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Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.
This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.
A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).
From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (
Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.
PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969
An individual's mental health is fundamental to living a healthy and enjoyable lifestyle. Studies estimate that 1 in 3 people may suffer from a mental illness during their lifetime [
Depressive disorders are a family of mental disorders ranging in severity from mild temporary episodes of sadness to more severe and persistent depression [
The use of serious games, defined as games that have a purpose other than entertainment, has seen a rise in recent years [
Gaming as a therapeutic tool in mental health can potentially offer several specific advantages that may be missing from traditional forms of delivery. The gaming industry is, as ever, popular globally [
Many studies have assessed the effectiveness of serious games to alleviate depression. Aggregating the evidence from these studies is very important to draw more definitive conclusions about the effectiveness of serious games as viable therapeutic interventions in depressive disorders. Several published reviews have summarized the evidence about the effectiveness of serious games for depression [
We conducted a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement (
We utilized the following bibliographic databases to retrieve relevant studies: MEDLINE (via Ovid), PsycInfo (via EBSCO), CINAHL (via EBSCO), IEEE Xplore, ACM Digital Library, and Scopus. These databases were searched on March 30, 2021 by the first author. When applicable, we set auto alerts to conduct an automatic search weekly for 12 weeks (ending on June 30, 2021). We also searched the search engine “Google Scholar” to identify grey literature. We checked only the first 10 pages (ie, 100 hits) because Google Scholar retrieved a vast number of studies and it ordered them based on their relevancy. To identify further studies of relevance to the review, we conducted backward reference list checking (ie, screening the reference lists of the included studies and relevant reviews) and forward reference list checking (ie, screening the studies that cited the included studies).
The search query in this review was developed by consulting 2 experts in digital mental health and by checking systematic reviews of relevance to the review. These terms were chosen based on the target intervention (eg, serious games, exergames, and gamification), target outcome (eg, depression and melancholy), and target study design (eg, RCT and clinical trial).
This review included only RCTs that assessed the effectiveness of serious games for alleviating the severity of depressive symptoms. To be more precise, the intervention of interest in this review was serious games that were delivered on any digital platform such as computers, consoles (eg, Xbox, PlayStation), mobile phones, tablets, handheld devices, or any other computerized devices. The intervention had to utilize elements of gaming as an integral and primary method for therapeutic or prevention purposes. We did not consider nondigital games and those used for other purposes such as monitoring, screening, and diagnosis. We included RCTs whether they were parallel RCTs, cluster RCTs, crossover RCTs, or factorial RCTs but we excluded quasi-experiments, observational studies, and reviews. We focused on studies in which one of the measured outcomes was depression or depressive symptoms regardless of the outcome measures. Only trials in the English language were eligible for inclusion in this review. RCTs published as journal articles, conference proceedings, and dissertations were included, whereas we excluded conference abstracts and posters, commentaries, preprints, proposals, and editorials. We did not apply restrictions related to the population, year of publication, country of publication, comparator, and study settings.
We followed 3 steps to identify the relevant studies. In the first step, we exported the retrieved studies to EndNote to identify and remove duplicates. Then, 2 reviewers (EA and MA) independently screened the titles and abstracts of all retrieved studies. In the last step, the 2 reviewers independently screened the full texts of studies included from the second step. A third reviewer (AA) resolved any disagreements between the 2 reviewers in the second and third steps. Cohen κ in this review indicated a very good level of interrater agreement in the first (0.85) and second (0.90) steps [
Two reviewers (EA and MA) independently extracted data from the included reviews using Microsoft Excel (Microsoft Corporation, Redmond, WA).
