Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet

Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. Design Multicentre randomised controlled non-inferiority trial. Setting 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). Participants 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. Interventions Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. Outcomes The primary outcome was the change in score on the children’s depression rating scale-revised. Secondary outcomes included response and remission on the children’s depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children’s anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. Results 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n=85, treatment as usual n=85) were assessed after intervention and 168 (90%, SPARX n=83, treatment as usual n=85) were assessed at the three month follow-up point. Per protocol analyses (n=143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children’s depression rating scale-revised (between group difference 2.73, 95% confidence interval −0.31 to 5.77; P=0.079). Remission rates were significantly higher in the SPARX arm (n=31, 43.7%) than in the treatment as usual arm (n=19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P=0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n=47) and treatment as usual arm (58.3%, n=42) (difference 7.9%, −7.9% to 24%; P=0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as “possibly” or “probably” related to the intervention did not differ between groups (SPARX n=11; treatment as usual n=11). Conclusions SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. Trial registration Australian New Zealand Clinical Trials ACTRN12609000249257.

Computer games are ubiquitous and can be utilized for serious purposes such as health and education. “Applied games” including serious games (in brief, computerized games for serious purposes) and gamification (gaming elements used outside of games) have the potential to increase the impact of mental health internet interventions via three processes. First, by extending the reach of online programs to those who might not otherwise use them. Second, by improving engagement through both game-based and “serious” motivational dynamics. Third, by utilizing varied mechanisms for change, including therapeutic processes and gaming features. In this scoping review, we aim to advance the field by exploring the potential and opportunities available in this area. We review engagement factors which may be exploited and demonstrate that there is promising evidence of effectiveness for serious games for depression from contemporary systematic reviews. We illustrate six major categories of tested applied games for mental health (exergames, virtual reality, cognitive behavior therapy-based games, entertainment games, biofeedback, and cognitive training games) and demonstrate that it is feasible to translate traditional evidence-based interventions into computer gaming formats and to exploit features of computer games for therapeutic change. Applied games have considerable potential for increasing the impact of online interventions for mental health. However, there are few independent trials, and direct comparisons of game-based and non-game-based interventions are lacking. Further research, faster iterations, rapid testing, non-traditional collaborations, and user-centered approaches are needed to respond to diverse user needs and preferences in rapidly changing environments.

To report the prevalence of students according to four gender groups (i.e., those who reported being non-transgender, transgender, or not sure about their gender, and those who did not understand the transgender question), and to describe their health and well-being. Logistic regressions were used to examine the associations between gender groups and selected outcomes in a nationally representative high school health and well-being survey, undertaken in 2012. Of the students (n = 8,166), 94.7% reported being non-transgender, 1.2% reported being transgender, 2.5% reported being not sure about their gender, and 1.7% did not understand the question. Students who reported being transgender or not sure about their gender or did not understand the question had compromised health and well-being relative to their non-transgender peers; in particular, for transgender students perceiving that a parent cared about them (odds ratio [OR], .3; 95% confidence interval [CI], .2-.4), depressive symptoms (OR, 5.7; 95% CI, 3.6-9.2), suicide attempts (OR, 5.0; 95% CI, 2.9-8.8), and school bullying (OR, 4.5; 95% CI, 2.4-8.2). This is the first nationally representative survey to report the health and well-being of students who report being transgender. We found that transgender students and those reporting not being sure are a numerically small but important group. Transgender students are diverse and are represented across demographic variables, including their sexual attractions. Transgender youth face considerable health and well-being disparities. It is important to address the challenging environments these students face and to increase access to responsive services for transgender youth.

Co-design, defined as collective creativity across the entire design process, can lead to the development of interventions that are more engaging, satisfying, and useful to potential users. However, using this methodology within the research arena requires a shift from traditional practice. Co-design of eHealth interventions with children and young people has additional challenges. This review summarizes the applied core principles of co-design and recommends techniques for undertaking co-design with children and young people. Three examples of co-design during the development of eHealth interventions (Starship Rescue, a computer game for treating anxiety in children with long-term physical conditions, a self-monitoring app for use during treatment of depression in young people, and HABITS, the development of an emotional health and substance use app, and eHealth platform for young people) are provided to illustrate the value and challenges of this contemporary process.

The development and use of serious games for mental health disorders are on the rise. Yet, little is known about the impact of these games on clinical mental health symptoms. We conducted a systematic review and meta-analysis of randomized controlled trials that evaluated the effectiveness of serious games on symptoms of mental disorder. We conducted a systematic search in the PubMed, PsycINFO, and Embase databases, using mental health and serious games-related keywords. Ten studies met the inclusion criteria and were included in the review, and nine studies were included in the meta-analysis. All of the serious games were provided via personal computer, mostly on CD-ROM without the need for an internet connection. The studies targeted age groups ranging from 7 to 80 years old. The serious games focused on symptoms of depression (n = 2), post-traumatic stress disorder (n = 2), autism spectrum disorder (n = 2), attention deficit hyperactivity disorder (n = 1), cognitive functioning (n = 2), and alcohol use disorder (n = 1). The studies used goal-oriented (n = 4) and cognitive training games (n = 6). A total of 674 participants were included in the meta-analysis (380 in experimental and 294 in control groups). A meta-analysis of 9 studies comprising 10 comparisons, using a random effects model, showed a moderate effect on improvement of symptoms [g = 0.55 (95% confidence interval 0.28-0.83); P < 0.001], favoring serious games over no intervention controls. Though the number of comparisons in the meta-analysis was small, these findings suggest that serious gaming interventions may be effective for reducing disorder-related symptoms. More studies are needed in order to attain deeper knowledge of the efficacy for specific mental disorders and the longer term effects of this new type of treatment for mental disorders.