Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis Background: 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. Objective: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. Methods: 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). Results: 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 (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). Conclusions: 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 https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 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. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969 (JMIR Serious Games 2022;10(1):e32331) doi: 10.2196/32331 KEYWORDS serious games; exergames; depression; cognitive behavioral therapy; systematic reviews; meta-analysis educational resources for health care professionals [16]. Introduction Moreover, serious games have been used as a nonpharmacological therapeutic intervention for mental Background disorders [17]. Serious games have been utilized as a treatment An individual's mental health is fundamental to living a healthy for various mental disorders, including depression [18,19], and enjoyable lifestyle. Studies estimate that 1 in 3 people may anxiety [20], posttraumatic stress disorder [21,22], autism suffer from a mental illness during their lifetime [1]. The World spectrum disorder [23,24], dementia [25,26], alcohol use Health Organization (WHO) reports that depression is a “leading disorder [27], attention deficit hyperactivity disorder [28], and cause of disability worldwide and is a major contributor to the obsessive-compulsive disorder [13,29]. overall global burden of disease” affecting more than 264 Gaming as a therapeutic tool in mental health can potentially million people of all ages globally [2]. Depression is a mental offer several specific advantages that may be missing from health disorder that the Sustainable Development Goals of the traditional forms of delivery. The gaming industry is, as ever, United Nations (2015) has listed among its 270 targets and 230 popular globally [30] and arguably easier to access than even indicators. Depressive disorders account for most of the total basic mental health services [31]. Games by their very nature disability-adjusted life years globally. Although depressive have the potential to engage the user in game play that can be disorders are global, they particularly affect those living in high rewarding through scoring points or following story arcs that and upper-middle-income nations [3]. This heavy toll is can help improve user involvement and lower attrition rates exacerbated by the fact that up to one-half (50%) of the people [32,33]. Additionally, as the technology improves, gaming can living in high-income countries and 90% of those living in utilize accessories to provide richer sensory environments and low-resource settings receive no treatment for depressive immersive user experiences that allow users to simulate real-life disorders [4]. scenarios more safely and help in educating and achieving Depressive disorders are a family of mental disorders ranging cognitive and behavioral changes through overlearning and in severity from mild temporary episodes of sadness to more repetition [33,34]. severe and persistent depression [5]. Depressive disorders Research Gap and Aim include disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance- or medication-induced depressive Many studies have assessed the effectiveness of serious games disorder, and major depressive disorder [6]. Depressive disorders to alleviate depression. Aggregating the evidence from these are characterized by disturbances in mood, thoughts, or studies is very important to draw more definitive conclusions behaviors. Furthermore, depressive disorders do not affect the about the effectiveness of serious games as viable therapeutic mind alone but are reported to impact a person’s body [7,8]. interventions in depressive disorders. Several published reviews Depression is known to be caused by a number of factors that have summarized the evidence about the effectiveness of serious interact in complex mechanisms: social, genetic, pathological, games for depression [18,19,35-37]. However, these reviews and chemical [9]. Treatments for depressive disorders are are undermined by certain technical shortcomings that limit the generally classified into either pharmacological or psychosocial generalization of the findings. Specifically, these reviews (1) (ie, nonpharmacological) interventions. Pharmacological focused on a certain type of serious games (ie, exergames) treatments involve the use of drugs (eg, antidepressants) while [19,37]; (2) focused on a certain age group (older adults) [37]; examples of psychosocial treatments include cognitive (3) included non-randomized controlled trials (RCTs) [19,35]; behavioral therapy (CBT), exposure therapy, and exercise [10]. (4) did not search technical databases (such IEEE Xplore and the ACM Digital Library), thereby including only a few studies The use of serious games, defined as games that have a purpose [35-37]; (5) did not assess the quality of the evidence other than entertainment, has seen a rise in recent years [11]. [18,19,35-37]; and (6) were outdated publications [18,19,35]. Serious games use elements unique to gaming in order to Therefore, this study aimed to assess the effectiveness of serious educate or influence change in experience or behaviors [12]. games for alleviating depression by summarizing and pooling Several industries have adopted and continue to use serious the results of previous studies and providing an up-to-date games including health care, education, and airlines [13]. Among review. other things, serious games have been effectively utilized for education, prevention, and treatment of chronic conditions (eg, asthma and diabetes) [14], therapeutic rehabilitation [15], and https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Study Selection Methods We followed 3 steps to identify the relevant studies. In the first We conducted a systematic review in accordance with the step, we exported the retrieved studies to EndNote to identify PRISMA (Preferred Reporting Items for Systematic Reviews and remove duplicates. Then, 2 reviewers (EA and MA) and Meta-Analyses) statement (Multimedia Appendix 1) [38]. independently screened the titles and abstracts of all retrieved studies. In the last step, the 2 reviewers independently screened Search Strategy the full texts of studies included from the second step. A third reviewer (AA) resolved any disagreements between the 2 Search Sources reviewers in the second and third steps. Cohen κ in this review We utilized the following bibliographic databases to retrieve indicated a very good level of interrater agreement in the first relevant studies: MEDLINE (via Ovid), PsycInfo (via EBSCO), (0.85) and second (0.90) steps [39]. CINAHL (via EBSCO), IEEE Xplore, ACM Digital Library, and Scopus. These databases were searched on March 30, 2021 Data Extraction by the first author. When applicable, we set auto alerts to Two reviewers (EA and MA) independently extracted data from conduct an automatic search weekly for 12 weeks (ending on the included reviews using Microsoft Excel (Microsoft June 30, 2021). We also searched the search engine “Google Corporation, Redmond, WA). Multimedia Appendix 3 shows Scholar” to identify grey literature. We checked only the first the data extraction form that was used by the 2 reviewers to 10 pages (ie, 100 hits) because Google Scholar retrieved a vast extract the data precisely and systematically from the included number of studies and it ordered them based on their relevancy. studies. The form was pilot tested using 3 included studies. Any To identify further studies of relevance to the review, we disagreements between the reviewers were resolved by conducted backward reference list checking (ie, screening the consulting a third reviewer (AA). The interrater agreement reference lists of the included studies and relevant reviews) and between the reviewers was 0.87, indicating a very good level forward reference list checking (ie, screening the studies that of agreement [39]. Some outcome data (eg, mean, standard cited the included studies). deviation, sample size in each group) were missing in 10 studies. Therefore, we contacted their corresponding authors to get them, Search Terms and 5 corresponding authors did not reply to our emails even The search query in this review was developed by consulting after sending 2 reminders. 2 experts in digital mental health and by checking systematic reviews of relevance to the review. These terms were chosen Risk of Bias Assessment based on the target intervention (eg, serious games, exergames, Two reviewers (EA and MA) independently assessed the risk and gamification), target outcome (eg, depression and of bias in the included studies using the Risk-of-Bias 2 (RoB melancholy), and target study design (eg, RCT and clinical 2) tool, which is recommended by the Cochrane Collaboration trial). Multimedia Appendix 2 shows the detailed search query [40]. This tool appraises the risk of bias in 5 domains in RCTs: used to search each of the aforementioned databases. randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and Study Eligibility Criteria selection of the reported result [40]. The risk of bias judgments This review included only RCTs that assessed the effectiveness in these domains is used to determine the overall risk of bias of serious games for alleviating the severity of depressive for each included study. A third reviewer (AA) resolved any symptoms. To be more precise, the intervention of interest in disagreements in judgments between the 2 reviewers. Interrater this review was serious games that were delivered on any digital agreement between the reviewers was very good (Cohen κ=0.93) platform such as computers, consoles (eg, Xbox, PlayStation), [39]. mobile phones, tablets, handheld devices, or any other computerized devices. The intervention had to utilize elements Data Synthesis of gaming as an integral and primary method for therapeutic or We utilized narrative and statistical approaches to synthesize prevention purposes. We did not consider nondigital games and the extracted data. Specifically, in narrative synthesis, texts and those used for other purposes such as monitoring, screening, tables were used to describe the characteristics of the included and diagnosis. We included RCTs whether they were parallel studies, population, intervention, comparator, and outcome RCTs, cluster RCTs, crossover RCTs, or factorial RCTs but we measures. Then, we grouped and summarized the findings of excluded quasi-experiments, observational studies, and reviews. the included studies according to the type of serious games (ie, We focused on studies in which one of the measured outcomes exergames or computerized CBT games). A meta-analysis was was depression or depressive symptoms regardless of the conducted when at least 2 studies of the same type of serious outcome measures. Only trials in the English language were game reported enough data for the analysis (ie, mean, standard eligible for inclusion in this review. RCTs published as journal deviation, number of participants in each intervention group). articles, conference proceedings, and dissertations were When this information was not reported in any included study, included, whereas we excluded conference abstracts and posters, we contacted the first and corresponding authors to get the commentaries, preprints, proposals, and editorials. We did not missing information. apply restrictions related to the population, year of publication, country of publication, comparator, and study settings. 