Two reviewers (EA and MA) independently assessed the risk of bias in the included studies using the Risk-of-Bias 2 (RoB 2) tool, which is recommended by the Cochrane Collaboration [
We utilized narrative and statistical approaches to synthesize the extracted data. Specifically, in narrative synthesis, texts and tables were used to describe the characteristics of the included studies, population, intervention, comparator, and outcome measures. Then, we grouped and summarized the findings of the included studies according to the type of serious games (ie, exergames or computerized CBT games). A meta-analysis was conducted when at least 2 studies of the same type of serious game reported enough data for the analysis (ie, mean, standard deviation, number of participants in each intervention group). When this information was not reported in any included study, we contacted the first and corresponding authors to get the missing information.
Review Manager (RevMan 5.4) was used to conduct the meta-analysis. We measured the effect of each trial and the overall effect using the standardized mean difference (SMD; Cohen
When the meta-analysis showed a statistically significant difference between groups, we examined whether this difference was clinically important. A minimal clinically important difference (MCID) is defined as the smallest change in a measured outcome that a patient would consider as worthy and significant and which mandates a change in a patient’s treatment. The MCID boundaries for an outcome were calculated as ±0.5 times the SMD of the meta-analyzed studies.
We checked the characteristics of participants, interventions, comparator, and outcomes in studies included in the meta-analysis to assess their clinical heterogeneity. We also examined the statistical heterogeneity of the meta-analyzed studies by calculating a Chi-square
We assessed the overall quality of evidence from the meta-analyses using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, which assesses the quality of evidence based on 5 domains: risk of bias, inconsistency (ie, heterogeneity), indirectness, imprecision, and publication bias [
As shown in
Flow chart of the study selection process.
The included studies were published between 2012 and 2021 (
Characteristics of studies and population.
Author(s), year | Country | Publication type | RCTa type | Sample size, n | Mean age (years) | Sex (male), % | Health condition | Setting |
Ruivo et al [ |
Ireland | Journal article | Parallel | 32 | 59.9 | 81.3 | Cardiovascular diseases | Clinical, community, educational |
Ferraz et al [ |
Brazil | Journal article | Parallel | 62 | 69 | 59.7 | Parkinson disease | Clinical |
Song and Park [ |
South Korea | Journal article | Parallel | 40 | 50.1 | 55.0 | Stroke | Clinical |
Schumacher et al [ |
Germany | Journal article | Parallel | 42 | 56.3 | 59.5 | Hematopoietic stem cell transplantation recipients | Clinical |
Meldrum et al [ |
Ireland | Journal article | Parallel | 71 | 54.1 | 38.0 | Unilateral peripheral vestibular loss | Clinical |
Zhou et al [ |
Qatar | Journal article | Parallel | 73 | 64.6 | 45.2 | Diabetes and end-stage renal disease | Clinical |
Vieira et al [ |
Portugal | Journal article | Parallel | 46 | 57.7 | -b | Coronary artery disease | Clinical |
Tollár et al [ |
Hungary | Journal article | Parallel | 74 | 69.4 | 48.6 | Parkinson disease | Clinical |
