Gamification and the Psychology of Game Design in Transforming Mental Health Care
Venue: Journal of the American Psychiatric Nurses Association

Researchers and health professionals have long been curious about the potential of electronic games for purposes beyond entertainment. This topic is of particular importance given the rapid growth of the game industry, whose products are enjoyed by over 1.5 billion people worldwide (EEDAR, 2015) many of them on mobile devices. As the number of smartphone users continues to grow, with conservative estimates projecting a rise from 2 billion worldwide at the end of 2015 to 6.1 billion in 2020 (Ericsson, 2015) the mobile games market is likely to keep pace. By 2020, 4.5 billion people, nearly half the world's population, will be gamers. As such, there have been a number of efforts to leverage game related techniques and technologies for positive impact, mostly through gamification and serious games. Most, however, have been met with limited success. Gamification is traditionally defined as the addition of game mechanics to everyday processes (Huotari Hamari, 2012) In an attempt to increase motivation for otherwise unpleasant tasks, it is currently one of the leading buzzwords in the health care sector. Like big data, it was positioned as a magic bullet that would combat lack of adherence to medications, encourage healthy eating and exercise habits, and otherwise help people manage their conditions. The reality falls short of the hype, with 80% of all gamification initiatives failing to meet their objectives, especially as they pertain to long term change (Gartner, Inc. 2012) Serious games, a somewhat oxymoronic term deriving from the Renaissance serio ludere, refers to entertainment that dealt with serious matters (Djaouti, Alvarez, Jessel, Rampnoux, 2011) These are games that have something other than "entertainment, enjoyment or fun as their primary purpose" (Michael Chen, 2005) They long predate the concept of gamification and, indeed, account for some of the earliest games, predating even Pong (Djaouti et al. 2011) However, despite their long and storied history, most of these games have never been commercially successful. SPARX, an award winning game developed as a self help intervention for adolescents with mild to moderate depression, is a good example of this (Metia Interactive, 2011) In clinical trials, it was shown to be more effective than treatment by trained counselors, with 44% of those who played the game achieving remission from depression, as opposed to the 26% in usual care (Merry et al. 2012) However, its clinical efficacy and its many awards for innovation did not translate to commercial success, with Linkedwellness, the startup that published SPARX in North America, shutting down in 2015. SPARX's lack of widespread appeal is not atypical of serious games, which are often effective in accomplishing limited clinical or learning goals but fail to gain much traction outside the clinical or classroom environment. The obvious question of why these game based interventions, while initially promising, fail to achieve wider success has an equally obvious answer: bad design (Gartner, Inc. 2012) This is not by intention, but by oversight, as health care professionals that work with developers often lack an understanding of the principles of design and how to clearly communicate their vision with their team and with the general public. SPARX is an excellent example, with its problematic branding as a game for depression, made obvious by the inclusion of PHQ 9 (Patient Health Questionnaire) before every play session and references to enemies as GNATs (Gloomy Negative Automatic Thoughts) compounded by the poor quality of the version Linkedwellness released for mobile devices (Merry et al. 2012) This meant that potential users were not only turned off by the stigma around mental illness but also by an unusable user interface, a weak storyline, and a game that was simply not much fun. To better leverage the potential of games and gamebased techniques, we must take a more holistic approach, examining how clinical knowledge can be applied to work in conjunction with the principles of design, in crafting engaging, immersive experiences with the power to heal. As it turns out, the two need not conflict, as the core of game design is largely informed by or at least 636857 JAPXXX10.1177/1078390316636857Journal of the American Psychiatric Nurses AssociationLee research