipment. Treatment group received three 1-hour sessions of AE training per week for 12 weeks. Control group received standard psychiatric care. | Single-blind RCT. Individuals with schizophrenia living in the community (N=25). Training targets were set on the basis of individual max heart rate (HR) as set at baseline (VO2 peak test). Minimal AE intensity was set at 60% of max HR week 1; 65%, week 2; 70%, week 3; and 75%, weeks 4–12 | X box most popular over traditional exercise, and users reported high acceptability. Participants in the AE group significantly increased their aerobic fitness, while the control group showed virtually no change. Provided preliminary support for the use of active play video games as part of an AE program for individuals with schizophrenia |
Leutwyler et al., 2015 (60) | USA | Described the impact of a video game–based physical activity program using the Kinect for Xbox 360 game system on physical activity in older adults. Participants played an active video game for 30 minutes once a week for 6 weeks. | One-group, pretest-posttest pilot study. N=20. Age >55, schizophrenia and schizoaffective disorder | Subjective assessment of physical activity, Yale Physical Activity Scale. Objective assessment of physical activity, SenseWear Pro armband worn by participants for 7 days between weeks 1 and 2 and weeks 5 and 6. Adherence measured by comparing actual attendance with possible number of attendances. Actual activity overreported by participants. No statistically significant difference in objectively measured physical activity |
Leutwyler et al., 2014 (62) | USA | Described adherence to and acceptability of a video game–based physical activity program using Kinect for Xbox 360 game system in older adults. Participants played an active video game using Kinect for Xbox 360 game system for 30 minutes once a week for 6 weeks. | Descriptive longitudinal study, inpatient facilities. Older adults with schizophrenia (N=34). | Acceptability assessed by open-ended questionnaire. Adherence assessed by number of sessions attended. Mobility assessed objectively by timed Get Up and Go and subjectively by the physical function items from the 12-item Short-Form Health Survey. High adherence to and acceptability of game; 50% of participants attended all 6 sessions |
Leutwyler et al., 2012 (61) | USA | Described the preliminary acceptability of a video game–based physical activity program using the Kinect for Xbox 360 game system in older adults. Participants engaged in a 30-minute session once a week for 6 weeks. | Pilot study of acceptability. Mixed methodology. Inpatient and locked mental health wards. Schizophrenia and schizoaffective disorder. N=15 | Posttest quantitative and qualitative rating of acceptability using Borg Scale. It was feasible and acceptable to incorporate Kinect for Xbox 360 game system into treatment programs. Participants rated games as fun and as an enjoyable way to be active. Secondary finding: in order for users to continue playing game, they need to feel they have the skills to play the game |
Bespoke game | ||||
Olivet et al., 2018 (51) | USA | Developed a prototype, computer-based, role-playing game (OnTrack). Determined feasibility and whether game improved consumers’ attitude toward treatment and recovery.20 participants; played game for 45–60 minutes | Pilot study. Mixed methods. First-episode psychosis (FEP) | Preassessment at baseline and postassessment at 2 weeks. Assessments: hope (Herth Hope Index), recovery (Recovery Attitudes Questionnaire), stigma, empowerment (Rodgers Empowerment Scale), and engagement in treatment (Singh O’Brian Level of Engagement Scale). Postassessment: 20-minute semistructured interview about game play experience, FEP-related content, and how game could be improved. Recovery only measure that showed a statistically significant improvement |
