Schizophrenia can lead to high functional disability and is associated with a heavy economic burden worldwide. The World Health Organization lists it as one of the top 10 conditions in terms of the global burden of disease [1,2]. Schizophrenia is a disease characterized by impairments in cognitive functions. Positive symptoms of this disorder, such as delusions and hallucinations, respond relatively well to antipsychotic medication, whereas the management of negative symptoms remains a clinical challenge [3,4]. Negative symptoms are associated with severe deterioration in cognition and global functioning [5,6]. Patients with negative symptoms often exhibit weak motivation for activities, which accelerates the degradation of cognitive functions. Schizophrenia is a condition that inherently leads to impaired cognitive function, compounded by patients’ low motivation to engage in activities, which further accelerates cognitive decline. A study conducted in Singapore evaluated the utility of the Mini Mental State Examination (MMSE) among long-term hospitalized patients diagnosed with schizophrenia or schizoaffective disorder. The findings indicated that MMSE scores were significantly influenced by sociodemographic and clinical variables, including age, educational attainment, and duration of illness [7]. A study conducted in the United States assessed partially remitted outpatients attending a depot antipsychotic clinic or a clozapine clinic (N=272) using the MMSE. The findings indicated that the cognitive gap did not appear to widen significantly with increasing age. The most commonly observed deficits among patients with poorer performance were in memory, attention, and constructional tasks. The MMSE was found to be easy to administer and applicable for use among outpatient populations with schizophrenia [8].

Exercise not only improves physical function but also serves as a crucial factor in enhancing cognitive function. Multiple factors hinder the efficacy of treating patients with schizophrenia, including limited insight, poor adherence, treatment resistance [9], antipsychotic-related side effects [10], and cultural factors [11]. Therefore, new treatment options are required to promote recovery and optimize rehabilitation [12]. Many studies have indicated that exercise can be an additional option for the prevention and treatment of schizophrenia [4,13-15] and it can improve patients’ positive and negative symptoms, quality of life, and cognitive function [13,16]. In addition, exercise enhances physical well-being and decreases potential somatic comorbidities such as metabolic syndrome [3] and cardiovascular diseases in patients with schizophrenia [3]. A systematic review indicated that exercise significantly improved patients’ working memory, social cognition, and attention and vigilance [17].

A previous systematic review identified exercise interventions as one of the most effective strategies for improving mental health. These interventions typically lasted for 1 to 3 months, with a frequency of 2 to 3 sessions per week and most sessions lasting between 30 and 60 minutes [18]. Exercise not only increases cerebral blood flow—providing the brain with more oxygen and nutrients—but also reduces neuronal apoptosis, promotes neurogenesis and brain plasticity, and enhances cognitive reserve. A previous study systematically reviewed the relationship among exercise, brain-derived neurotrophic factor, neural plasticity, and cognitive function. The results indicated that exercise can elevate brain-derived neurotrophic factor levels in the brain, thereby promoting neural plasticity and enhancing cognitive function [19].

Most patients with schizophrenia lack motivation for physical activities such as exercise and social interaction owing to various factors, including the effects of negative symptoms [3,4,18,19]. However, in recent decades, they have been recognized as interested in modern technology-assisted activities [20], and such activities are a possible method of rehabilitation. For example, video games, active video games (AVGs) [21-24], and virtual reality [25] have been documented as novel interventions for cognitive training and for alleviating psychotic symptoms in patients with schizophrenia [24,26,27]. A systematic review also found a positive relationship between video games and cognitive functions such as memory [28-30], social cognition [31], executive function [32], attention [33], and reaction time [34]. It has been suggested that playing video games can have cognitive, motivational, emotional, and social benefits [23] with a lower cost than those of other cognitive interventions [35].

With the rapidly changing technologies in today’s world, AVGs not only are fun but can also serve as exercise tools, making it more convenient for people to exercise. AVGs refer to exercises that use video games to make exercise more fun [36]. A previous systematic review focused on interactive motion-sensing games that required players to engage in physical movements such as waving, jumping, kicking, or full-body motion to control internet-based characters or complete in-game tasks. These games integrate entertainment with physical activity, breaking away from the traditional sedentary gaming model [37]. AVGs are considered capable of enhancing an individual’s behavioral intention to engage in these activities by fostering imagination, control, challenge, and curiosity. Engagement in exercise can increase either through consistently finding satisfaction in familiar activities or by trying new ones to sustain interest and motivation. [38]. One study reported that >90% of the participants were satisfied with playing AVGs, and most participants (76.9%) agreed that this intervention promotes healthier lifestyles and is an acceptable alternative way to perform physical activity [39]. AVGs significantly improve cognitive domains, including processing speed, attention and vigilance, working memory, verbal learning, visual learning, reasoning and problem-solving [40], social cognition, social functioning, and motivation [24] and also reduce cognitive impairments and psychological stress [41]. A systematic review indicated that AVGs were globally beneficial for patients with schizophrenia, particularly with regard to their cognitive function [42].