Ozdogar et al [ |
Turkey | Journal article | Parallel | 60 | 40.1 | 27.1 | Multiple sclerosis | Clinical |
Kempf and Martin [ |
Germany | Journal article | Parallel | 220 | 61.1 | 45.9 | Type 2 diabetes | Clinical, community |
Rendon et al [ |
United States | Journal article | Parallel | 40 | 84.5 | 35.0 | Older adults | Clinical |
Jahouh et al [ |
Spain | Journal article | Parallel | 80 | 84.2 | 44.0 | Older adults | Clinical |
Rica et al [ |
Brazil | Journal article | Parallel | 50 | - | 0.0 | Older adults | Clinical, community |
Andrade et al [ |
Brazil | Journal article | Cluster | 140 | 9.41 | 42.1 | Elementary students | Educational |
Shin et al [ |
South Korea | Journal article | Parallel | 35 | 54 | 75 | Stroke | Clinical |
Adomavičienė et al [ |
Lithuania | Journal article | Parallel | 60 | 64.6 | 66.7 | Stroke | Clinical |
Fleming et al [ |
New Zealand | Journal article | Crossover | 32 | 14.9 | 56 | Depression | Educational |
Merry et al [ |
New Zealand | Journal article | Parallel | 187 | 15.6 | 34.2 | Depression | Clinical, educational |
Donker et al [ |
Netherlands | Journal article | Parallel | 193 | 41.3 | 33.2 | Acrophobia | Community |
Perry et al [ |
Australia | Journal article | Cluster | 540 | 16.7 | 36.9 | Secondary students | Educational |
Cooney et al [ |
Ireland | Journal article | Parallel | 52 | 40.6 | 38.8 | Anxiety, depression, and/or intellectual disability | Clinical |
Poppelaars et al [ |
Netherlands | Journal article | Parallel | 208 | 13.4 | 0.0 | Depression | Educational |
Välimäki et al [ |
Finland | Journal article | Parallel | 90 | 41 | 50.0 | Traumatic brain injury | Clinical |
Wijnhoven et al [ |
Netherlands | Journal article | Parallel | 109 | 11.1 | 77.1 | Anxiety and autism spectrum disorder | Clinical, educational |
Haberkamp et al [ |
Germany | Journal article | Parallel | 68 | 22.8 | 13.0 | Arachnophobia | Educational |
Butler et al [ |
Germany | Journal article | Parallel | 40 | 33.4 | 100 | Posttraumatic stress disorder | Clinical |
David et al [ |
Germany | Journal article | Parallel | 165 | 12.9 | 35.9 | Stroke | Educational |
aRCT: randomized controlled trial.
bNot reported.
The sample size in the included studies varied from 32 to 540, with an average of 104. The mean age of participants in the included studies ranged between 9.41 years and 84.5 years, with an average of 43.9 years. The percentage of the sample who were men reported in 26 studies ranged from 0% to 100%, with an average of 46.1%. Participants’ health conditions were varied between studies, and depression and stroke were the most common (n=4 each). Participants in most studies were recruited from clinical settings (n=20).
The intervention in the included studies was only serious games in 19 studies, serious games plus occupational therapy in 2 studies, and serious games plus psychotherapy in 1 study (
Characteristics of interventions.
Author(s) | Intervention | Serious game name | Serious game type | Serious game genre | Platform | Duration (minutes) | Frequency (times/week) | Period (weeks) |
Ruivo et al [ |
Serious game | Wii-Sports | Exergame | Purpose-shifted | Wii console and Kinect | 60 | 2 | 6 |
Ferraz et al [ |
Serious game | Kinect Adventures | Exergame | Purpose-shifted | Xbox console and Kinect | 50 | 3 | 8 |
Song and Park [ |