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; https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Cohen d) because the outcome data (severity of depressive Assessment, Development, and Evaluation (GRADE) approach, symptoms) were continuous and tools used to measure the which assesses the quality of evidence based on 5 domains: risk outcome were different between the included studies. The of bias, inconsistency (ie, heterogeneity), indirectness, random effects model was used in the analysis given the clinical imprecision, and publication bias [42]. Two reviewers (CT and heterogeneity between the meta-analyzed studies in terms of AA) independently assessed the overall quality of meta-analyzed serious game characteristics (eg, types, duration, frequency, and evidence, and any disagreements were resolved through period), population characteristics (eg, sample size, mean age, discussion and consensus. Interrater agreement between the and health condition), and outcome measures (ie, tools and reviewers was very good (Cohen κ=0.88) [39]. follow-up period). Results When the meta-analysis showed a statistically significant difference between groups, we examined whether this difference Search Results was clinically important. A minimal clinically important As shown in Figure 1, we retrieved 966 citations from searching difference (MCID) is defined as the smallest change in a the 7 electronic databases. Using the software EndNote, we measured outcome that a patient would consider as worthy and identified and removed 225 duplicates of the retrieved citations. significant and which mandates a change in a patient’s treatment. Screening titles and abstracts of the remaining 741 citations led The MCID boundaries for an outcome were calculated as ±0.5 to excluding 592 citations because (1) they did not use serious times the SMD of the meta-analyzed studies. games (n=354); (2) the severity of depressive symptoms was We checked the characteristics of participants, interventions, not a measured outcome (n=69); (3) they were not RCTs comparator, and outcomes in studies included in the (n=119); (4) they were not peer-reviewed articles, theses, nor meta-analysis to assess their clinical heterogeneity. We also conference proceedings (n=39); and (5) they were published in examined the statistical heterogeneity of the meta-analyzed non-English languages (n=11). Reading the full text of the studies by calculating a Chi-square P value and I , which remaining 149 publications led to excluding 127 publications measures the statistical significance of heterogeneity and the because (1) they did not use serious games (n=39), (2) the degree of heterogeneity, respectively. A Chi-square P value severity of depressive symptoms was not a measured outcome ≤.05 indicates heterogeneous meta-analyzed studies [41]. The (n=32), (3) they were not RCTs (n=53), and (4) they were degree of heterogeneity was considered unimportant, moderate, published in non-English languages (n=3). We identified 5 additional RCTs through backward and forward reference list substantial, or considerable when I was 0%-40%, 30%-60%, checking. In total, 27 RCTs were included in the current review 50%-90%, or 75%-100%, respectively [41]. [43-69]. Of those, 16 RCTs were included in the meta-analyses We assessed the overall quality of evidence from the [45-52,54,59-65]. meta-analyses using the Grading of Recommendations https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Figure 1. Flow chart of the study selection process. studies were carried out in 15 different countries, as shown in Characteristics of Included Reviews Table 1. The country that published the largest number of the The included studies were published between 2012 and 2021 included studies was Germany (n=5). All included papers were (Table 1). The years that witnessed the largest number of papers published in peer-reviewed journals. The trial type used included studies were 2018 (n=5) and 2020 (n=5). The included in the most included studies was parallel RCTs (n=24). https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 1. Characteristics of studies and population. Author(s), year Country Publica- Sample Mean age Sex Health condition Setting RCT type tion type size, n (years) (male), % Ruivo et al [43], Ireland Journal Parallel 32 59.9 81.3 Cardiovascular diseases Clinical, com- 2017 article munity, educa- tional Ferraz et al [44], Brazil Journal Parallel 62 69 59.7 Parkinson disease Clinical 2018 article Song and Park [45], South Ko- Journal Parallel 40 50.1 55.0 Stroke Clinical 2015 rea article Schumacher et al Germany Journal Parallel 42 56.3 59.5 Hematopoietic stem cell transplan- Clinical [46], 2018 article tation recipients Meldrum et al [47], Ireland Journal Parallel 71 54.1 38.0 Unilateral peripheral vestibular Clinical 2015 article loss Zhou et al [48], Qatar Journal Parallel 73 64.6 45.2 Diabetes and end-stage renal dis- Clinical 2020 article ease Vieira et al [49], Portugal Journal Parallel 46 57.7 Coronary artery disease Clinical 2017 article Tollár et al [50], Hungary Journal Parallel 74 69.4 48.6 Parkinson disease Clinical 2018 article Ozdogar et al [51], Turkey Journal Parallel 60 40.1 27.1 Multiple sclerosis Clinical 2020 article Kempf and Martin Germany Journal Parallel 220 61.1 45.9 Type 2 diabetes Clinical, com- [52], 2013 article munity Rendon et al [53], United Journal Parallel 40 84.5 35.0 Older adults Clinical 2012 States article Jahouh et al [54], Spain Journal Parallel 80 84.2 44.0 Older adults Clinical 2021 article Rica et al [55], 2019 Brazil Journal Parallel 50 - 0.0 Older adults Clinical, com- article munity Andrade et al [56], Brazil Journal Cluster 140 9.41 42.1 Elementary students Educational 2020 article Shin et al [57], 2015 South Ko- Journal Parallel 35 54 75 Stroke Clinical rea article Adomavičienė et al Lithuania Journal Parallel 60 64.6 66.7 Stroke Clinical [58], 2019 article Fleming et al [59], New Journal Crossover 32 14.9 56 Depression Educational 2012 Zealand article Merry et al [60], New Journal Parallel 187 15.6 34.2 Depression Clinical, edu- 2012 Zealand article cational Donker et al [61], Nether- Journal Parallel 193 41.3 33.2 Acrophobia Community 2019 lands article Perry et al [62], Australia Journal Cluster 540 16.7 36.9 Secondary students Educational 2017 article Cooney et al [63], Ireland Journal Parallel 52 40.6 38.8 Anxiety, depression, and/or intel- Clinical 2017 article lectual disability Poppelaars et al Nether- Journal Parallel 208 13.4 0.0 Depression Educational [64], 2016 lands article Välimäki et al [65], Finland Journal Parallel 90 41 50.0 Traumatic brain injury Clinical 2018 article Wijnhoven et al Nether- Journal Parallel 109 11.1 77.1 Anxiety and autism spectrum dis- Clinical, edu- [66], 2020 lands article order cational Haberkamp et al Germany Journal Parallel 68 22.8 13.0 Arachnophobia Educational [67], 2021 article https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s), year Country Publica- Sample Mean age Sex Health condition Setting RCT type tion type size, n (years) (male), % Butler et al [68], Germany Journal Parallel 40 33.4 100 Posttraumatic stress disorder Clinical 2020 article David et al [69], Germany Journal Parallel 165 12.9 35.9 Stroke Educational 2018 article RCT: randomized controlled trial. Not reported. The sample size in the included studies varied from 32 to 540, therapy games (n=1), brain training games (n=1), rational with an average of 104. The mean age of participants in the emotive behavioral therapy (REBT) and rational emotive included studies ranged between 9.41 years and 84.5 years, with behavioral therapy education (REBE)–based game (n=1). an average of 43.9 years. The percentage of the sample who Although games were designed with a “serious” purpose from were men reported in 26 studies ranged from 0% to 100%, with the beginning (designed serious games) in 14 studies, they were an average of 46.1%. Participants’ health conditions were varied not designed as serious games but were being used for a serious between studies, and depression and stroke were the most purpose (purpose-shifted games) in the remaining 13 studies. common (n=4 each). Participants in most studies were recruited The most common platforms used for playing the games were from clinical settings (n=20). computers (n=12) and video game consoles and their accessories (eg, balance board; n=12). The duration of the games in the The intervention in the included studies was only serious games included studies ranged between 5 minutes and 85 minutes, but in 19 studies, serious games plus occupational therapy in 2 it ranged between 20 minutes and 45 minutes in most studies studies, and serious games plus psychotherapy in 1 study (Table (n=14). The frequency of playing the games varied between 2). The most common games used in the included studies were once a week and once a day, but it ranged between once a week SPARX (n=4) and Wii Fit (n=4). There were 5 types of serious and 3 times a week in 20 studies. The period of the intervention games based on the therapeutic modality that they deliver: varied between 1 week and 24 weeks, but it ranged from 4 to 8 exergames (n=16), computerized CBT games (n=8), exposure weeks in 19 studies. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 2. Characteristics of interventions. Author(s) Intervention Serious game Serious game Serious Platform Duration Frequency Period name type game (minutes) (times/week) (weeks) genre Ruivo et al [43] Serious game Wii-Sports Exergame Purpose- Wii console 60 2 6 shifted and Kinect Ferraz et al [44] Serious game Kinect Adven- Exergame Purpose- Xbox console 50 3 8 tures shifted and Kinect Song and Park [45] Serious game Kinect Sport, Exergame Purpose- Computer and 30 5 8 Kinect Sport shifted Xbox Kinect Season 2, Kinect Adven- ture, and Kinect Gunstringer Schumacher et al [46] Serious game Wii Fit and Exergame Purpose- Wii console 30 5 2 Wii-Sports shifted and balance board Meldrum et al [47] Serious game Wii Fit Plus Exergame Purpose- Wii console 15 5 6 shifted and balance board and Frii Board Zhou et al [48] Serious game Exergame Designed Computer and 30 3 4 N/R wearables (sensors) Vieira et al [49] Serious game Kinect-Rehab- Exergame Designed Computer and 70-85 3 24 Play Xbox Kinect Tollár et al [50] Serious game Reflex Ridge, Exergame Purpose- Xbox console 60 5 5 Space Pop, Just shifted and Kinect Dance Ozdogar et al [51] Serious game Kinect Sports Exergame Purpose- Xbox console 45 1 8 Rivals shifted and Kinect Kempf and Martin [52] Serious game Wii Fit Plus Exergame Purpose- Wii console ≥30 1 12 shifted and balance board Rendon et al [53] Serious game Wii Fit Exergame Purpose- Wii console 35-45 3 6 shifted and balance board Jahouh et al [54] Serious game Step, Nodding Exergame Purpose- Wii console 40-45 2-3 8 shifted Rica et al [55] Serious game Kinect Sports Exergame Purpose- Xbox console 60 3 12 Ultimate Collec- shifted and Kinect tion, Your Shape Fitness Evolved, Dance Central, and Kinect Training Andrade et al [56] Serious game Just Dance Exergame Purpose- Xbox console 40 2 1 2015 shifted and Kinect Shin et al [57] Serious game + RehabMaster Exergame Designed Computer, 60 5 4 occupational sensors, and therapy infrared projec- tor Adomavičienė et al [58] Serious game N/R Exergame Designed Computer and 45 Once a day 2 Kinect Fleming et al [59] Serious game SPARX Computerized Designed Computer 30 1-2 5 CBT game Merry et al [60] Serious game SPARX Computerized Designed Computer 20-40 1-2 4-7 CBT game https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s) Intervention Serious game Serious game Serious Platform Duration Frequency Period name type game (minutes) (times/week) (weeks) genre Donker et al [61] Serious game ZeroPhobia Computerized Designed Smartphone 5-40 2 3 CBT game and wearables (VR goggles) Perry et al [62] Serious game SPARX-R Computerized Designed Computer 20-30 1-2 5-7 CBT game Cooney et al [63] Serious game Pesky Gnats: Computerized Designed Computer 60 1 7 The Feel Good CBT game Island Poppelaars et al [64] Serious game SPARX Computerized Designed Computer 20-40 1 7 CBT game Välimäki et al [65] Serious game CogniFit Computerized Designed Computer ≥30 Once a day 8 CBT game Wijnhoven et al [66] Serious game MindLight Computerized Designed Computer and 60 1 6 CBT game wearable (headset) Haberkamp et al [67] Serious game Spider App Exposure thera- Designed Smartphone 12 2 1 py game Butler et al [68] Serious game + Tetris Brain-training Purpose- Nintendo DS 60 2 6 psychotherapy game shifted XL console David et al [69] Serious game REThink Designed Tablet 50 3 4 REBT - and REBE -based game N/R: not reported. CBT: cognitive behavioral theory. VR: virtual reality. REBT: rational emotive behavioral therapy. REBE: rational emotive behavioral education. As shown in Table 3, the comparison groups received inactive comparators varied between 1 week and 24 weeks. The outcome interventions in 15 studies, while they received active of interest (eg, severity of depressive symptoms) was measured interventions in 18 studies (eg, conventional exercises, CBT using 18 different tools, but the most common tool used by the programs, video games, and psychotherapy). Note that the included studies was the Beck Depression Inventory (BDI; n=6), numbers do not add up because 6 studies delivered both active followed by the Hospital Anxiety and Depression Scale (HADS; and inactive interventions as comparators. The duration of the n=4). The outcome of interest was measured immediately after active comparators ranged between 12 minutes and 100 minutes. the intervention in all included studies, and the most common The frequency of playing the active comparators varied between follow-up period was 3 months (n=6). Participant attrition was once a week and once a day. The period of the active reported in 24 studies and ranged from 0 to 134. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 3. Characteristics of comparators and outcomes. Author(s) Comparator Duration Frequency Period Outcome measures Follow up Attrition, n (minutes) (times/week) (weeks) Ruivo et al [43] Conventional exercises 50 3 8 Postintervention 10 GDS (functional training), conventional exercises (bicycle exercise) Ferraz et al [44] Robot-assisted trainings 45 Once a day 2 Postintervention 18 HADS c d Song and Park Conventional exercises 30 5 8 Postintervention BDI N/R [45] Schumacher et al Conventional exercises 30 5 2 Postintervention, 30- 11 HADS-D [46] day follow-up, 100-day follow-up Meldrum et al Conventional exercises 15 5 6 HADS-D Postintervention 9 [47] Zhou et al [48] Conventional exercises 30 3 4 Postintervention 0 CES-D Vieira et al [49] Conventional exercises, 70-85 3 24 Postintervention, mid- 13 DASS-21 control intervention (3 months) Tollár et al [50] Conventional exercises 60 2 6 HADS Postintervention, 2- 4 month follow-up Ozdogar et al Conventional exercises, 45 1 8 BDI Postintervention 3 [51] control h i j Kempf and Mar- Control N/A N/A Postintervention 44 N/A WHO-5 , PAID , tin [52] ADS-L Rendon et al [53] Control N/A N/A N/A GDS Postintervention 6 Jahouh et al [54] Control N/A N/A N/A Postintervention N/R GDS, GADS Rica et al [55] Conventional exercises, 60 5 5 BDI Postintervention 0 control Andrade et al Physical education 40 2 1 Postintervention 0 BMS [56] Shin et al [57] Occupational therapy 60 5 4 Postintervention 3 HAMD Adomavičienė et Conventional exercises, 60 5 5 BDI Postintervention 0 al [58] control o p Fleming et al [59] Control N/A N/A N/A Postintervention 5 CDRS-R , RADS-2 Merry et al [60] Control N/A N/A N/A CDRS-R, RADS-2 Postintervention, 3- 17 month follow-up Donker et al [61] Control N/A N/A N/A Postintervention, 3- 59 PHQ-9 month follow-up Perry et al [62] Interactive online pro- 20-30 1-2 5-7 Postintervention, 6- 134 MDI gram month follow-up, 18- month follow-up Cooney et al [63] Control N/A N/A N/A Postintervention, 3- 3 GAS-LD month follow-up Poppelaars et al CBT pro- 1 7 RADS-2 Postintervention, 3- 10 CBT program + serious [64] gram + seri- month follow-up, 6- game, CBT program, ous game month follow-up, 12- control (80-100), month follow-up CBT pro- gram (60) Välimäki et al Video game, control ≥30 Once a day 8 PHQ-9 Postintervention, 3- 20 [65] month follow-up Wijnhoven et al Video game 60 1 6 Postintervention, 3- 35 CDI-2 [66] month follow-up https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s) Comparator Duration Frequency Period Outcome measures Follow up Attrition, n (minutes) (times/week) (weeks) Haberkamp et al Video game 12 2 1 BDI-II Postintervention, 2- 6 [67] week follow-up Butler et al [68] Psychotherapy 60 2 6 BDI-II Postintervention, 6- 0 month follow-up David et al [69] Rational emotive behav- 50 3 4 Postintervention 23 EATQ-R ioral therapy and educa- tion, control GDS: Geriatric Depression Scale. HADS: Hospital Anxiety and Depression Scale. BDI: Beck Depression Inventory. N/R: not reported. HADS-D: depression subscale of the HADS. CES-D: Center for Epidemiologic Studies Depression Scale. DASS-21: Depression, Anxiety and Stress Scale 21. N/A: not applicable. WHO-5: WHO 5-item Well-Being Index. PAID: Problem Areas in Diabetes. ADS-L: Allgemeine Depressionsskala. GADS: Goldberg Anxiety and Depression Scale. BMS: Brunel’s Mood Scale. HAMD: Hamilton Depression Rating Scale. CDRS-R: Children’s Depression Rating Scale-Revised. RADS-2: Reynolds Adolescent Depression Scale. PHQ-9: Patient Health Questionnaire-9. MDI: Major Depression Inventory. GAS-LD: Glasgow Depression Scale for people with a learning disability. CBT: cognitive behavioral therapy. CDI-2: Child Depression Inventory 2. EATQ-R: Early Adolescent Temperament Questionnaire-Revised. enrolled and assigned to interventions, and groups were not Results of Risk of Bias Appraisal comparable in 4 studies. Accordingly, the risk of bias due to The random allocation sequence for the randomization process the randomization process was rated as low for only 8 studies was appropriate in 23 included studies. However, only 10 studies (Figure 2). concealed the allocation sequence until participants were Figure 2. Review authors’ judgments about each “risk of bias” domain. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Participants and individuals delivering the interventions were studies were grouped into 3 categories based on the types of aware of assigned interventions during the experiment in 22 serious games. and 20 studies, respectively. Deviation from the intended Exergames intervention occurred in 2 studies due to the experimental Exergames were the intervention in 16 studies [43-58]. contexts. Only 14 studies used an appropriate analysis Exergames were compared with conventional exercises, no (intention-to-treat or modified intention-to-treat analyses) to intervention, physical education, and occupational therapy. The estimate the effect of assignment to intervention. Therefore, the results of these comparisons are summarized in the following risk of bias due to the deviations from the intended interventions sections. was judged as low in only 8 studies (Figure 2). Exergames Versus Conventional Exercises Outcome data were not available for all or nearly all participants in 21 studies, and there was evidence that the findings were not In 9 studies, the effect of exergames was compared with that of biased by missing outcome data in only 5 studies. The reasons conventional exercises on the severity of depressive symptoms for missing outcome data could not be related to the true value [43-51]. Although 1 study did find a statistically significant of the outcome in 18 studies. As a result, 17 studies were judged difference in the severity of depressive symptoms between the as having a low risk of bias in the “missing outcome data” groups [45], the remaining 8 studies did not [43,44,46-51]. domain. Specifically, Song and Park [45] compared the effect of exergames (Kinect Sport, Kinect Sport Season 2, Kinect All included studies assessed the outcome of interest (ie, Adventure, and Kinect Gunstringer) with that of conventional depression level) using appropriate measures and used exercises (ergometer bicycle training) on the severity of measurement methods comparable across intervention groups. depressive symptoms (measured using the BDI) among patients However, the assessor of the outcome was blinded in only 9 with stroke. The study found a statistically significant difference studies. For this reason, only these studies were rated as low (P<.05) in depressive symptoms between the groups, favoring risk of bias in the “measuring the outcome” domain (Figure 2). exergames over ergometer training. Another study assessed the In 17 studies, a prespecified analysis plan (ie, protocol) was not effect of exergames (Wii Fit Plus) on the severity of depressive published. Only 4 studies reported outcome measurements symptoms (measured using the HADS-D) among patients with different from those specified in the analysis plan. There is no unilateral peripheral vestibular loss [47]. The study did not find evidence that all included studies selected their results from any statistically significant difference (P=.49) in the severity many results produced from multiple eligible analyses of the of depressive symptoms between the exergame group and data. Accordingly, the risk of bias due to the selection of the conventional exercise group [47]. Schumacher et al [46] assessed reported results was considered low in 4 studies (Figure 2). the effects of exergames (Wii Fit and Wii-Sports) and conventional exercises on depression symptoms (measured In the last domain “overall bias,” the risk of bias was considered using the HADS-D) among hematopoietic stem cell high in 20 studies as they were judged as having a high risk of transplantation recipients and found no significant difference bias in at least one domain; 6 studies were judged to have some (P=.07) between both groups in the severity of depressive concerns in the domain of overall bias as they had some symptoms. A study by Ozdogar et al [51] examined the effects concerns in at least one of the domains and were not at high of exergames (Kinect Sports Rivals) and conventional exercises risk for any domain. The remaining study was judged to be at on the severity of depressive symptoms among patients with low risk of bias for the domain of overall bias given that it was multiple sclerosis, and there was no significant difference rated to be at low risk of bias for all domains. Reviewers’ (P>.05) in the severity of depressive symptoms between the 2 judgments about each “risk of bias” domain for each included groups. A study examining the effect of exergames study are presented in Multimedia Appendix 4. (Kinect-RehabPlay) on the severity of depressive symptoms Results of Studies (measured using the BDI) among patients with coronary artery disease in comparison with conventional exercises found no Types of Serious Games significant difference in the severity of depressive symptoms As mentioned earlier, we identified 5 types of serious games between the 2 groups [49]. In another study [48], no significant based on the therapeutic modality that they deliver in the difference in the severity of depressive symptoms (measured included studies. The first type is exergames, which refer to using the Center for Epidemiologic Studies Depression Scale video games that require physical exercises (eg, fitness and in patients with diabetes and end-stage renal disease) was balance exercises) in order to be played. The second type is detected between the exergame group and conventional exercise computerized CBT games, which are video games that provide group. Tollár et al [50] compared the effect of exergames CBT for the users. The third type is exposure therapy games, (Reflex Ridge, Space Pop, Just Dance) with that of conventional which are video games that apply exposure principles to reduce exercises (ergometer bicycle training) on the severity of anxiety in users with phobias. The fourth type is brain training depressive symptoms (measured using the BDI) among patients games, which are video games that are based on cognitive with Parkinson disease. The study showed no statistically interference tasks to reconsolidate traumatic memories. The last significant difference (P=.27) in the severity of depressive type is REBT- and REBE-based games, which are video games symptoms between the 2 groups. A study assessed the effects that enable users to replace irrational beliefs (eg, demandingness, of exergames (Wii-Sports) and conventional exercises on the intolerance, and frustration) with rational beliefs (eg, severity of depressive symptoms (measured by HADS) among unconditional acceptance and tolerance). Results of the included https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al patients with a high risk of cardiovascular diseases [43]. No Results of 7 studies were meta-analyzed as shown in Figure 3 statistically significant difference between the groups was [45-49,51]. No statistically significant difference (P=.12) in the reported in the study [43]. In the last study, no significant severity of depressive symptoms was found between the difference in the severity of depressive symptoms (measured exergame group and conventional exercise group (SMD –0.32, using the Geriatric Depression Scale [GDS] in patients with 95% CI –0.71 to 0.08). There was substantial heterogeneity in Parkinson disease) was detected between the exergame group the evidence (P=.005; I =67%). The quality of the evidence (Kinect Adventures) and 2 conventional exercise groups was very low, as it was downgraded by 5 levels due to a high (functional training and bicycle exercises) [44]. risk of bias, heterogeneity, and imprecision (Multimedia Appendix 5). Figure 3. Forest plot of 7 studies comparing the effect of exergames with that of conventional exercises on the severity of depressive symptoms. al [54] assessed the effect of exergames (Wii Fit game) on the Exergames Versus No Intervention severity of depressive symptoms (measured using the GDS and In 7 studies, the effect of exergames was compared with that of Goldberg Anxiety and Depression Scale [GADS]) among older no intervention on the severity of depressive symptoms [49-55]. adults. No significant difference in the severity of depressive Although 4 studies showed a statistically significant difference symptoms as measured using the GDS (P=.43) and GADS in the severity of depressive symptoms between the groups (P=.21) was detected between the exergame group and the [50-52,55], 3 studies did not [49,53,54]. Specifically, Kempf control group [54]. Another study examining the effect of and Martin [52] compared the effect of exergames (Wii Fit Plus) exergames (Kinect-RehabPlay) on the severity of depressive with that of no intervention on the severity of depressive symptoms (measured using the BDI) among patients with symptoms (measured using the WHO 5-item Well-Being Index coronary artery disease in comparison with no intervention [WHO-5], Problem Areas in Diabetes [PAID], and Allgemeine found no significant difference (P>.05) in the severity of Depressionsskala [ADS-L]) in patients with type 2 diabetes. depressive symptoms between the 2 groups [49]. The effects of The study found a statistically significant effect of exergames exergames and no intervention on the severity of depressive over no intervention on the severity of depressive symptoms as symptoms (measured by GDS) among older adults were measured using the WHO-5 (P<.001), PAID (P=.007), and compared in another study [53], and no significant difference ADS-L (P=.002) [52]. A study conducted by Ozdogar et al [51] (P=.09) was found in the severity of depressive symptoms examined the effects of exergames (Kinect Sports Rivals) and between the 2 groups [53]. no intervention on the severity of depressive symptoms We meta-analyzed results of 5 studies, as they reported enough (measured using the BDI) among patients with multiple and appropriate data for the analysis [49-52,54]. Of the 5 studies, sclerosis. Interestingly, the study demonstrated a statistically 2 assessed the severity of depressive symptoms using more than significant difference (P<.05) between the groups, favoring no one measure (ie, WHO-5, PAID, and ADS-L [52]; GDS and intervention over exergames [51]. In another study [55], the GADS [54]); therefore, we included the results of all these influence of exergames (Kinect Sports Ultimate Collection, measures in the meta-analysis. The meta-analysis showed a Your Shape Fitness Evolved, Dance Central, Kinect Training) statistically significant difference in the severity of depressive and no intervention on the severity of depressive symptoms symptoms (P=.004) between exergame and control groups, (measured using the BDI) among older women was investigated, favoring exergames over no intervention (SMD –0.39, 95% CI and a statistically significant difference in the severity of –0.65 to –0.12; Figure 4). This difference was also clinically depressive symptoms between groups was detected, favoring important as the overall effect was outside the MCID boundaries exergames over no intervention. Tollár et al [50] compared the (–0.195 to 0.195) and its CI did not cross the “no effect” line effect of exergames (Reflex Ridge, Space Pop, Just Dance) with (zero effect) and both MCID boundaries. The statistical that of no intervention on the severity of depressive symptoms heterogeneity of the evidence was substantial (P=.003; I =68%). (measured using the BDI) among patients with Parkinson The quality of the evidence was very low, as it was downgraded disease. The study showed a statistically significant difference by 6 levels due to a high risk of bias, heterogeneity, and (P<.001) in the severity of depressive symptoms between the imprecision (Multimedia Appendix 5). 