Reynolds et al., 2017 (55) | UK | Prototype serious game developed by service users and researchers and studied in a clinical setting. Study aims: game development and exploration of usability and acceptability of serious gaming in forensic mental health services | Development and trial of game. User-centered design approach developed formative game versions for evaluation in focus groups. Male, low secure patients planning for discharge in the next 12 months. Participants were given the option of being a game producer (N=8) or tester (N=6). | Game evaluated in situ by testers and focus groups. Views of service-user focus group on usability and acceptability of serious gaming in forensic mental health services were audio-recorded and transcribed. Findings supported the utility of serious gaming in forensic services to support service-user recovery. Codesign approach allowed for a realistic and enjoyable game. The development of environments and dialogue that reflect real-life experiences helped promote service-user engagement. |
Amado et al., 2016 (52) | France | Virtual game in an imaginary town. Hypothesis: a virtual reality (VR) environment improves cognitive abilities of prospective memory and planning and social functioning. Participants attended a weekly 1.5-hour session for 3 months. In first session patients listed their difficulties in everyday organization and planning. Further sessions focused on these difficulties in the game. | Pilot study (N=10). Schizophrenia or schizoaffective disorder. Assessment at week 0 and week 12 | Quantitative assessment: clinical assessment, Brief Psychiatric Rating Scale (BPRS) and GAF). Psychosocial, Social Autonomy Scale (EAS);Schizophrenia Questionnaire for Quality of Life; Self-Esteem Rating Scale; Birchwood Insight Scale Questionnaire . Neurological, attention, visual scanning abilities; speed processing (D2 cancellation test); motor speed processing; verbal and visual working memory (Wechsler Adult Intelligence Scale; verbal learning (Grober and Buschke verbal learning test); executive functioning (zoo map test and Battery for Assessment of Dysexecutive Syndrome; and visuospatial abilities (Rey–Osterrieth Complex Figure Test). Qualitative assessment: opinions of participants gathered by clinicians. Quantitative results: Significant improvement in BPRS, GAF, and EAS scores. Benefits shown in attention and in working, prospective, and retrospective memory but no improvement in planning. Qualitative results: benefit in sparing time, planning, and management of housework. The VR game shows promise in improving neurocognitive deficits. Further evolution of game is required. |
Van der Krieke et al., 2014 (54) | Holland | Identified ways of making cognitive-bias modification (CBM) more attractive. Explore service-user experience of engaging CBM in game format and making changes in response to findings. Bias Buster is an electronic serious game to train participants to appraise social situations positively and to manage social anxiety and self-deprecating thoughts. | Pilot study. Mixed methods. N=7. Psychotic disorders, FEP | Gaming experience assessed with the Gaming Experience Questionnaire. Participants liked game design and found it pleasant to play. But scenarios were too easy, the game structure was unclear, and participants stopped playing. |
Fitzgerald et al., 2011 (56) | UK | Use of a serious game to consult service users in service development. Game played 4 times over 4 months. Aim 1, to involve service users in the design, layout, and furnishing of new low secure unit; aim 2, to answer specific design questions from builders and architects; and aim 3, to explore feasibility and acceptability of new medication-dispensing system proposed for unit | Qualitative study; schizophrenia, schizoaffective disorder, bipolar disorder; 25 out of a possible 30 service users who experienced serious mental illness and who resided on the low secure service participated | Outcome measure: Six Stages of Service User Involvement in Mental Health Services. All design questions answered. Service users rejected the new medication dispensing system proposed for unit. Participants stated that they enjoyed playing game and were satisfied with impact on the design and development process. Serious games offer a flexible, inclusive, and meaningful way of engaging service users in service development. |
Shrimpton and Hurworth,2005 (53) | Australia | Determined feasibility and acceptability of Pogo’s Pledge in meeting the program objective—supporting young people to improve their mental health by learning about their psychosis and the strategies they can use to maximize their mental health | ||