Serious game | Kinect Sport, Kinect Sport Season 2, Kinect Adventure, and Kinect Gunstringer | Exergame | Purpose-shifted | Computer and Xbox Kinect | 30 | 5 | 8 |
Schumacher et al [ |
Serious game | Wii Fit and Wii-Sports | Exergame | Purpose-shifted | Wii console and balance board | 30 | 5 | 2 |
Meldrum et al [ |
Serious game | Wii Fit Plus | Exergame | Purpose-shifted | Wii console and balance board and Frii Board | 15 | 5 | 6 |
Zhou et al [ |
Serious game | N/Ra | Exergame | Designed | Computer and wearables (sensors) | 30 | 3 | 4 |
Vieira et al [ |
Serious game | Kinect-RehabPlay | Exergame | Designed | Computer and Xbox Kinect | 70-85 | 3 | 24 |
Tollár et al [ |
Serious game | Reflex Ridge, Space Pop, Just Dance | Exergame | Purpose-shifted | Xbox console and Kinect | 60 | 5 | 5 |
Ozdogar et al [ |
Serious game | Kinect Sports Rivals | Exergame | Purpose-shifted | Xbox console and Kinect | 45 | 1 | 8 |
Kempf and Martin [ |
Serious game | Wii Fit Plus | Exergame | Purpose-shifted | Wii console and balance board | ≥30 | 1 | 12 |
Rendon et al [ |
Serious game | Wii Fit | Exergame | Purpose-shifted | Wii console and balance board | 35-45 | 3 | 6 |
Jahouh et al [ |
Serious game | Step, Nodding | Exergame | Purpose-shifted | Wii console | 40-45 | 2-3 | 8 |
Rica et al [ |
Serious game | Kinect Sports Ultimate Collection, Your Shape Fitness Evolved, Dance Central, and Kinect Training | Exergame | Purpose-shifted | Xbox console and Kinect | 60 | 3 | 12 |
Andrade et al [ |
Serious game | Just Dance 2015 | Exergame | Purpose-shifted | Xbox console and Kinect | 40 | 2 | 1 |
Shin et al [ |
Serious game + occupational therapy | RehabMaster | Exergame | Designed | Computer, sensors, and infrared projector | 60 | 5 | 4 |
Adomavičienė et al [ |
Serious game | N/R | Exergame | Designed | Computer and Kinect | 45 | Once a day | 2 |
Fleming et al [ |
Serious game | SPARX | Computerized CBTb game | Designed | Computer | 30 | 1-2 | 5 |
Merry et al [ |
Serious game | SPARX | Computerized CBT game | Designed | Computer | 20-40 | 1-2 | 4-7 |
Donker et al [ |
Serious game | ZeroPhobia | Computerized CBT game | Designed | Smartphone and wearables (VRc goggles) | 5-40 | 2 | 3 |
Perry et al [ |
Serious game | SPARX-R | Computerized CBT game | Designed | Computer | 20-30 | 1-2 | 5-7 |
Cooney et al [ |
Serious game | Pesky Gnats: The Feel Good Island | Computerized CBT game | Designed | Computer | 60 | 1 | 7 |
Poppelaars et al [ |
Serious game | SPARX | Computerized CBT game | Designed | Computer | 20-40 | 1 | 7 |
Välimäki et al [ |
Serious game | CogniFit | Computerized CBT game | Designed | Computer | ≥30 | Once a day | 8 |
Wijnhoven et al [ |
Serious game | MindLight | Computerized CBT game | Designed | Computer and wearable (headset) | 60 | 1 | 6 |
Haberkamp et al [ |
Serious game | Spider App | Exposure therapy game | Designed | Smartphone | 12 | 2 | 1 |
Butler et al [ |
Serious game + psychotherapy | Tetris | Brain-training game | Purpose-shifted | Nintendo DS XL console | 60 | 2 | 6 |
David et al [ |
Serious game | REThink | REBTd- and REBEe-based game | Designed | Tablet | 50 | 3 | 4 |
aN/R: not reported.
bCBT: cognitive behavioral theory.
cVR: virtual reality.
dREBT: rational emotive behavioral therapy.
eREBE: rational emotive behavioral education.
As shown in
Characteristics of comparators and outcomes.