2 groups, favoring exergames over no intervention. Jahouh et https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Figure 4. Forest plot of 5 studies (8 comparisons) comparing the effect of exergames with that of no intervention on the severity of depressive symptoms. depressive symptoms (measured using the Major Depression Exergames Versus Other Active Interventions Inventory) among secondary students was compared with In 3 studies, the effect of exergames was compared with that of placebo, an interactive online program (LIFESTYLE) that active interventions on the severity of depressive symptoms, provides information about several topics unrelated to mental and no statistically significant difference was found between health. The study found a statistically significant difference in the groups [56-58]. To be more precise, the first study examined the severity of depressive symptoms (as measured the effects of an exergame (Just Dance 2015) and physical postintervention, P<.001, and at a 6-month follow-up, P=0.01) education on the severity of depressive symptoms (measured between the groups, favoring SPARX-R over LIFESTYLE [62]. with the Brunel Mood Scale) among elementary students and In contrast, the third study found no statistically significant demonstrated no statistically significant difference (P=.13) in difference between the 2 groups in the severity of depressive the severity of depressive symptoms between the exergame symptoms as measured with the CDRS-R (P=.26) and RADS-2 group and physical education group [56]. The second study (P=.16) [60]. Similarly, the fourth study did not show any compared the effect of exergames (RehabMaster) with that of statistically significant difference (P=.96) in the severity of occupational therapy on the severity of depressive symptoms depressive symptoms between the SPARX group and the control (measured using the Hamilton Depression Rating Scale) among group [64]. Another study examined the effects of a patients with stroke. The study found no statistically significant computerized CBT game (Pesky Gnats: The Feel Good Island) difference (P=.56) in the severity of depressive symptoms and no intervention on the severity of depressive symptoms between the exergame group and occupational therapy group (measured using the Glasgow Depression Scale for people with [57]. The third study compared the effect of exergames with a learning disability) among patients with anxiety, depression, that of robot-assisted training on the severity of depressive or intellectual disability [63]. No statistically significant symptoms (measured using the HADS) among patients with difference (P=.25) in the severity of depressive symptoms was stroke and did not find any statistically significant difference detected between the groups [63]. Välimäki et al [65] compared between the groups [58]. the effect of a computerized CBT game (CogniFit) with that of no intervention on the severity of depressive symptoms Computerized CBT Games (measured using the Patient Health Questionnaire-9 [PHQ-9]) Computerized CBT games were the intervention in 8 studies among patients with traumatic brain injury and found no [59-66]. Computerized CBT games were compared with no statistically significant difference (P=.76) between the groups. intervention, video games, and conventional CBT. The results In the last study in this comparison, the effects of a computerized of these comparisons are summarized in the following sections. CBT game (ZeroPhobia) and no intervention on the severity of depressive symptoms (measured using the PHQ-9) among Computerized CBT Games Versus No Intervention patients with acrophobia were investigated [61]. No statistically In 7 studies, the effect of computerized CBT games was significant difference (P=.12) in the severity of depressive compared with that of no intervention on the severity of symptoms was found between the 2 groups [61]. depressive symptoms [59-65], and 4 of these studies assessed the effect of a computerized CBT game (SPARX) on the severity Results of these 7 studies were meta-analyzed, as shown in of depressive symptoms among patients with depression Figure 5. Because 2 of these studies assessed the severity of [59,60,64]. The first study found a statistically significant effect depressive symptoms using 2 different measures (CDRS-R and of the computerized CBT game over no intervention on the RADS-2), we included the results of both measures of each severity of depressive symptoms as measured using the study in the meta-analysis. The overall effect was statistically Children’s Depression Rating Scale-Revised (CDRS-R; P=.001) significant (P=.003) indicating that computerized CBT games but not the Reynolds Adolescent Depression Scale (RADS-2; are more effective than no intervention in alleviating depressive P=.08) [59]. In the second study [62], the effect of a symptoms: (SMD –0.20, 95% CI –0.34 to –0.07). This computerized CBT game (SPARX-R) on the severity of difference was also clinically important as the overall effect https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al was outside the MCID boundaries (–0.10 to 0.10) and its CI did evidence was not a concern (P=.26; I = 20%). The quality of not cross the “no effect” line (zero effect) and both MCID the evidence was very low, as it was downgraded by 3 levels boundaries. For this outcome, MCID boundaries were calculated due to the high risk of bias and impression (Multimedia as ±0.5 times the SMD value (–.20). The heterogeneity of the Appendix 5). Figure 5. Forest plot of 7 studies (9 comparisons) comparing the effect of CBT games with that of no intervention on depression. severity of depressive symptoms between the groups, favoring Computerized CBT Games Versus Active Interventions REBT- and REBE-based games over conventional REBE Välimäki et al [65] compared the effect of a computerized CBT (P=.03) and no intervention (P<.001). game (CogniFit) with that of entertainment video games on the severity of depressive symptoms (measured using the PHQ-9) Discussion among patients with traumatic brain injury and found no statistically significant difference (P=.36) between the groups. Principal Findings Another study compared the effect of a computerized CBT game This review assessed the effectiveness of serious games on the (MindLight) with that of an entertainment video game (Triple severity of depressive symptoms as reported by RCTs. Although Town) on the severity of depressive symptoms (Child 27 RCTs were included in the current review, 16 studies were Depression Inventory 2) among patients with autism spectrum included in the meta-analysis. Very low-quality evidence from disorder and anxiety [66]. No statistically significant difference 7 RCTs showed no statistically significant effect of exergames (P>.05) in the severity of depressive symptoms was detected on the severity of depressive symptoms as compared with between the groups [66]. A study carried out by Poppelaars et conventional exercises. Furthermore, 3 studies that compared al [64] assessed the effects of a computerized CBT game the effect of exergames with that of other active interventions (SPARX) and a conventional CBT program on the severity of (eg, occupational therapy and robot-assisted training) on the depressive symptoms (measured using the RADS-2) among severity of depressive symptoms and were not included in the patients with depression. The study did not detect a statistically meta-analyses found no statistically significant difference significant difference (P=.58) in the severity of depressive between the groups. These findings indicate that exergames are symptoms between the groups. as effective as active interventions, which are usually delivered and supervised by health care providers (eg, physiotherapists, Other Types of Serious Games occupational therapists, and psychologists). One study compared the effect of an exposure therapy game (Spider App) with that of an entertainment video game (Bubble Very low-quality evidence from 5 RCTs showed a statistically Shooter) on the severity of depressive symptoms (measured and clinically significant effect of exergames on the severity of using the BDI-II) among patients with arachnophobia [67]. No depressive symptoms when compared with no intervention. statistically significant difference (P=.95) in the severity of Findings in this review are comparable to other reviews. depressive symptoms was detected between the groups [67]. Specifically, a recently published meta-analysis of 5 RCTs Butler et al [68] examined the effects of brain training games conducted by Yen and Chiu [37] showed an overall statistically and psychotherapy on the severity of depressive symptoms significant effect (P<.001) of exergames on depression. (measured using the BDI) among patients with posttraumatic Additionally, another recent meta-analysis of 8 RCTs conducted stress disorder. No statistically significant difference (P=.95) by Li et al [19] showed a significant effect of exergames on in the severity of depressive symptoms between the 2 groups depression. However, both reviews [19,37] compared the effect was detected [68]. In another study, the effect of REBT- and of exergames with the effects of different active and inactive REBE-based games on the severity of depressive symptoms interventions through one meta-analysis, while our review (measured using the Early Adolescent Temperament conducted 2 separate meta-analyses to compare exergames with Questionnaire-Revised) among patients with stroke was conventional exercises and no intervention respecting the compared with conventional REBE and no intervention [69]. uniqueness of these 2 interventions. Further, in contrast to our The study found a statistically significant difference in the https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al review, 5 of the 8 studies included in the review by Li et al were validity than any other study design [70] and owing to practical not RCTs (quasi-experimental or pre-post one-group trials) [19]. constraints, it was not feasible to translate all non-English studies. Very low-quality evidence from 6 RCTs showed a statistically and clinically significant effect of computerized CBT games Most included studies recruited patients without depression; on the severity of depressive symptoms when compared with thereby, the effect of serious games on the severity of depression no intervention. In contrast, 3 studies that compared the effect symptoms was not significant. Further, the overall risk of bias of computerized CBT games with those of active interventions was high in most included studies, and the quality of evidence (eg, video games and conventional CBT) on depressive for the meta-analyses was very low. Accordingly, findings in symptoms and were not included in the meta-analyses found this review must be interpreted with caution. no statistically significant difference between the groups. This Research and Practical Implications insignificant effect can be attributed to the fact that conventional CBT is comparable to the active interventions, thereby Research Implications comparing the effect of 2 comparable interventions usually Although the severity of depression was one of the measured produces no significant difference, which indicates that outcomes in all included studies, only 5 studies recruited patients computerized CBT games are at least as effective as these active with depression. This might lead to underestimating the effect interventions. None of the previous reviews [18,19,35-37] of serious games. Therefore, future studies need to recruit assessed the effect of computerized CBT games on depression. participants with depression to assess the effectiveness of serious games on depression. Strengths and Limitations The therapeutic modalities provided by serious games in most Strengths included studies were either exercises or CBT. Further, serious This review bridged the gaps of previous reviews by focusing games were not designed specifically to alleviate depression in on all types of serious games, including only RCTs, targeting about half of the studies. Thus, there is a pressing need to assess all age groups, searching technical databases, assessing the the effectiveness of serious games that are designed specifically quality of evidence, and synthesizing the data statistically. to alleviate depression and deliver other therapeutic modalities Therefore, it is more comprehensive than previous reviews such as art therapy, psychotherapy, relaxation-based exercises, [18,19,35-37]. As we followed highly recommended guidelines psychoeducation, rational emotive behavioral therapy, and (ie, PRISMA) to conduct this review, it can be considered a exposure therapy, and the list goes on. robust and high-quality review. Most included studies were carried out in high-income countries; The risk of publication bias in this review is