Expert review. N=19. Sampling of participants with reputational standing using snowballing techniques | Face-to-face interviews with 2 focus groups of 15 professionals working in game design, multimedia graphic/interface design, multimedia educational design and FEP and 1 focus group of 4 young people with lived experience of FEP. Substantial redevelopment of game needed. Educational games designed to engage young people are unlikely to succeed if they do not mimic the levels of design sophistication and iterative testing of the computer and console games already played by this population. | |||
Card game | ||||
Khazaal et al., 2015 (59) | Switzerland, France, Monaco, and Italy | Evaluated the effect of Michael’s Game (MG) on delusional conviction. Collaborative group, 80-card game targeting the ability to generate alternative hypotheses to explain a given experience. Training group leaders (2 per session) direct the game during weekly sessions lasting for about 1 hour. Game is completed when all 80 cards are played. Game directors: urses (N=14), psychologists (N=12), and psychiatrists specifically trained to deliver MG (N=6) | RCT. N=172. Adult outpatients with psychotic disorders. Compared treatment as usual plus participation in MG with treatment as usual plus being on a waiting list. Assessments at inclusion (T1, baseline), 3 months (T2, posttreatment), and 6 months after second assessment (T3, follow-up) | Assessments: conviction, distress, and preoccupation (Peters Delusion Inventory [21 items] [PDI-21]); symptoms (BPRS); cognition (Beck’s Cognitive Insight Scale [BCIS]); functioning GAF and Social and Occupational Functioning Assessment Scale); and belief flexibility (Maudsley Assessment of Delusional Schedule). Long-term treatment effect on primary outcome for conviction (p=.002). Long-term treatment effect on secondary outcomes of distress (p=.002), preoccupation (p=.001), and belief flexibility (p=.001). At T2, a positive treatment effect was observed on the primary outcome of conviction (p=.005). At T3, a sustained effect was observed for conviction (p=.002). At T3, further effects observed for distress (p=.002), preoccupation (p=.001), and belief flexibility (p=.001). Significant beneficial effect of playing MG was found. |
Oker et al., 2015 (70) | France | Four parts to this investigation: overview of impaired functioning in schizophrenia; description of how VR settings may prove useful for investigating social interaction, especially through the use of virtual agents; illustration of these ideas with the proposal of a new paradigm based on a virtual affective agent and how it may be used with patients; and examination of the use of a VR card game to identify emotions from facial expressions. Hypothesis: virtual agents and the use of naturalistic settings could prove useful for assessing the intermediate link between cognition and real-life functioning | Mixed-methods study. Persons with schizophrenia and healthy subjects. Generation of subjective reports of users’ experience of engagement with VR agent | Subjective experience: 11-item questionnaire. Participants welcomed the use of VR affective agent and were motivated to engage. VR paradigms are effective agents in the assessment of social interaction of people who experience schizophrenia. |
Khazaal et al., 2011 (58) | Switzerland, Belgium, and France | Tested the feasibility and impact of intervention, MG, in a naturalistic setting; 3–7 patients took part in groups that participated in 10–18 sessions facilitated by trained game supervisors | Pre-post test design. N=135/N=115 at end point. Outpatient day centers or rehabilitation units. Schizophrenia, schizoaffective disorder, and delusional disorder | PDI-21; self-report questionnaire assessing presence of 21 beliefs; and BCIS. Significant improvement in BCIS and reduction in severity of convictions and preoccupation score on PDI–21. Findings support the feasibility and effectiveness of game in a naturalistic setting. |
Khazaal et al., 2006 (69) | Belgium, France, and Switzerland | Tested the feasibility and impact of MG in naturalistic settings | Pre-post test design. N=55/ N=45 at end point. Schizophrenia, schizoaffective disorder, and depression. Outpatient and inpatient units. | Pre- and posttest assessment using PDI-21. Self-report questionnaire assessing presences of 21 beliefs. Significant reduction in conviction and preoccupation scores, suggesting potential therapeutic effect of playing game. Easy to use in a natural setting after a short training session. Findings support the feasibility and effectiveness of MG in a naturalistic setting. |