Author(s) | Comparator | Duration (minutes) | Frequency (times/week) | Period (weeks) | Outcome measures | Follow up | Attrition, n |
Ruivo et al [ |
Conventional exercises (functional training), conventional exercises (bicycle exercise) | 50 | 3 | 8 | GDSa | Postintervention | 10 |
Ferraz et al [ |
Robot-assisted trainings | 45 | Once a day | 2 | HADSb | Postintervention | 18 |
Song and Park [ |
Conventional exercises | 30 | 5 | 8 | BDIc | Postintervention | N/Rd |
Schumacher et al [ |
Conventional exercises | 30 | 5 | 2 | HADS-De | Postintervention, 30-day follow-up, 100-day follow-up | 11 |
Meldrum et al [ |
Conventional exercises | 15 | 5 | 6 | HADS-D | Postintervention | 9 |
Zhou et al [ |
Conventional exercises | 30 | 3 | 4 | CES-Df | Postintervention | 0 |
Vieira et al [ |
Conventional exercises, control | 70-85 | 3 | 24 | DASS-21g | Postintervention, mid-intervention (3 months) | 13 |
Tollár et al [ |
Conventional exercises | 60 | 2 | 6 | HADS | Postintervention, 2-month follow-up | 4 |
Ozdogar et al [ |
Conventional exercises, control | 45 | 1 | 8 | BDI | Postintervention | 3 |
Kempf and Martin [ |
Control | N/Ah | N/A | N/A | WHO-5i, PAIDj, ADS-Lk | Postintervention | 44 |
Rendon et al [ |
Control | N/A | N/A | N/A | GDS | Postintervention | 6 |
Jahouh et al [ |
Control | N/A | N/A | N/A | GDS, GADSl | Postintervention | N/R |
Rica et al [ |
Conventional exercises, control | 60 | 5 | 5 | BDI | Postintervention | 0 |
Andrade et al [ |
Physical education | 40 | 2 | 1 | BMSm | Postintervention | 0 |
Shin et al [ |
Occupational therapy | 60 | 5 | 4 | HAMDn | Postintervention | 3 |
Adomavičienė et al [ |
Conventional exercises, control | 60 | 5 | 5 | BDI | Postintervention | 0 |
Fleming et al [ |
Control | N/A | N/A | N/A | CDRS-Ro, RADS-2p | Postintervention | 5 |
Merry et al [ |
Control | N/A | N/A | N/A | CDRS-R, RADS-2 | Postintervention, 3-month follow-up | 17 |
Donker et al [ |
Control | N/A | N/A | N/A | PHQ-9q | Postintervention, 3-month follow-up | 59 |
Perry et al [ |
Interactive online program | 20-30 | 1-2 | 5-7 | MDIr | Postintervention, 6-month follow-up, 18-month follow-up | 134 |
Cooney et al [ |
Control | N/A | N/A | N/A | GAS-LDs | Postintervention, 3-month follow-up | 3 |
Poppelaars et al [ |
CBTt program + serious game, CBT program, control | CBT program + serious game (80-100), CBT program (60) | 1 | 7 | RADS-2 | Postintervention, 3-month follow-up, 6-month follow-up, 12-month follow-up | 10 |
Välimäki et al [ |
Video game, control | ≥30 | Once a day | 8 | PHQ-9 | Postintervention, 3-month follow-up | 20 |
Wijnhoven et al [ |
Video game | 60 | 1 | 6 | CDI-2u | Postintervention, 3-month follow-up | 35 |
Haberkamp et al [ |
Video game | 12 | 2 | 1 | BDI-II | Postintervention, 2-week follow-up | 6 |
Butler et al [ |
Psychotherapy | 60 | 2 | 6 | BDI-II | Postintervention, 6-month follow-up | 0 |
David et al [ |
Rational emotive behavioral therapy and education, control | 50 | 3 | 4 | EATQ-Rv | Postintervention | 23 |
aGDS: Geriatric Depression Scale.
bHADS: Hospital Anxiety and Depression Scale.
cBDI: Beck Depression Inventory.
dN/R: not reported.
eHADS-D: depression subscale of the HADS.
fCES-D: Center for Epidemiologic Studies Depression Scale.
gDASS-21: Depression, Anxiety and Stress Scale 21.
hN/A: not applicable.
iWHO-5: WHO 5-item Well-Being Index.
jPAID: Problem Areas in Diabetes.
kADS-L: Allgemeine Depressionsskala.
lGADS: Goldberg Anxiety and Depression Scale.
mBMS: Brunel’s Mood Scale.
nHAMD: Hamilton Depression Rating Scale.
oCDRS-R: Children’s Depression Rating Scale-Revised.
pRADS-2: Reynolds Adolescent Depression Scale.
qPHQ-9: Patient Health Questionnaire-9.
rMDI: Major Depression Inventory.
sGAS-LD: Glasgow Depression Scale for people with a learning disability.
tCBT: cognitive behavioral therapy.
uCDI-2: Child Depression Inventory 2.
vEATQ-R: Early Adolescent Temperament Questionnaire-Revised.
