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. 2023 May 3:11:e37105.
doi: 10.2196/37105.

Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study

Arka Ghosh  1 , Jagriti Agnihotri  1 , Sradha Bhalotia  1 , Bharat Kumar Sati  1 , Latika Agarwal  1 , Akash A  1 , Swastika Tandon  1 , Komal Meena  1 , Shreyash Raj  1 , Yatin Azad  1 , Silky Gupta  2 , Nitin Gupta  1   2   3
Affiliations

Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study

Arka Ghosh et al. JMIR Serious Games. .

Abstract

Background: Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring.

Objective: In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm.

Methods: We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged.

Results: We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users.

Conclusions: These games may help improve the effectiveness and engagement levels of computerized interventions for depression.

Keywords: cognitive bias modification; depression; digital intervention; learned helplessness; mobile phone; serious games.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Screenshots of the game for automatic interpretation bias modification. (A) The user finds words that are contained in the sentence by linearly connecting letters in the grid. (B) The ambiguous sentence is shown in full once the user finds 4 words. (C) The user is asked if the word (Bonus in the shown example) is related to the sentence on the previous screen.
Figure 2
Figure 2
Screenshots of the game for executive control training. (A) The avatar faces an obstacle, a jumping frog. (B) The avatar faces an obstacle, a pit. (C) The avatar faces a longer pit with floating platforms. (D) The instructions for the cognitive bias modification paradigm. (E) An incongruent flanker task as a part of the cognitive bias modification paradigm. The user must press the button corresponding to the middle arrow in the flanker task. (F) A green circle as a part of the cognitive bias modification paradigm. The user must press the button (green button on the right side) corresponding to the circle in the center.
Figure 3
Figure 3
Screenshots of the game for negative attention bias training, showing (A) a 1 × 2 grid, (B) a 2 × 2 grid, and (C) a 3 × 2 grid of faces with different emotions.
Figure 4
Figure 4
Screenshots of the game for positive imagery training. (A) A scenario is shown that can be resolved positively or negatively by providing one or more words to fill in the blank. (B) If the user resolves the scenario negatively, they are asked to try again. (C) If the user resolves the scenario positively, the game moves forward and another scenario is presented.
Figure 5
Figure 5
Screenshots of the circle-triangle mini-game in the game for learned helplessness. (A) The initial state in level 4. (B) An intermediate state in level 4. (C) An intermediate state in level 6.
Figure 6
Figure 6
The 3 unsolvable mini-games within the game for learned helplessness. (A) The goal in this mini-game is to arrange the tiles in the increasing order of the numbers. Configuration A1 is solvable, and A2 is unsolvable. (B) The goal in this mini-game is to get the butterfly to sit on all the flowers. The butterfly can be moved forward and sideways using the cursor keys on a keyboard or the swipe action on a touchscreen device. Once a butterfly sits on a flower, the flower withers away and the butterfly cannot move to a position without a flower. B1 is solvable, and B2 is unsolvable. (C) The goal in this mini-game is to insert the small red arc into the big blue arc. The user can move the solid black ball using cursor keys or swipe action to the adjacent squares (if the square contains an arc open in the direction of the ball, the ball moves inside the arc). Once the ball is inside an arc, the arc can be moved along with the ball to an adjacent square that is empty or contains a bigger arc with an opening in the direction from which the smaller arc is coming. The ball comes out of the small arc if moved in the direction in which the arc is open. C1 is solvable, and C2 is unsolvable.
Figure 7
Figure 7
Flowchart describing the sequence of mini-games in the game for learned helplessness. CTML: circle-triangle mini-game level.
Figure 8
Figure 8
Acceptability results of the game for (A) automatic interpretation bias modification, (B) executive control training, (C) negative attention bias modification, (D) positive imagery training, and (E) learned helplessness. Overall (1) the instructions for the games were clear; (2) the games were fun to play; and (3) the purpose of the games was clear.
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