minimal, as we thereby, our findings may not be generalizable to low-income searched the most popular databases in information technology countries. Researchers should conduct more studies to assess and health fields; conducted backward and forward reference the effectiveness of serious games in low-income countries. We list checking; used a comprehensive search query; searched excluded many studies that assessed the effectiveness of serious grey literature databases; and did not restrict our search to a games on other mental disorders such as anxiety and dementia. certain country, year, setting, population, and comparator. Further systematic reviews need to be carried out to investigate The risk of selection bias in this review is minimal because 2 the effectiveness of serious in alleviating other mental disorders. reviewers independently performed the study selection, data The overall risk of bias was high in most included studies mainly extraction, risk of bias assessment, and quality of evidence due to issues in the randomization process, deviations from the evaluation with a very good interrater agreement for all intended outcomes, and selection of the reported result. Further, processes. The quality of the evidence was appraised to enable several studies were not included in the meta-analysis due to the reader to draw more accurate conclusions. When possible, missing outcome data. For this reason, we encourage researchers we synthesized data statistically, and this improved the power to follow recommended guidelines or tools (eg, RoB 2 [40]) of studies and increased the estimates of the likely size of the when conducting and reporting RCTs to avoid such biases. effect of serious games on depression. This review hopefully augurs the possible potential of serious Limitations games in mental health disorders, but it also underlines that this The intervention of interest in this review was restricted to field, albeit full of potential, is still in its infancy. More studies serious games delivered on any digital platform and used as a are needed to prove the significant role of serious games in therapeutic intervention. Thus, this review cannot comment on alleviating depression. the effectiveness of nondigital serious games and those used Practical Implications for other purposes such as monitoring, screening, or diagnosis. The outcome of interest in this review was depression; therefore, Overall, this study showed that serious games can be effective we cannot comment on the effectiveness of serious games on in alleviating depression in comparison with no intervention, other mental health outcomes. and they can be comparable to other traditional therapeutic interventions for alleviating depressive symptoms. However, The review was restricted to RCTs written in the English findings in this review must be interpreted with caution because language; therefore, many studies were excluded because they the overall risk of bias was high in most included studies, the were quasi-experiments or written in other languages. This quality of evidence in the meta-analyses was very low, few restriction was necessary because RCTs have higher internal https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al studies recruited patients with depression, and serious games should be exploited to alleviate depression in low-income in half of the studies were purpose-shifted. Therefore, we can countries. only recommend health care providers consider offering serious Gaming and mental health have traditionally been two distinctly games as an adjunct to existing interventions until further, more separate fields and come with their own unique pedagogy and robust evidence is available. praxis. The potential of utilizing the advantages inherent to As mentioned before, serious games in more than half of the gaming, as described earlier, from its reach to its transformative studies were not designed to specifically alleviate depression potential in mental health holds a lot of promise in theory. and did not deliver other therapeutic modalities such as art However, to achieve this potential, experts from the two therapy, REBT, and psychoeducation. This may be attributed disciplines need to work together in order to understand the to the lack of such serious games in real life. Accordingly, there unique strengths and limitations of each field when designing is a need to develop more serious games that are designed to serious games. specifically alleviate depression and deliver other therapeutic Conclusion modalities. Overall, serious games can be better than no intervention in The most common platforms used for playing the games were alleviating depression and as effective in alleviating depression computers and video game consoles and their accessories, which as other active interventions (eg, conventional CBT, exposure are relatively more expensive and less accessible than therapy, conventional exercise). However, definitive conclusions smartphones that were the platform for serious games in only regarding the effectiveness of serious games could not be drawn 1 study. The number of smartphone users in the world exceeded in this review because the overall risk of bias was high in most 6.4 billion in 2021 [71], which forms about 82% of the global included studies, the quality of the meta-analyzed evidence was population (7.8 billion) [72]. We encourage developers to very low, and few studies recruited patients with depression. develop serious games that can be played through smartphones. Therefore, we can only recommend health care providers consider offering serious games as an adjunct to existing Most studies were carried out in high-income countries, and interventions until further, more robust evidence is available. this may indicate the lack of serious games in low-income To have sufficient evidence, future studies should assess the countries. People in low-income countries may be more in need effectiveness of serious games that are designed specifically to of serious games than those in high-income countries because alleviate depression and deliver other therapeutic modalities, low-income countries have a greater shortage of mental health recruit participants with depression, and avoid biases by professionals than high-income countries (0.1 per 1,000,000 following recommended guidelines for conducting and reporting people vs 90 per 1,000,000 people) [73,74]. Serious games RCTs (eg, RoB 2). Conflicts of Interest None declared. Multimedia Appendix 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. [DOCX File , 33 KB-Multimedia Appendix 1] Multimedia Appendix 2 Search strategy. [DOCX File , 31 KB-Multimedia Appendix 2] Multimedia Appendix 3 Data extraction form. [DOCX File , 26 KB-Multimedia Appendix 3] Multimedia Appendix 4 Reviewers’ judgements about each “risk of bias” domain for each included study. [DOCX File , 45 KB-Multimedia Appendix 4] Multimedia Appendix 5 Grading of Recommendations Assessment, Development and Evaluation (GRADE) Profile for comparison of serious games to control or conventional exercises for depression. [DOCX File , 19 KB-Multimedia Appendix 5] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al References 1. Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, et al. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol 2014 Apr;43(2):476-493 [FREE Full text] [doi: 10.1093/ije/dyu038] [Medline: 24648481] 2. Depression. World Health Organization. URL: https://www.who.int/news-room/fact-sheets/detail/depression [accessed 2022-01-09] 3. Rehm J, Shield KD. Global burden of disease and the impact of mental and addictive disorders. Curr Psychiatry Rep 2019 Feb 07;21(2):10. [doi: 10.1007/s11920-019-0997-0] [Medline: 30729322] 4. Roland J, Lawrance E, Insel T, Christensen H. The digital mental health revolution: Transforming care through innovation and scale-up. World Innovation Summit for Health. 2020. URL: https://www.wish.org.qa/reports/ the-digital-mental-health-revolution-transforming-care-through-innovation-and-scale-up/ [accessed 2021-01-09] 5. Hall-Flavin DK. What does the term "clinical depression" mean? Mayo Clinic. 2017 May 13. URL: https://www. mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770 [accessed 2022-01-09] 6. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Publishing; 7. Haller H, Anheyer D, Cramer H, Dobos G. Complementary therapies for clinical depression: an overview of systematic reviews. BMJ Open 2019 Aug 05;9(8):e028527 [FREE Full text] [doi: 10.1136/bmjopen-2018-028527] [Medline: 31383703] 8. Riccelli R, Passamonti L, Cerasa A, Nigro S, Cavalli SM, Chiriaco C, et al. Individual differences in depression are associated with abnormal function of the limbic system in multiple sclerosis patients. Mult Scler 2016 Jul;22(8):1094-1105. [doi: 10.1177/1352458515606987] [Medline: 26453680] 9. Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med 2017 Dec;195:42-49 [FREE Full text] [doi: 10.1016/j.socscimed.2017.11.008] [Medline: 29132081] 10. Park S, Oh HS, Oh D, Jung SA, Na K, Lee H, et al. Evidence-based, non-pharmacological treatment guideline for depression in Korea. J Korean Med Sci 2014 Jan;29(1):12-22 [FREE Full text] [doi: 10.3346/jkms.2014.29.1.12] [Medline: 24431900] 11. Dias L, Barbosa J, Vianna H. Gamification and serious games in depression care: A systematic mapping study. Telematics and Informatics 2018 Apr;35(1):213-224 [FREE Full text] [doi: 10.1016/j.tele.2017.11.002] 12. Chatham RE. Games for training. Commun. ACM 2007 Jul;50(7):36-43. [doi: 10.1145/1272516.1272537] 13. Hwang H, Bae S, Hong JS, Han DH. Comparing effectiveness between a mobile app program and traditional cognitive behavior therapy in obsessive-compulsive disorder: evaluation study. JMIR Ment Health 2021 Jan 19;8(1):e23778 [FREE Full text] [doi: 10.2196/23778] [Medline: 33464208] 14. Charlier N, Zupancic N, Fieuws S, Denhaerynck K, Zaman B, Moons P. Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis. J Am Med Inform Assoc 2016 Jan;23(1):230-239 [FREE Full text] [doi: 10.1093/jamia/ocv100] [Medline: 26186934] 15. Wiemeyer J, Kliem A. Serious games in prevention and rehabilitation—a new panacea for elderly people? Eur Rev Aging Phys Act 2011 Dec 08;9(1):41-50. [doi: 10.1007/s11556-011-0093-x] 16. Wang R, DeMaria S, Goldberg A, Katz D. A systematic review of serious games in training health care professionals. Simul Healthc 2016 Feb;11(1):41-51. [doi: 10.1097/SIH.0000000000000118] [Medline: 26536340] 17. Zayeni D, Raynaud J, Revet A. Therapeutic and preventive use of video games in child and adolescent psychiatry: a systematic review. Front Psychiatry 2020;11:36 [FREE Full text] [doi: 10.3389/fpsyt.2020.00036] [Medline: 32116851] 18. Li J, Theng Y, Foo S. Game-based digital interventions for depression therapy: a systematic review and meta-analysis. Cyberpsychol Behav Soc Netw 2014 Aug;17(8):519-527 [FREE Full text] [doi: 10.1089/cyber.2013.0481] [Medline: 24810933] 19. Li J, Theng Y, Foo S. Effect of exergames on depression: a systematic review and meta-analysis. Cyberpsychol Behav Soc Netw 2016 Jan;19(1):34-42. [doi: 10.1089/cyber.2015.0366] [Medline: 26716638] 20. Matthyssens L, Vanhulle A, Seldenslach L, Vander Stichele G, Coppens M, Van Hoecke E. A pilot study of the effectiveness of a serious game CliniPup® on perioperative anxiety and pain in children. J Pediatr Surg 2020 Feb;55(2):304-311 [FREE Full text] [doi: 10.1016/j.jpedsurg.2019.10.031] [Medline: 31761458] 21. Radkowski R, Huck W, Domik G, Holtmann M. Serious Games for the Therapy of the Posttraumatic Stress Disorder of Children and Adolescents. In: Shumaker R, editor. Virtual and Mixed Reality - Systems and Applications. VMR 2011. Lecture Notes in Computer Science, vol 6774. Berlin, Germany: Springer; 2011:44-53. 22. Jones M, Denisova A, Mitchell S, Owen T. Acceptability of a plasticity-focused serious game intervention for posttraumatic stress disorder: user requirements analysis. JMIR Serious Games 2019 Apr 16;7(2):e11909 [FREE Full text] [doi: 10.2196/11909] [Medline: 30990461] 23. Barajas AO, Osman HA, Shirmohammadi S. A Serious Game for children with Autism Spectrum Disorder as a tool for play therapy. 2017 Presented at: IEEE 5th International Conference on Serious Games and Applications for Health (SeGAH); April 2-4, 2017; Perth, Western Australia URL: https://ieeexplore.ieee.org/document/7939266 [doi: 10.1109/segah.2017.7939266] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 18 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 24. Tang JSY, Falkmer M, Chen NTM, B lte S, Girdler S. Designing a serious game for youth with ASD: perspectives from end-users and professionals. J Autism Dev Disord 2019 Mar;49(3):978-995. [doi: 10.1007/s10803-018-3801-9] [Medline: 30377883] 25. McCallum S, Boletsis C. Dementia Games: A Literature Review of Dementia-Related Serious Games. In: Ma M, Oliveira MF, Petersen S, Hauge JB, editors. Serious Games Development and Applications. SGDA 2013. Lecture Notes in Computer Science, vol 8101. Berlin, Germany: Springer; 2013:15-27. 26. Zhao Y, Feng H, Wu X, Du Y, Yang X, Hu M, et al. Effectiveness of exergaming in improving cognitive and physical function in people with mild cognitive impairment or dementia: systematic review. JMIR Serious Games 2020 Jun 30;8(2):e16841 [FREE Full text] [doi: 10.2196/16841] [Medline: 32602841] 27. Verduin ML, LaRowe SD, Myrick H, Cannon-Bowers J, Bowers C. Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder. J Subst Abuse Treat 2013 Mar;44(3):316-322. [doi: 10.1016/j.jsat.2012.08.006] [Medline: 23009800] 28. Dovis S, Van der Oord S, Wiers RW, Prins PJM. Improving executive functioning in children with ADHD: training multiple executive functions within the context of a computer game. a randomized double-blind placebo controlled trial. PLoS One 2015;10(4):e0121651 [FREE Full text] [doi: 10.1371/journal.pone.0121651] [Medline: 25844638] 29. Hong JS, Kim SM, Aboujaoude E, Han DH. Investigation of a mobile "serious game" in the treatment of obsessive-compulsive disorder: a pilot study. Games Health J 2018 Oct;7(5):317-326. [doi: 10.1089/g4h.2017.0158] [Medline: 30129775] 30. Cruz R. The Modern Economics of the Video Games Industry. University of Miami. URL: https://com.miami.edu/wp-content/ uploads/2021/06/mma_2021_firstplace.pdf [accessed 2022-01-09] 31. Mental health. World Health Organization. URL: https://www.who.int/health-topics/mental-health#tab=tab_1 [accessed 2022-01-09] 32. Eyal N. Hooked: How to build habit-forming products. Brentford, Middlesex, United Kingdom: Portfolio; 2014. 33. Fleming TM, Bavin L, Stasiak K, Hermansson-Webb E, Merry SN, Cheek C, et al. Serious games and gamification for mental health: current status and promising directions. Front Psychiatry 2016;7:215 [FREE Full text] [doi: 10.3389/fpsyt.2016.00215] [Medline: 28119636] 34. Cheek C, Fleming T, Lucassen MF, Bridgman H, Stasiak K, Shepherd M, et al. Integrating health behavior theory and design elements in serious games. JMIR Ment Health 2015;2(2):e11 [FREE Full text] [doi: 10.2196/mental.4133] [Medline: 26543916] 35. Fleming TM, Cheek C, Merry SN, Thabrew H, Bridgman H, Stasiak K, et al. Juegos serios para el tratamiento o la prevención de la depresión: una revisión sistemática. RPPC 2015 Jan 15;19(3):227. [doi: 10.5944/rppc.vol.19.num.3.2014.13904] 36. Lau HM, Smit JH, Fleming TM, Riper H. Serious games for mental health: are they accessible, feasible, and effective? A systematic review and meta-analysis. Front Psychiatry 2016;7:209 [FREE Full text] [doi: 10.3389/fpsyt.2016.00209] [Medline: 28149281] 37. Yen H, Chiu H. Virtual reality exergames for improving older adults' cognition and depression: a systematic review and meta-analysis of randomized control trials. J Am Med Dir Assoc 2021 May;22(5):995-1002. [doi: 10.1016/j.jamda.2021.03.009] [Medline: 33812843] 38. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009 Jul 21;339(jul21 1):b2700-b2700 [FREE Full text] [doi: 10.1136/bmj.b2700] [Medline: 19622552] 39. Altman DG. Practical statistics for medical research. Boca Raton, FL: CRC press; 1990. 40. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019 Aug 28;366:l4898. [doi: 10.1136/bmj.l4898] [Medline: 31462531] 41. Deeks JJ, Higgins JPT, Altman DG, Cochrane Statistical Methods Group. Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Sussex, UK: John Wiley & Sons; 2008:243-296. 42. Schunemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziou P, Cochrane Applicability and Recommendations Methods Group. Interpreting results and drawing conclusions. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Sussex, UK: John Wiley & Sons; 2008:359-387. 43. Ruivo JMADS, Karim K, O Shea R, Oliveira RCS, Keary L, O Brien C, et al. In-class active video game supplementation and adherence to cardiac rehabilitation. J Cardiopulm Rehabil Prev 2017 Jul;37(4):274-278. [doi: 10.1097/HCR.0000000000000224] [Medline: 28350640] 44. Ferraz DD, Trippo KV, Duarte GP, Neto MG, Bernardes Santos KO, Filho JO. The effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly patients with Parkinson cisease: A pilot randomized controlled single-blinded trial. Arch Phys Med Rehabil 2018 May;99(5):826-833. [doi: 10.1016/j.apmr.2017.12.014] [Medline: 29337023] 45. Song GB, Park EC. Effect of virtual reality games on stroke patients' balance, gait, depression, and interpersonal relationships. J Phys Ther Sci 2015 Jul;27(7):2057-2060 [FREE Full text] [doi: 10.1589/jpts.27.2057] [Medline: 26311925] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 19 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 46. Schumacher H, Stüwe S, Kropp P, Diedrich D, Freitag S, Greger N, et al. A prospective, randomized evaluation of the feasibility of exergaming on patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2018 May;53(5):584-590. [doi: 10.1038/s41409-017-0070-8] [Medline: 29335629] 47. Meldrum D, Herdman S, Vance R, Murray D, Malone K, Duffy D, et al. Effectiveness of conventional versus virtual reality-based balance exercises in vestibular rehabilitation for unilateral peripheral vestibular loss: results of a randomized controlled trial. Arch Phys Med Rehabil 2015 Jul;96(7):1319-1328.e1. [doi: 10.1016/j.apmr.2015.02.032] [Medline: 25842051] 48. Zhou H, Al-Ali F, Kang GE, Hamad AI, Ibrahim RA, Talal TK, et al. Application of wearables to facilitate virtually supervised intradialytic exercise for reducing depression symptoms. Sensors (Basel) 2020 Mar 12;20(6):1 [FREE Full text] [doi: 10.3390/s20061571] [Medline: 32178231] 49. Vieira A, Melo C, Machado J, Gabriel J. Virtual reality exercise on a home-based phase III cardiac rehabilitation program, effect on executive function, quality of life and depression, anxiety and stress: a randomized controlled trial. Disabil Rehabil Assist Technol 2018 Feb;13(2):112-123. [doi: 10.1080/17483107.2017.1297858] [Medline: 28285574] 50. Tollár J, Nagy F, Hortobágyi T. Vastly different exercise programs similarly improve Parkinsonian symptoms: a randomized clinical trial. Gerontology 2019;65(2):120-127. [doi: 10.1159/000493127] [Medline: 30368495] 51. Ozdogar AT, Ertekin O, Kahraman T, Yigit P, Ozakbas S. Effect of video-based exergaming on arm and cognitive function in persons with multiple sclerosis: A randomized controlled trial. Mult Scler Relat Disord 2020 May;40:101966. [doi: 10.1016/j.msard.2020.101966] [Medline: 32045868] 52. Kempf K, Martin S. Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial. BMC Endocr Disord 2013 Dec 10;13:57 [FREE Full text] [doi: 10.1186/1472-6823-13-57] [Medline: 24321337] 53. Rendon AA, Lohman EB, Thorpe D, Johnson EG, Medina E, Bradley B. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing 2012 Jul;41(4):549-552. [doi: 10.1093/ageing/afs053] [Medline: 22672915] 54. Jahouh M, González-Bernal JJ, González-Santos J, Fernández-Lázaro D, Soto-Cámara R, Mielgo-Ayuso J. Impact of an intervention with Wii video games on the autonomy of activities of daily living and psychological-cognitive components in the institutionalized elderly. Int J Environ Res Public Health 2021 Feb 07;18(4):1 [FREE Full text] [doi: 10.3390/ijerph18041570] [Medline: 33562249] 55. Rica RL, Shimojo GL, Gomes MC, Alonso AC, Pitta RM, Santa-Rosa FA, et al. Effects of a Kinect-based physical training program on body composition, functional fitness and depression in institutionalized older adults. Geriatr Gerontol Int 2020 Mar;20(3):195-200. [doi: 10.1111/ggi.13857] [Medline: 31923924] 56. Andrade A, Cruz WMD, Correia CK, Santos ALG, Bevilacqua GG. Effect of practice exergames on the mood states and self-esteem of elementary school boys and girls during physical education classes: A cluster-randomized controlled natural experiment. PLoS One 2020;15(6):e0232392 [FREE Full text] [doi: 10.1371/journal.pone.0232392] [Medline: 32502164] 57. Shin J, Bog Park S, Ho Jang S. Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: A randomized, controlled study. Comput Biol Med 2015 Aug;63:92-98. [doi: 10.1016/j.compbiomed.2015.03.011] [Medline: 26046499] 58. Adomavičienė A, Daunoravičienė K, Kubilius R, Varžaitytė L, Raistenskis J. Influence of new technologies on post-stroke rehabilitation: a comparison of Armeo Spring to the Kinect system. Medicina (Kaunas) 2019 Apr 09;55(4):98 [FREE Full text] [doi: 10.3390/medicina55040098] [Medline: 30970655] 59. Fleming T, Dixon R, Frampton C, Merry S. A pragmatic randomized controlled trial of computerized CBT (SPARX) for symptoms of depression among adolescents excluded from mainstream education. Behav Cogn Psychother 2012 Oct;40(5):529-541. [doi: 10.1017/S1352465811000695] [Medline: 22137185] 60. Merry SN, Stasiak K, Shepherd M, Frampton C, Fleming T, Lucassen MFG. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012 Apr 18;344(apr18 3):e2598-e2598 [FREE Full text] [doi: 10.1136/bmj.e2598] [Medline: 22517917] 61. Donker T, Cornelisz I, van Klaveren C, van Straten A, Carlbring P, Cuijpers P, et al. Effectiveness of self-guided app-based virtual reality cognitive behavior therapy for acrophobia: a randomized clinical trial. JAMA Psychiatry 2019 Jul 01;76(7):682-690 [FREE Full text] [doi: 10.1001/jamapsychiatry.2019.0219] [Medline: 30892564] 62. Perry Y, Werner-Seidler A, Calear A, Mackinnon A, King C, Scott J, et al. Preventing depression in final year secondary students: school-based randomized controlled trial. J Med Internet Res 2017 Nov 02;19(11):e369 [FREE Full text] [doi: 10.2196/jmir.8241] [Medline: 29097357] 63. Cooney P, Jackman C, Coyle D, O'Reilly G. Computerised cognitive-behavioural therapy for adults with intellectual disability: randomised controlled trial. Br J Psychiatry 2017 Aug;211(2):95-102. [doi: 10.1192/bjp.bp.117.198630] [Medline: 28596245] 64. Poppelaars M, Tak YR, Lichtwarck-Aschoff A, Engels RCME, Lobel A, Merry SN, et al. A randomized controlled trial comparing two cognitive-behavioral programs for adolescent girls with subclinical depression: A school-based program (Op Volle Kracht) and a computerized program (SPARX). Behav Res Ther 2016 May;80:33-42. [doi: 10.1016/j.brat.2016.03.005] [Medline: 27019280] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 20 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 65. Välimäki M, Mishina K, Kaakinen JK, Holm SK, Vahlo J, Kirjonen M, et al. Digital gaming for improving the functioning of people with traumatic brain injury: randomized clinical feasibility study. J Med Internet Res 2018 Mar 19;20(3):e77 [FREE Full text] [doi: 10.2196/jmir.7618] [Medline: 29555622] 66. Wijnhoven LA, Creemers DH, Vermulst AA, Lindauer RJ, Otten R, Engels RC, et al. Effects of the video game 'Mindlight' on anxiety of children with an autism spectrum disorder: A randomized controlled trial. J Behav Ther Exp Psychiatry 2020 Sep;68:101548. [doi: 10.1016/j.jbtep.2020.101548] [Medline: 32155470] 67. Haberkamp A, Walter H, Althaus P, Schmuck M, Rief W, Schmidt F. Testing a gamified Spider App to reduce spider fear and avoidance. J Anxiety Disord 2021 Jan;77:102331. [doi: 10.1016/j.janxdis.2020.102331] [Medline: 33166870] 68. Butler O, Herr K, Willmund G, Gallinat J, Kühn S, Zimmermann P. Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder. J Psychiatry Neurosci 2020 Jul 01;45(4):279-287 [FREE Full text] [doi: 10.1503/jpn.190027] [Medline: 32293830] 69. David OA, Cardo  RAI, Matu S. Is REThink therapeutic game effective in preventing emotional disorders in children and adolescents? Outcomes of a randomized clinical trial. Eur Child Adolesc Psychiatry 2019 Jan 10;28(1):111-122. [doi: 10.1007/s00787-018-1192-2] [Medline: 29992353] 70. Bhattacherjee A. Social science research: Principles, methods, and practices. Scotts Valley, CA: CreateSpace Independent Publishing Platform; 2012. 71. Ericsson Mobility Report. Ericsson. 2021 Jun 23. URL: https://www.ericsson.com/en/mobility-report/ mobility-visualizer?f=1&ft=1&r=1&t=8&s=1&u=1&y=2016,2021&c=1 [accessed 2022-01-09] 72. Worldometer. Current World Population. 2021 July 23, 2021. Jul 23. URL: https://www.worldometers.info/world-population/ [accessed 2022-01-09] 73. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012 Dec 15;380(9859):2197-2223. [doi: 10.1016/S0140-6736(12)61689-4] [Medline: 23245608] 74. Oladeji BD, Gureje O. Brain drain: a challenge to global mental health. BJPsych Int 2016 Aug 02;13(3):61-63 [FREE Full text] [doi: 10.1192/s2056474000001240] [Medline: 29093905] Abbreviations ADS-L: Allgemeine Depressionsskala BDI: Beck Depression Inventory CBT: Cognitive behavioral therapy CDRS-R: Children’s Depression Rating Scale-Revised GADS: Goldberg Anxiety and Depression Scale GDS: Geriatric Depression Scale GRADE: Grading of Recommendations Assessment, Development and Evaluation HADS: Hospital Anxiety and Depression Scale MCID: minimal clinically important difference PAID: Problem Areas in Diabetes PHQ-9: Patient Health Questionnaire-9 PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses RADS-2: Reynolds Adolescent Depression Scale RCT: randomized controlled trial REBE: rational emotive behavioral education REBT: rational emotive behavioral therapy RoB 2: Risk-of-Bias 2 SMD: standardized mean difference WHO: World Health Organization WHO-5: WHO 5-item Well-Being Index Edited by N Zary; submitted 24.07.21; peer-reviewed by F Shuweihdi, S Bae; comments to author 10.09.21; revised version received 10.09.21; accepted 26.09.21; published 14.01.22 Please cite as: Abd-Alrazaq A, Al-Jafar E, Alajlani M, Toro C, Alhuwail D, Ahmed A, Reagu SM, Al-Shorbaji N, Househ M JMIR Serious Games 2022;10(1):e32331 URL: https://games.jmir.org/2022/1/e32331 doi: 10.2196/32331 PMID: https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 21 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al ©Alaa Abd-Alrazaq, Eiman Al-Jafar, Mohannad Alajlani, Carla Toro, Dari Alhuwail, Arfan Ahmed, Shuja Mohd Reagu, Najeeb Al-Shorbaji, Mowafa Househ. Originally published in JMIR Serious Games (https://games.jmir.org), 14.01.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 22 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

Loading next page...
 
/lp/jmir-publications/the-effectiveness-of-serious-games-for-alleviating-depression-aS0ejgP01n

References

References for this paper are not available at this time. We will be adding them shortly, thank you for your patience.

Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/32331
Publisher site
See Article on Publisher Site

Abstract

Background: 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. Objective: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. Methods: 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). Results: 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 (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). Conclusions: 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 https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 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. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969 (JMIR Serious Games 2022;10(1):e32331) doi: 10.2196/32331 KEYWORDS serious games; exergames; depression; cognitive behavioral therapy; systematic reviews; meta-analysis educational resources for health care professionals [16]. Introduction Moreover, serious games have been used as a nonpharmacological therapeutic intervention for mental Background disorders [17]. Serious games have been utilized as a treatment An individual's mental health is fundamental to living a healthy for various mental disorders, including depression [18,19], and enjoyable lifestyle. Studies estimate that 1 in 3 people may anxiety [20], posttraumatic stress disorder [21,22], autism suffer from a mental illness during their lifetime [1]. The World spectrum disorder [23,24], dementia [25,26], alcohol use Health Organization (WHO) reports that depression is a “leading disorder [27], attention deficit hyperactivity disorder [28], and cause of disability worldwide and is a major contributor to the obsessive-compulsive disorder [13,29]. overall global burden of disease” affecting more than 264 Gaming as a therapeutic tool in mental health can potentially million people of all ages globally [2]. Depression is a mental offer several specific advantages that may be missing from health disorder that the Sustainable Development Goals of the traditional forms of delivery. The gaming industry is, as ever, United Nations (2015) has listed among its 270 targets and 230 popular globally [30] and arguably easier to access than even indicators. Depressive disorders account for most of the total basic mental health services [31]. Games by their very nature disability-adjusted life years globally. Although depressive have the potential to engage the user in game play that can be disorders are global, they particularly affect those living in high rewarding through scoring points or following story arcs that and upper-middle-income nations [3]. This heavy toll is can help improve user involvement and lower attrition rates exacerbated by the fact that up to one-half (50%) of the people [32,33]. Additionally, as the technology improves, gaming can living in high-income countries and 90% of those living in utilize accessories to provide richer sensory environments and low-resource settings receive no treatment for depressive immersive user experiences that allow users to simulate real-life disorders [4]. scenarios more safely and help in educating and achieving Depressive disorders are a family of mental disorders ranging cognitive and behavioral changes through overlearning and in severity from mild temporary episodes of sadness to more repetition [33,34]. severe and persistent depression [5]. Depressive disorders Research Gap and Aim include disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance- or medication-induced depressive Many studies have assessed the effectiveness of serious games disorder, and major depressive disorder [6]. Depressive disorders to alleviate depression. Aggregating the evidence from these are characterized by disturbances in mood, thoughts, or studies is very important to draw more definitive conclusions behaviors. Furthermore, depressive disorders do not affect the about the effectiveness of serious games as viable therapeutic mind alone but are reported to impact a person’s body [7,8]. interventions in depressive disorders. Several published reviews Depression is known to be caused by a number of factors that have summarized the evidence about the effectiveness of serious interact in complex mechanisms: social, genetic, pathological, games for depression [18,19,35-37]. However, these reviews and chemical [9]. Treatments for depressive disorders are are undermined by certain technical shortcomings that limit the generally classified into either pharmacological or psychosocial generalization of the findings. Specifically, these reviews (1) (ie, nonpharmacological) interventions. Pharmacological focused on a certain type of serious games (ie, exergames) treatments involve the use of drugs (eg, antidepressants) while [19,37]; (2) focused on a certain age group (older adults) [37]; examples of psychosocial treatments include cognitive (3) included non-randomized controlled trials (RCTs) [19,35]; behavioral therapy (CBT), exposure therapy, and exercise [10]. (4) did not search technical databases (such IEEE Xplore and the ACM Digital Library), thereby including only a few studies The use of serious games, defined as games that have a purpose [35-37]; (5) did not assess the quality of the evidence other than entertainment, has seen a rise in recent years [11]. [18,19,35-37]; and (6) were outdated publications [18,19,35]. Serious games use elements unique to gaming in order to Therefore, this study aimed to assess the effectiveness of serious educate or influence change in experience or behaviors [12]. games for alleviating depression by summarizing and pooling Several industries have adopted and continue to use serious the results of previous studies and providing an up-to-date games including health care, education, and airlines [13]. Among review. other things, serious games have been effectively utilized for education, prevention, and treatment of chronic conditions (eg, asthma and diabetes) [14], therapeutic rehabilitation [15], and https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Study Selection Methods We followed 3 steps to identify the relevant studies. In the first We conducted a systematic review in accordance with the step, we exported the retrieved studies to EndNote to identify PRISMA (Preferred Reporting Items for Systematic Reviews and remove duplicates. Then, 2 reviewers (EA and MA) and Meta-Analyses) statement (Multimedia Appendix 1) [38]. independently screened the titles and abstracts of all retrieved studies. In the last step, the 2 reviewers independently screened Search Strategy the full texts of studies included from the second step. A third reviewer (AA) resolved any disagreements between the 2 Search Sources reviewers in the second and third steps. Cohen κ in this review We utilized the following bibliographic databases to retrieve indicated a very good level of interrater agreement in the first relevant studies: MEDLINE (via Ovid), PsycInfo (via EBSCO), (0.85) and second (0.90) steps [39]. CINAHL (via EBSCO), IEEE Xplore, ACM Digital Library, and Scopus. These databases were searched on March 30, 2021 Data Extraction by the first author. When applicable, we set auto alerts to Two reviewers (EA and MA) independently extracted data from conduct an automatic search weekly for 12 weeks (ending on the included reviews using Microsoft Excel (Microsoft June 30, 2021). We also searched the search engine “Google Corporation, Redmond, WA). Multimedia Appendix 3 shows Scholar” to identify grey literature. We checked only the first the data extraction form that was used by the 2 reviewers to 10 pages (ie, 100 hits) because Google Scholar retrieved a vast extract the data precisely and systematically from the included number of studies and it ordered them based on their relevancy. studies. The form was pilot tested using 3 included studies. Any To identify further studies of relevance to the review, we disagreements between the reviewers were resolved by conducted backward reference list checking (ie, screening the consulting a third reviewer (AA). The interrater agreement reference lists of the included studies and relevant reviews) and between the reviewers was 0.87, indicating a very good level forward reference list checking (ie, screening the studies that of agreement [39]. Some outcome data (eg, mean, standard cited the included studies). deviation, sample size in each group) were missing in 10 studies. Therefore, we contacted their corresponding authors to get them, Search Terms and 5 corresponding authors did not reply to our emails even The search query in this review was developed by consulting after sending 2 reminders. 2 experts in digital mental health and by checking systematic reviews of relevance to the review. These terms were chosen Risk of Bias Assessment based on the target intervention (eg, serious games, exergames, Two reviewers (EA and MA) independently assessed the risk and gamification), target outcome (eg, depression and of bias in the included studies using the Risk-of-Bias 2 (RoB melancholy), and target study design (eg, RCT and clinical 2) tool, which is recommended by the Cochrane Collaboration trial). Multimedia Appendix 2 shows the detailed search query [40]. This tool appraises the risk of bias in 5 domains in RCTs: used to search each of the aforementioned databases. randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and Study Eligibility Criteria selection of the reported result [40]. The risk of bias judgments This review included only RCTs that assessed the effectiveness in these domains is used to determine the overall risk of bias of serious games for alleviating the severity of depressive for each included study. A third reviewer (AA) resolved any symptoms. To be more precise, the intervention of interest in disagreements in judgments between the 2 reviewers. Interrater this review was serious games that were delivered on any digital agreement between the reviewers was very good (Cohen κ=0.93) platform such as computers, consoles (eg, Xbox, PlayStation), [39]. mobile phones, tablets, handheld devices, or any other computerized devices. The intervention had to utilize elements Data Synthesis of gaming as an integral and primary method for therapeutic or We utilized narrative and statistical approaches to synthesize prevention purposes. We did not consider nondigital games and the extracted data. Specifically, in narrative synthesis, texts and those used for other purposes such as monitoring, screening, tables were used to describe the characteristics of the included and diagnosis. We included RCTs whether they were parallel studies, population, intervention, comparator, and outcome RCTs, cluster RCTs, crossover RCTs, or factorial RCTs but we measures. Then, we grouped and summarized the findings of excluded quasi-experiments, observational studies, and reviews. the included studies according to the type of serious games (ie, We focused on studies in which one of the measured outcomes exergames or computerized CBT games). A meta-analysis was was depression or depressive symptoms regardless of the conducted when at least 2 studies of the same type of serious outcome measures. Only trials in the English language were game reported enough data for the analysis (ie, mean, standard eligible for inclusion in this review. RCTs published as journal deviation, number of participants in each intervention group). articles, conference proceedings, and dissertations were When this information was not reported in any included study, included, whereas we excluded conference abstracts and posters, we contacted the first and corresponding authors to get the commentaries, preprints, proposals, and editorials. We did not missing information. apply restrictions related to the population, year of publication, country of publication, comparator, and study settings. 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; https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Cohen d) because the outcome data (severity of depressive Assessment, Development, and Evaluation (GRADE) approach, symptoms) were continuous and tools used to measure the which assesses the quality of evidence based on 5 domains: risk outcome were different between the included studies. The of bias, inconsistency (ie, heterogeneity), indirectness, random effects model was used in the analysis given the clinical imprecision, and publication bias [42]. Two reviewers (CT and heterogeneity between the meta-analyzed studies in terms of AA) independently assessed the overall quality of meta-analyzed serious game characteristics (eg, types, duration, frequency, and evidence, and any disagreements were resolved through period), population characteristics (eg, sample size, mean age, discussion and consensus. Interrater agreement between the and health condition), and outcome measures (ie, tools and reviewers was very good (Cohen κ=0.88) [39]. follow-up period). Results When the meta-analysis showed a statistically significant difference between groups, we examined whether this difference Search Results was clinically important. A minimal clinically important As shown in Figure 1, we retrieved 966 citations from searching difference (MCID) is defined as the smallest change in a the 7 electronic databases. Using the software EndNote, we measured outcome that a patient would consider as worthy and identified and removed 225 duplicates of the retrieved citations. significant and which mandates a change in a patient’s treatment. Screening titles and abstracts of the remaining 741 citations led The MCID boundaries for an outcome were calculated as ±0.5 to excluding 592 citations because (1) they did not use serious times the SMD of the meta-analyzed studies. games (n=354); (2) the severity of depressive symptoms was We checked the characteristics of participants, interventions, not a measured outcome (n=69); (3) they were not RCTs comparator, and outcomes in studies included in the (n=119); (4) they were not peer-reviewed articles, theses, nor meta-analysis to assess their clinical heterogeneity. We also conference proceedings (n=39); and (5) they were published in examined the statistical heterogeneity of the meta-analyzed non-English languages (n=11). Reading the full text of the studies by calculating a Chi-square P value and I , which remaining 149 publications led to excluding 127 publications measures the statistical significance of heterogeneity and the because (1) they did not use serious games (n=39), (2) the degree of heterogeneity, respectively. A Chi-square P value severity of depressive symptoms was not a measured outcome ≤.05 indicates heterogeneous meta-analyzed studies [41]. The (n=32), (3) they were not RCTs (n=53), and (4) they were degree of heterogeneity was considered unimportant, moderate, published in non-English languages (n=3). We identified 5 additional RCTs through backward and forward reference list substantial, or considerable when I was 0%-40%, 30%-60%, checking. In total, 27 RCTs were included in the current review 50%-90%, or 75%-100%, respectively [41]. [43-69]. Of those, 16 RCTs were included in the meta-analyses We assessed the overall quality of evidence from the [45-52,54,59-65]. meta-analyses using the Grading of Recommendations https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Figure 1. Flow chart of the study selection process. studies were carried out in 15 different countries, as shown in Characteristics of Included Reviews Table 1. The