The random allocation sequence for the randomization process was appropriate in 23 included studies. However, only 10 studies concealed the allocation sequence until participants were enrolled and assigned to interventions, and groups were not comparable in 4 studies. Accordingly, the risk of bias due to the randomization process was rated as low for only 8 studies (
Review authors’ judgments about each “risk of bias” domain.
Participants and individuals delivering the interventions were aware of assigned interventions during the experiment in 22 and 20 studies, respectively. Deviation from the intended intervention occurred in 2 studies due to the experimental contexts. Only 14 studies used an appropriate analysis (intention-to-treat or modified intention-to-treat analyses) to estimate the effect of assignment to intervention. Therefore, the risk of bias due to the deviations from the intended interventions was judged as low in only 8 studies (
Outcome data were not available for all or nearly all participants in 21 studies, and there was evidence that the findings were not biased by missing outcome data in only 5 studies. The reasons for missing outcome data could not be related to the true value of the outcome in 18 studies. As a result, 17 studies were judged as having a low risk of bias in the “missing outcome data” domain.
All included studies assessed the outcome of interest (ie, depression level) using appropriate measures and used measurement methods comparable across intervention groups. However, the assessor of the outcome was blinded in only 9 studies. For this reason, only these studies were rated as low risk of bias in the “measuring the outcome” domain (
In 17 studies, a prespecified analysis plan (ie, protocol) was not published. Only 4 studies reported outcome measurements different from those specified in the analysis plan. There is no evidence that all included studies selected their results from many results produced from multiple eligible analyses of the data. Accordingly, the risk of bias due to the selection of the reported results was considered low in 4 studies (
In the last domain “overall bias,” the risk of bias was considered high in 20 studies as they were judged as having a high risk of bias in at least one domain; 6 studies were judged to have some concerns in the domain of overall bias as they had some concerns in at least one of the domains and were not at high risk for any domain. The remaining study was judged to be at low risk of bias for the domain of overall bias given that it was rated to be at low risk of bias for all domains. Reviewers’ judgments about each “risk of bias” domain for each included study are presented in
As mentioned earlier, we identified 5 types of serious games based on the therapeutic modality that they deliver in the included studies. The first type is exergames, which refer to video games that require physical exercises (eg, fitness and balance exercises) in order to be played. The second type is computerized CBT games, which are video games that provide CBT for the users. The third type is exposure therapy games, which are video games that apply exposure principles to reduce anxiety in users with phobias. The fourth type is brain training games, which are video games that are based on cognitive interference tasks to reconsolidate traumatic memories. The last type is REBT- and REBE-based games, which are video games that enable users to replace irrational beliefs (eg, demandingness, intolerance, and frustration) with rational beliefs (eg, unconditional acceptance and tolerance). Results of the included studies were grouped into 3 categories based on the types of serious games.
Exergames were the intervention in 16 studies [
In 9 studies, the effect of exergames was compared with that of conventional exercises on the severity of depressive symptoms [
Results of 7 studies were meta-analyzed as shown in
Forest plot of 7 studies comparing the effect of exergames with that of conventional exercises on the severity of depressive symptoms.
In 7 studies, the effect of exergames was compared with that of no intervention on the severity of depressive symptoms [
We meta-analyzed results of 5 studies, as they reported enough and appropriate data for the analysis [
Forest plot of 5 studies (8 comparisons) comparing the effect of exergames with that of no intervention on the severity of depressive symptoms.
In 3 studies, the effect of exergames was compared with that of active interventions on the severity of depressive symptoms, and no statistically significant difference was found between the groups [
Computerized CBT games were the intervention in 8 studies [
In 7 studies, the effect of computerized CBT games was compared with that of no intervention on the severity of depressive symptoms [
Results of these 7 studies were meta-analyzed, as shown in
Forest plot of 7 studies (9 comparisons) comparing the effect of CBT games with that of no intervention on depression.