In summary, AVGs are accessible and easy to operate for patients with disabilities [43,44], and many studies indicate that interventions integrating gameplay with physical exercise can enhance motivation for device-assisted activities; alleviate residual symptoms; and improve cognitive, social, and occupational functioning, thereby contributing to an improved quality of life among patients with schizophrenia. Nevertheless, despite the growing global emphasis on digital health interventions, studies specifically investigating the impact of AVGs on this population in Taiwan remain scarce. This highlights a critical need to develop innovative, accessible, and engaging strategies to facilitate recovery and rehabilitation in patients living with schizophrenia. Furthermore, addressing cognitive deficits—a core and profoundly disabling characteristic of the disorder—is imperative due to their significant influence on daily functioning and overall well-being [19].

This study aimed to explore the role of AVGs in influencing the behavioral intention of patients with schizophrenia to participate in novel device-assisted activities and examine their efficacy in improving cognitive function.

We hypothesized that the experimental group would show greater improvement in cognitive function than the control group at each assessment point (3 and 6 weeks) during the intervention. In addition, we expected that playing AVGs would increase the experimental group’s behavioral intention to continue engaging with AVGs after the intervention.

The protocol was registered with ClinicalTrials.gov (NCT05933356) at the time of submission. We used an experimental design with random sampling, treating each day care center as a unit. Patients within these centers were assigned to either the experimental or control group using a random number generator (Microsoft Excel). This study was single blinded, with the research assistants being the blinded party. All participants received usual care, whereas those in the experimental group additionally engaged with AVGs over the 6-week study period.

This was an experimental study with participants recruited from day care centers from 2 hospitals in southern Taiwan. The MMSE and a behavioral intention questionnaire were administered before and after playing the AVGs.

The sample size was calculated using G*Power (version 3.1.1) for the F₁ test and its repeated measures with an effect size of 0.25, a significance level of .05, a power (1–β) of 0.80, and an estimated minimum sample size of 78 [45]. A total of 103 patients with schizophrenia participated in our study, and 82 (79.6%) completed all intervention processes and questionnaires. Before data collection, the principal investigator explained the purpose and process to the nurses in each ward and invited them to participate in the study.

The inclusion criteria for patients were as follows: (1) diagnosis of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [46]; (2) age of 20 to 65 years; (3) ability to read and understand traditional Chinese; and (4) current admission to a psychiatric day care center. The exclusion criteria were as follows: (1) patients with unstable mental conditions, such as delusions or hallucinations; and (2) patients with an intellectual disability or severe cognitive function impairment (MMSE score of <14) [47].

Each participant was required to complete a demographic characteristic and behavioral intention questionnaire, and their cognitive functions were assessed using the MMSE. The principal investigator initially collected participants’ demographic information through structured interviews. To ensure the accuracy and completeness of the data, the collected information was subsequently verified in collaboration with nurses at the day care center. Data were collected between April 2021 and September 2022.

Descriptive analyses using chi-square and independent-sample t tests were conducted using the SPSS software (version 21.0; IBM Corp). Descriptive analysis was based on participants’ demographic characteristics, such as age, gender, educational level, marital status, and religious beliefs. After controlling for the confounding factor of age, a generalized estimating equation was used to assess changes in behavioral intention and cognitive functions (including orientation, memory, attention and calculation, language, reasoning and problem-solving, and executive function) from baseline to the end of the intervention in the 2 groups. All tests were 2-tailed, with a significance level set at P<.05.

This study was approved by the institutional review boards of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUHIRB-SV (I)–20200105) and Taipei Veterans General Hospital (2023-07-002A). Written informed consent was obtained from all participants, and they were assured of data confidentiality and anonymity and that they could withdraw from the study at any time without providing a reason. The principal investigator visited each psychiatric day care center, explained the study’s purpose and process to all participants, and inquired regarding their willingness to take part. Each participant was offered TWD $400 (US $13-$14) as compensation for their taking part.

A total of 82 participants met the inclusion criteria and completed all the processes of our protocol. The participants were divided into the experimental and control groups (Figure 1), and we compared demographic data between these groups. The independent-sample 2-tailed t test and chi-square test results showed no statistically significant differences between the 2 groups (Table 2).

