Title Game-based digital interventions for depression therapy : a systematic review and meta-analysis

The aim of this study was to review the existing literature on game-based digital interventions for depression systematically and examine their effectiveness through a meta-analysis of randomized controlled trials (RCTs). Database searching was conducted using specific search terms and inclusion criteria. A standard meta-analysis was also conducted of available RCT studies with a random effects model. The standard mean difference (Cohen’s d) was used to calculate the effect size of each study. Nineteen studies were included in the review, and 10 RCTs (eight studies) were included in the meta-analysis. Four types of game interventions—psycho-education and training, virtual reality exposure therapy, exercising, and entertainment—were identified, with various types of support delivered and populations targeted. The meta-analysis revealed a moderate effect size of the game interventions for depression therapy at posttreatment (d = 0.47 [95% CI 0.69 to 0.24]). A subgroup analysis showed that interventions based on psycho-education and training had a smaller effect than those based on the other forms, and that self-help interventions yielded better outcomes than supported interventions. A higher effect was achieved when a waiting list was used as the control. The review and meta-analysis support the effectiveness of game-based digital interventions for depression. More large-scale, high-quality RCT studies with sufficient long-term data for treatment evaluation are needed. Introduction Depression is a highly prevalent mental disorder worldwide. According to the World Health Organization, more than 350 million people of all ages suffer from depression. Depression significantly decreases quality of life, and is reported to be a major risk factor for suicide. However, many people are unable or reluctant to access and engage in effective treatment due to barriers such as personal stigma, high costs, waiting lists, and a shortage of trained professionals. In recent years, the home computer boom has triggered a flood of research on the development of novel and cost-effective technologies for mental health therapy. Among these innovative technologies, recent decades have witnessed the increasing use of digital interventions with game-like components to treat mental disorders. Initially developed for entertainment, a ‘‘game’’ is generally considered to be an activity with the key features of challenge, motivation, and reward. Game-based digital interventions have been found to have practical effects in addressing the main barriers of access and engagement in the healthcare domain, particularly for the young. Evidence from neuropsychological research further suggests the therapeutic value of game-based digital interventions in depression therapy, finding that positive game-playing experiences trigger the release of hormones such as endorphins and striatal dopamine that are responsible for feelings of pleasure and well-being. Guided by reasoning, game-based interventions have specific potential for reducing depression through the natural benefits afforded by the game elements involved. Preliminary results from some early attempts to use this approach in the field have supported this claim by showing the effectiveness of individual games in reducing depression levels and enhancing social support. As digital game interventions for mental health is a relatively new research area, systematic reviews and metaanalyses of their effectiveness in treating depression are scarce. A few recent reviews have focused on computerbased or Internet-delivered psychological interventions for depression disorders, but they did not specifically focus on digital intervention with a game component. Previous reviews that have targeted the use of video games to encourage health improvement have not covered the effects of such treatment on depression. Further research is thus required to determine the overall effects of digital gamebased interventions compared with other treatments. We aimed to conduct a systematic review of trial studies that emphasized game-based digital interventions and depression improvements in a categorized fashion, thus identifying the Wee Kim Wee School of Communication and Information, Nanyang Technological University, Singapore. CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING Volume 17, Number 8, 2014 a Mary Ann Liebert, Inc. DOI: 10.1089/cyber.2013. 0481