Välimäki et al [
One study compared the effect of an exposure therapy game (Spider App) with that of an entertainment video game (Bubble Shooter) on the severity of depressive symptoms (measured using the BDI-II) among patients with arachnophobia [
This review assessed the effectiveness of serious games on the severity of depressive symptoms as reported by RCTs. Although 27 RCTs were included in the current review, 16 studies were included in the meta-analysis. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises. Furthermore, 3 studies that compared the effect of exergames with that of other active interventions (eg, occupational therapy and robot-assisted training) on the severity of depressive symptoms and were not included in the meta-analyses found no statistically significant difference between the groups. These findings indicate that exergames are as effective as active interventions, which are usually delivered and supervised by health care providers (eg, physiotherapists, occupational therapists, and psychologists).
Very low-quality evidence from 5 RCTs showed a statistically and clinically significant effect of exergames on the severity of depressive symptoms when compared with no intervention.
Findings in this review are comparable to other reviews. Specifically, a recently published meta-analysis of 5 RCTs conducted by Yen and Chiu [
Very low-quality evidence from 6 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms when compared with no intervention. In contrast, 3 studies that compared the effect of computerized CBT games with those of active interventions (eg, video games and conventional CBT) on depressive symptoms and were not included in the meta-analyses found no statistically significant difference between the groups. This insignificant effect can be attributed to the fact that conventional CBT is comparable to the active interventions, thereby comparing the effect of 2 comparable interventions usually produces no significant difference, which indicates that computerized CBT games are at least as effective as these active interventions. None of the previous reviews [
This review bridged the gaps of previous reviews by focusing on all types of serious games, including only RCTs, targeting all age groups, searching technical databases, assessing the quality of evidence, and synthesizing the data statistically. Therefore, it is more comprehensive than previous reviews [
The risk of publication bias in this review is minimal, as we searched the most popular databases in information technology and health fields; conducted backward and forward reference list checking; used a comprehensive search query; searched grey literature databases; and did not restrict our search to a certain country, year, setting, population, and comparator.
The risk of selection bias in this review is minimal because 2 reviewers independently performed the study selection, data extraction, risk of bias assessment, and quality of evidence evaluation with a very good interrater agreement for all processes. The quality of the evidence was appraised to enable the reader to draw more accurate conclusions. When possible, we synthesized data statistically, and this improved the power of studies and increased the estimates of the likely size of the effect of serious games on depression.
The intervention of interest in this review was restricted to serious games delivered on any digital platform and used as a therapeutic intervention. Thus, this review cannot comment on the effectiveness of nondigital serious games and those used for other purposes such as monitoring, screening, or diagnosis. The outcome of interest in this review was depression; therefore, we cannot comment on the effectiveness of serious games on other mental health outcomes.
The review was restricted to RCTs written in the English language; therefore, many studies were excluded because they were quasi-experiments or written in other languages. This restriction was necessary because RCTs have higher internal validity than any other study design [
Most included studies recruited patients without depression; thereby, the effect of serious games on the severity of depression symptoms was not significant. Further, the overall risk of bias was high in most included studies, and the quality of evidence for the meta-analyses was very low. Accordingly, findings in this review must be interpreted with caution.
Although the severity of depression was one of the measured outcomes in all included studies, only 5 studies recruited patients with depression. This might lead to underestimating the effect of serious games. Therefore, future studies need to recruit participants with depression to assess the effectiveness of serious games on depression.
The therapeutic modalities provided by serious games in most included studies were either exercises or CBT. Further, serious games were not designed specifically to alleviate depression in about half of the studies. Thus, there is a pressing need to assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities such as art therapy, psychotherapy, relaxation-based exercises, psychoeducation, rational emotive behavioral therapy, and exposure therapy, and the list goes on.