We controlled the age and educational level as the MMSE scores were related to both of these factors. We used generalized estimating equations to analyze changes in participants’ cognitive functions and found significant improvements in the cognitive domains of orientation (T2: β=0.66; P=.04) and language (T2: β=0.28; P=.03), as well as in behavioral intention (T1: β=4.88 and P=.009; T2: β=4.24; P=.04), following the intervention with AVGs compared to baseline (T0) in the experimental group (Table 3).

The experimental group had significantly higher behavioral intention to participate in AVGs and showed significant improvements in the cognitive domains of orientation and language compared to the control group. These findings indicate that the intervention not only enhanced motivation among patients with schizophrenia to participate in AVG-based activities but also led to measurable cognitive gains. Taken together, the results suggest that AVG interventions are both feasible and potentially effective in simultaneously addressing cognitive deficits and motivational challenges in this population.

In patients with schizophrenia, cognitive impairment and motivational deficits are well-documented barriers to rehabilitation [59], and our results suggest that AVGs may help address both. Compared to traditional rehabilitation methods, which often require extensive professional oversight and may lack engaging elements, AVGs offer an interactive, motivating, and low-barrier alternative [60,61]. Traditional therapeutic activities in psychiatric day care settings, such as arts and crafts, group discussions, or paper-based cognitive tasks, while beneficial, are often passive, repetitive, or fail to sufficiently motivate patients with negative symptoms or attentional difficulties [62]. In contrast, AVGs offer a dynamic and patient-centered alternative with several distinct advantages. AVGs are interactive, provide real-time feedback, and present task-oriented challenges within immersive environments. These features are particularly effective in sustaining attention and promoting active engagement. Importantly, AVGs can be administered with minimal supervision and infrastructural demands, making them well suited for integration into community-based programs and other low-resource contexts [58-62].

Our findings support the potential of AVGs to address both cognitive and motivational deficits. Participants in the intervention group not only showed significant improvements in the cognitive domains of orientation and language but also demonstrated increased behavioral intention to engage with AVGs. The structured yet enjoyable gameplay likely fostered a sense of mastery and self-efficacy, which are key factors in enhancing intrinsic motivation. This is particularly relevant for patients with schizophrenia, who often struggle with motivation and social withdrawal.

While overall cognitive function did not show significant improvement, we observed notable gains in the domains of orientation and language. These domains are often relatively preserved and more responsive to interventions in patients with mild cognitive impairment or certain psychiatric conditions [63,64]. In addition, AVGs can significantly impact behavioral intention by motivating patients to engage in physical activity. For patients with schizophrenia, who often experience difficulties with motivation and social engagement, the interactive nature of AVGs provides a compelling, enjoyable way to encourage participation in exercise. The games’ structured yet fun activities help foster a sense of achievement, which can translate into more consistent engagement in physical activity. Taken together, these findings highlight the feasibility and clinical utility of AVGs as a scalable, low-barrier intervention for improving select cognitive domains and enhancing motivation among patients with schizophrenia. Their affordability, accessibility, and adaptability to various patient needs position them as promising adjuncts to traditional rehabilitation strategies in resource-limited or community-based psychiatric programs.

First, it is unclear whether the cognitive and behavioral gains associated with AVGs persist over time or depend on continued engagement. Second, future studies should explore how AVGs can be integrated into comprehensive, multidisciplinary care models. Personalizing AVG content according to patients’ cognitive status, physical capabilities, or symptom severity may further improve intervention efficacy. Third, conducting subgroup analyses across age groups, illness stages, and care settings could inform more personalized and scalable implementation strategies.

Our study has several limitations. First, we provided a relatively lower intensity and shorter duration of the intervention for patients with schizophrenia, which may limit the benefits of AVGs observed in our participants. Second, our sample size was sufficient but relatively small, which may limit the generalizability of the findings to the broader population. Further studies with a larger sample size, higher intervention intensity, and longer duration, along with long-term follow-up, are needed to overcome these limitations. Finally, we used the MMSE to assess cognitive function. However, the MMSE has limited sensitivity to executive function and working memory, which may explain the lack of significant findings in these domains. For future research, we recommend using the Montreal Cognitive Assessment as it is more effective in detecting cognitive impairments, particularly in patients with schizophrenia or mild cognitive impairment.

This study contributes to the growing body of evidence supporting AVGs as effective and engaging interventions for improving orientation, language, and behavioral motivation in patients with schizophrenia. Our structured 6-week program yielded meaningful improvements in these domains, which are often difficult to impact through traditional approaches. Although preliminary, the results highlight the potential of well-designed AVG interventions as scalable, low-barrier tools for psychiatric rehabilitation. Unlike conventional therapies that frequently rely on specialized resources or highly trained professionals, AVGs offer a flexible alternative suitable for diverse settings, including psychiatric wards, outpatient clinics, and community centers.