Online game | ||||
Nieman et al., 2015 (65) | Netherlands | Investigated cognitive-remediation game, Monster Valley, with psychiatric patients via an online cognitive game played 3 times per week for .5 hours for 12 weeks. Aim: test feasibility of using an online cognitive game and assessment tool by psychiatric patients at home | RCT. Pilot study. N=19. Allocated to treatment as usual or treatment as usual plus. Outcome measures taken at baseline and 12 weeks | Cognitive performance: online assessment tool assessed performance in memory, attention, working memory, psychomotor speed, and executive function Intervention group improved significantly in verbal memory performance compared with control group. Most participants were able to play the game and use the online assessment tool at home. Some participants did not adhere to minimum playtime because game was not challenging enough. A new and more challenging game has since been developed. |
Han et al., 2008 (63) | Korea | Video playing is reported to increase activity of the prefrontal cortex and leads to dopamine release. Hypothesized that video playing might improve positive symptoms and extrapyramidal symptoms (EPS) of service users who experience schizophrenia. Intervention: playing Internet video games; control: watching movies for an equivalent period of time for an 8-week period | Pretest/posttest design. N=81. Schizophrenia. Assessment at baseline and 8 weeks | Assessment: clinical symptoms, Schedule for the Assessment of Negative Symptoms and Schedule for the Assessment of Positive Symptoms (SAPS); EPS, Abnormal Voluntary Movement Scale (AIMS). Improvement in positive symptoms in both groups. Intervention group as measured by SAPS showed greater reduction in the subscale of delusion. Both groups showed a reduction in AIMS scores, intervention group showed greatest reduction. |
Game to evaluate interventions | ||||
Slater and Painter, 2016 (66) | UK | Used collaborative group game design as part of routine evaluation of patient and practitioner experience of C-Co CBTp (a variant of cognitive-behavioral therapy [CBT] for high secure settings) within high secure (HS) settings. What impact did C-Co CBTp have on patient and practitioner participants within a HS context? Is collaborative group game design an advantageous method of evaluating this impact? | Qualitative participatory action study. N=15. Purposeful sample of practitioners and patients who completed C-Co CBTp | As well as helping participants to evaluate the therapy experience, this approach consolidated and reinforced gains; offered a strong sense of collaboration and hope; and empowered participants to share and reflect. |
Themes in Use of Serious Games
Theme | ||||||
---|---|---|---|---|---|---|
Article | Game design | Ease of use | Adjunct and complement to treatment | Problem solving and learning | Collaboration | Goal orientation |
Shrimpton and Hurworth, 2005 (53) | ✓ | ✓ | ✓ | ✓ | ||
Khazaal et al., 2006 (69) | ✓ | ✓ | ✓ | ✓ | ||
Han et al., 2008 (63) | ✓ | |||||
Khazaal et al., 2011 (58) | ✓ | ✓ | ✓ | ✓ | ||
Leutwyler et al., 2012 (61) | ✓ | ✓ | ✓ | ✓ | ✓ | |
Leutwyler et al., 2014 (62) | ✓ | ✓ | ✓ | ✓ | ||
Van der Krieke et al., 2014 (54) | ✓ | ✓ | ✓ | ✓ | ||
Campos et al. 2015 (67) | ✓ | ✓ | ✓ | |||
Oker et al., 2015 (70) | ✓ | ✓ | ✓ | |||
Khazaal et al., 2015 (59) | ✓ | ✓ | ✓ | ✓ | ||
Kimhy et al., 2015 (68) | ✓ | ✓ | ✓ | |||
Leutwyler et al., 2015 (60) | ✓ | ✓ | ||||
Slater and Painter, 2016 (66) | ✓ | ✓ | ✓ | |||
Nieman et al., 2015 (65) | ✓ | |||||
Fitzgerald et al., 2011 (56) | ✓ | ✓ | ✓ | ✓ | ✓ | |
Amado et al., 2016 (52) | ✓ | ✓ | ||||
Reynolds et al., 2017 (55) | ✓ | ✓ | ✓ | ✓ | ||
Shimizu et al., 2017 (64) | ✓ | ✓ | ||||
Olivet et al., 2018 (51) | ✓ | ✓ | ||||
Leutwyler et al., 2018 (57) | ✓ | ✓ | ✓ | ✓ |
Game design.
Ease of use.
Adjuncts and complements to treatment.
Problem solving and learning.
Collaboration.
Goal orientation.
Informed Consent and Institutional Ethics Approval
Discussion
Conclusions
Supplementary Material
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