Most included studies were carried out in high-income countries; thereby, our findings may not be generalizable to low-income countries. Researchers should conduct more studies to assess the effectiveness of serious games in low-income countries. We excluded many studies that assessed the effectiveness of serious games on other mental disorders such as anxiety and dementia. Further systematic reviews need to be carried out to investigate the effectiveness of serious in alleviating other mental disorders.
The overall risk of bias was high in most included studies mainly due to issues in the randomization process, deviations from the intended outcomes, and selection of the reported result. Further, several studies were not included in the meta-analysis due to missing outcome data. For this reason, we encourage researchers to follow recommended guidelines or tools (eg, RoB 2 [
This review hopefully augurs the possible potential of serious games in mental health disorders, but it also underlines that this field, albeit full of potential, is still in its infancy. More studies are needed to prove the significant role of serious games in alleviating depression.
Overall, this study showed that serious games can be effective in alleviating depression in comparison with no intervention, and they can be comparable to other traditional therapeutic interventions for alleviating depressive symptoms. However, findings in this review must be interpreted with caution because the overall risk of bias was high in most included studies, the quality of evidence in the meta-analyses was very low, few studies recruited patients with depression, and serious games in half of the studies were purpose-shifted. Therefore, we can only recommend health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available.
As mentioned before, serious games in more than half of the studies were not designed to specifically alleviate depression and did not deliver other therapeutic modalities such as art therapy, REBT, and psychoeducation. This may be attributed to the lack of such serious games in real life. Accordingly, there is a need to develop more serious games that are designed to specifically alleviate depression and deliver other therapeutic modalities.
The most common platforms used for playing the games were computers and video game consoles and their accessories, which are relatively more expensive and less accessible than smartphones that were the platform for serious games in only 1 study. The number of smartphone users in the world exceeded 6.4 billion in 2021 [
Most studies were carried out in high-income countries, and this may indicate the lack of serious games in low-income countries. People in low-income countries may be more in need of serious games than those in high-income countries because low-income countries have a greater shortage of mental health professionals than high-income countries (0.1 per 1,000,000 people vs 90 per 1,000,000 people) [
Gaming and mental health have traditionally been two distinctly separate fields and come with their own unique pedagogy and praxis. The potential of utilizing the advantages inherent to gaming, as described earlier, from its reach to its transformative potential in mental health holds a lot of promise in theory. However, to achieve this potential, experts from the two disciplines need to work together in order to understand the unique strengths and limitations of each field when designing serious games.
Overall, serious games can be better than no intervention in alleviating depression and as effective in alleviating depression as other active interventions (eg, conventional CBT, exposure therapy, conventional exercise). However, definitive conclusions regarding the effectiveness of serious games could not be drawn in this review because the overall risk of bias was high in most included studies, the quality of the meta-analyzed evidence was very low, and few studies recruited patients with depression. Therefore, we can only recommend health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. To have sufficient evidence, future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs (eg, RoB 2).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.
Search strategy.
Data extraction form.
Reviewers’ judgements about each “risk of bias” domain for each included study.
Grading of Recommendations Assessment, Development and Evaluation (GRADE) Profile for comparison of serious games to control or conventional exercises for depression.
Allgemeine Depressionsskala
Beck Depression Inventory
Cognitive behavioral therapy
Children’s Depression Rating Scale-Revised
Goldberg Anxiety and Depression Scale
Geriatric Depression Scale
Grading of Recommendations Assessment, Development and Evaluation
Hospital Anxiety and Depression Scale
minimal clinically important difference
Problem Areas in Diabetes
Patient Health Questionnaire-9
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Reynolds Adolescent Depression Scale
randomized controlled trial
rational emotive behavioral education
rational emotive behavioral therapy
Risk-of-Bias 2
standardized mean difference
World Health Organization
WHO 5-item Well-Being Index
None declared.