country that published the largest number of the The included studies were published between 2012 and 2021 included studies was Germany (n=5). All included papers were (Table 1). The years that witnessed the largest number of papers published in peer-reviewed journals. The trial type used included studies were 2018 (n=5) and 2020 (n=5). The included in the most included studies was parallel RCTs (n=24). https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 1. Characteristics of studies and population. Author(s), year Country Publica- Sample Mean age Sex Health condition Setting RCT type tion type size, n (years) (male), % Ruivo et al [43], Ireland Journal Parallel 32 59.9 81.3 Cardiovascular diseases Clinical, com- 2017 article munity, educa- tional Ferraz et al [44], Brazil Journal Parallel 62 69 59.7 Parkinson disease Clinical 2018 article Song and Park [45], South Ko- Journal Parallel 40 50.1 55.0 Stroke Clinical 2015 rea article Schumacher et al Germany Journal Parallel 42 56.3 59.5 Hematopoietic stem cell transplan- Clinical [46], 2018 article tation recipients Meldrum et al [47], Ireland Journal Parallel 71 54.1 38.0 Unilateral peripheral vestibular Clinical 2015 article loss Zhou et al [48], Qatar Journal Parallel 73 64.6 45.2 Diabetes and end-stage renal dis- Clinical 2020 article ease Vieira et al [49], Portugal Journal Parallel 46 57.7 Coronary artery disease Clinical 2017 article Tollár et al [50], Hungary Journal Parallel 74 69.4 48.6 Parkinson disease Clinical 2018 article Ozdogar et al [51], Turkey Journal Parallel 60 40.1 27.1 Multiple sclerosis Clinical 2020 article Kempf and Martin Germany Journal Parallel 220 61.1 45.9 Type 2 diabetes Clinical, com- [52], 2013 article munity Rendon et al [53], United Journal Parallel 40 84.5 35.0 Older adults Clinical 2012 States article Jahouh et al [54], Spain Journal Parallel 80 84.2 44.0 Older adults Clinical 2021 article Rica et al [55], 2019 Brazil Journal Parallel 50 - 0.0 Older adults Clinical, com- article munity Andrade et al [56], Brazil Journal Cluster 140 9.41 42.1 Elementary students Educational 2020 article Shin et al [57], 2015 South Ko- Journal Parallel 35 54 75 Stroke Clinical rea article Adomavičienė et al Lithuania Journal Parallel 60 64.6 66.7 Stroke Clinical [58], 2019 article Fleming et al [59], New Journal Crossover 32 14.9 56 Depression Educational 2012 Zealand article Merry et al [60], New Journal Parallel 187 15.6 34.2 Depression Clinical, edu- 2012 Zealand article cational Donker et al [61], Nether- Journal Parallel 193 41.3 33.2 Acrophobia Community 2019 lands article Perry et al [62], Australia Journal Cluster 540 16.7 36.9 Secondary students Educational 2017 article Cooney et al [63], Ireland Journal Parallel 52 40.6 38.8 Anxiety, depression, and/or intel- Clinical 2017 article lectual disability Poppelaars et al Nether- Journal Parallel 208 13.4 0.0 Depression Educational [64], 2016 lands article Välimäki et al [65], Finland Journal Parallel 90 41 50.0 Traumatic brain injury Clinical 2018 article Wijnhoven et al Nether- Journal Parallel 109 11.1 77.1 Anxiety and autism spectrum dis- Clinical, edu- [66], 2020 lands article order cational Haberkamp et al Germany Journal Parallel 68 22.8 13.0 Arachnophobia Educational [67], 2021 article https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s), year Country Publica- Sample Mean age Sex Health condition Setting RCT type tion type size, n (years) (male), % Butler et al [68], Germany Journal Parallel 40 33.4 100 Posttraumatic stress disorder Clinical 2020 article David et al [69], Germany Journal Parallel 165 12.9 35.9 Stroke Educational 2018 article RCT: randomized controlled trial. Not reported. The sample size in the included studies varied from 32 to 540, therapy games (n=1), brain training games (n=1), rational with an average of 104. The mean age of participants in the emotive behavioral therapy (REBT) and rational emotive included studies ranged between 9.41 years and 84.5 years, with behavioral therapy education (REBE)–based game (n=1). an average of 43.9 years. The percentage of the sample who Although games were designed with a “serious” purpose from were men reported in 26 studies ranged from 0% to 100%, with the beginning (designed serious games) in 14 studies, they were an average of 46.1%. Participants’ health conditions were varied not designed as serious games but were being used for a serious between studies, and depression and stroke were the most purpose (purpose-shifted games) in the remaining 13 studies. common (n=4 each). Participants in most studies were recruited The most common platforms used for playing the games were from clinical settings (n=20). computers (n=12) and video game consoles and their accessories (eg, balance board; n=12). The duration of the games in the The intervention in the included studies was only serious games included studies ranged between 5 minutes and 85 minutes, but in 19 studies, serious games plus occupational therapy in 2 it ranged between 20 minutes and 45 minutes in most studies studies, and serious games plus psychotherapy in 1 study (Table (n=14). The frequency of playing the games varied between 2). The most common games used in the included studies were once a week and once a day, but it ranged between once a week SPARX (n=4) and Wii Fit (n=4). There were 5 types of serious and 3 times a week in 20 studies. The period of the intervention games based on the therapeutic modality that they deliver: varied between 1 week and 24 weeks, but it ranged from 4 to 8 exergames (n=16), computerized CBT games (n=8), exposure weeks in 19 studies. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 2. Characteristics of interventions. Author(s) Intervention Serious game Serious game Serious Platform Duration Frequency Period name type game (minutes) (times/week) (weeks) genre Ruivo et al [43] Serious game Wii-Sports Exergame Purpose- Wii console 60 2 6 shifted and Kinect Ferraz et al [44] Serious game Kinect Adven- Exergame Purpose- Xbox console 50 3 8 tures shifted and Kinect Song and Park [45] Serious game Kinect Sport, Exergame Purpose- Computer and 30 5 8 Kinect Sport shifted Xbox Kinect Season 2, Kinect Adven- ture, and Kinect Gunstringer Schumacher et al [46] Serious game Wii Fit and Exergame Purpose- Wii console 30 5 2 Wii-Sports shifted and balance board Meldrum et al [47] Serious game Wii Fit Plus Exergame Purpose- Wii console 15 5 6 shifted and balance board and Frii Board Zhou et al [48] Serious game Exergame Designed Computer and 30 3 4 N/R wearables (sensors) Vieira et al [49] Serious game Kinect-Rehab- Exergame Designed Computer and 70-85 3 24 Play Xbox Kinect Tollár et al [50] Serious game Reflex Ridge, Exergame Purpose- Xbox console 60 5 5 Space Pop, Just shifted and Kinect Dance Ozdogar et al [51] Serious game Kinect Sports Exergame Purpose- Xbox console 45 1 8 Rivals shifted and Kinect Kempf and Martin [52] Serious game Wii Fit Plus Exergame Purpose- Wii console ≥30 1 12 shifted and balance board Rendon et al [53] Serious game Wii Fit Exergame Purpose- Wii console 35-45 3 6 shifted and balance board Jahouh et al [54] Serious game Step, Nodding Exergame Purpose- Wii console 40-45 2-3 8 shifted Rica et al [55] Serious game Kinect Sports Exergame Purpose- Xbox console 60 3 12 Ultimate Collec- shifted and Kinect tion, Your Shape Fitness Evolved, Dance Central, and Kinect Training Andrade et al [56] Serious game Just Dance Exergame Purpose- Xbox console 40 2 1 2015 shifted and Kinect Shin et al [57] Serious game + RehabMaster Exergame Designed Computer, 60 5 4 occupational sensors, and therapy infrared projec- tor Adomavičienė et al [58] Serious game N/R Exergame Designed Computer and 45 Once a day 2 Kinect Fleming et al [59] Serious game SPARX Computerized Designed Computer 30 1-2 5 CBT game Merry et al [60] Serious game SPARX Computerized Designed Computer 20-40 1-2 4-7 CBT game https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s) Intervention Serious game Serious game Serious Platform Duration Frequency Period name type game (minutes) (times/week) (weeks) genre Donker et al [61] Serious game ZeroPhobia Computerized Designed Smartphone 5-40 2 3 CBT game and wearables (VR goggles) Perry et al [62] Serious game SPARX-R Computerized Designed Computer 20-30 1-2 5-7 CBT game Cooney et al [63] Serious game Pesky Gnats: Computerized Designed Computer 60 1 7 The Feel Good CBT game Island Poppelaars et al [64] Serious game SPARX Computerized Designed Computer 20-40 1 7 CBT game Välimäki et al [65] Serious game CogniFit Computerized Designed Computer ≥30 Once a day 8 CBT game Wijnhoven et al [66] Serious game MindLight Computerized Designed Computer and 60 1 6 CBT game wearable (headset) Haberkamp et al [67] Serious game Spider App Exposure thera- Designed Smartphone 12 2 1 py game Butler et al [68] Serious game + Tetris Brain-training Purpose- Nintendo DS 60 2 6 psychotherapy game shifted XL console David et al [69] Serious game REThink Designed Tablet 50 3 4 REBT - and REBE -based game N/R: not reported. CBT: cognitive behavioral theory. VR: virtual reality. REBT: rational emotive behavioral therapy. REBE: rational emotive behavioral education. As shown in Table 3, the comparison groups received inactive comparators varied between 1 week and 24 weeks. The outcome interventions in 15 studies, while they received active of interest (eg, severity of depressive symptoms) was measured interventions in 18 studies (eg, conventional exercises, CBT using 18 different tools, but the most common tool used by the programs, video games, and psychotherapy). Note that the included studies was the Beck Depression Inventory (BDI; n=6), numbers do not add up because 6 studies delivered both active followed by the Hospital Anxiety and Depression Scale (HADS; and inactive interventions as comparators. The duration of the n=4). The outcome of interest was measured immediately after active comparators ranged between 12 minutes and 100 minutes. the intervention in all included studies, and the most common The frequency of playing the active comparators varied between follow-up period was 3 months (n=6). Participant attrition was once a week and once a day. The period of the active reported in 24 studies and ranged from 0 to 134. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Table 3. Characteristics of comparators and outcomes. Author(s) Comparator Duration Frequency Period Outcome measures Follow up Attrition, n (minutes) (times/week) (weeks) Ruivo et al [43] Conventional exercises 50 3 8 Postintervention 10 GDS (functional training), conventional exercises (bicycle exercise) Ferraz et al [44] Robot-assisted trainings 45 Once a day 2 Postintervention 18 HADS c d Song and Park Conventional exercises 30 5 8 Postintervention BDI N/R [45] Schumacher et al Conventional exercises 30 5 2 Postintervention, 30- 11 HADS-D [46] day follow-up, 100-day follow-up Meldrum et al Conventional exercises 15 5 6 HADS-D Postintervention 9 [47] Zhou et al [48] Conventional exercises 30 3 4 Postintervention 0 CES-D Vieira et al [49] Conventional exercises, 70-85 3 24 Postintervention, mid- 13 DASS-21 control intervention (3 months) Tollár et al [50] Conventional exercises 60 2 6 HADS Postintervention, 2- 4 month follow-up Ozdogar et al Conventional exercises, 45 1 8 BDI Postintervention 3 [51] control h i j Kempf and Mar- Control N/A N/A Postintervention 44 N/A WHO-5 , PAID , tin [52] ADS-L Rendon et al [53] Control N/A N/A N/A GDS Postintervention 6 Jahouh et al [54] Control N/A N/A N/A Postintervention N/R GDS, GADS Rica et al [55] Conventional exercises, 60 5 5 BDI Postintervention 0 control Andrade et al Physical education 40 2 1 Postintervention 0 BMS [56] Shin et al [57] Occupational therapy 60 5 4 Postintervention 3 HAMD Adomavičienė et Conventional exercises, 60 5 5 BDI Postintervention 0 al [58] control o p Fleming et al [59] Control N/A N/A N/A Postintervention 5 CDRS-R , RADS-2 Merry et al [60] Control N/A N/A N/A CDRS-R, RADS-2 Postintervention, 3- 17 month follow-up Donker et al [61] Control N/A N/A N/A Postintervention, 3- 59 PHQ-9 month follow-up Perry et al [62] Interactive online pro- 20-30 1-2 5-7 Postintervention, 6- 134 MDI gram month follow-up, 18- month follow-up Cooney et al [63] Control N/A N/A N/A Postintervention, 3- 3 GAS-LD month follow-up Poppelaars et al CBT pro- 1 7 RADS-2 Postintervention, 3- 10 CBT program + serious [64] gram + seri- month follow-up, 6- game, CBT program, ous game month follow-up, 12- control (80-100), month follow-up CBT pro- gram (60) Välimäki et al Video game, control ≥30 Once a day 8 PHQ-9 Postintervention, 3- 20 [65] month follow-up Wijnhoven et al Video game 60 1 6 Postintervention, 3- 35 CDI-2 [66] month follow-up https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Author(s) Comparator Duration Frequency Period Outcome measures Follow up Attrition, n (minutes) (times/week) (weeks) Haberkamp et al Video game 12 2 1 BDI-II Postintervention, 2- 6 [67] week follow-up Butler et al [68] Psychotherapy 60 2 6 BDI-II Postintervention, 6- 0 month follow-up David et al [69] Rational emotive behav- 50 3 4 Postintervention 23 EATQ-R ioral therapy and educa- tion, control GDS: Geriatric Depression Scale. HADS: Hospital Anxiety and Depression Scale. BDI: Beck Depression Inventory. N/R: not reported. HADS-D: depression subscale of the HADS. CES-D: Center for Epidemiologic Studies Depression Scale. DASS-21: Depression, Anxiety and Stress Scale 21. N/A: not applicable. WHO-5: WHO 5-item Well-Being Index. PAID: Problem Areas in Diabetes. ADS-L: Allgemeine Depressionsskala. GADS: Goldberg Anxiety and Depression Scale. BMS: Brunel’s Mood Scale. HAMD: Hamilton Depression Rating Scale. CDRS-R: Children’s Depression Rating Scale-Revised. RADS-2: Reynolds Adolescent Depression Scale. PHQ-9: Patient Health Questionnaire-9. MDI: Major Depression Inventory. GAS-LD: Glasgow Depression Scale for people with a learning disability. CBT: cognitive behavioral therapy. CDI-2: Child Depression Inventory 2. EATQ-R: Early Adolescent Temperament Questionnaire-Revised. enrolled and assigned to interventions, and groups were not Results of Risk of Bias Appraisal comparable in 4 studies. Accordingly, the risk of bias due to The random allocation sequence for the randomization process the randomization process was rated as low for only 8 studies was appropriate in 23 included studies. However, only 10 studies (Figure 2). concealed the allocation sequence until participants were Figure 2. Review authors’ judgments about each “risk of bias” domain. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Participants and individuals delivering the interventions were studies were grouped into 3 categories based on the types of aware of assigned interventions during the experiment in 22 serious games. and 20 studies, respectively. Deviation from the intended Exergames intervention occurred in 2 studies due to the experimental Exergames were the intervention in 16 studies [43-58]. contexts. Only 14 studies used an appropriate analysis Exergames were compared with conventional exercises, no (intention-to-treat or modified intention-to-treat analyses) to intervention, physical education, and occupational therapy. The estimate the effect of assignment to intervention. Therefore, the results of these comparisons are summarized in the following risk of bias due to the deviations from the intended interventions sections. was judged as low in only 8 studies (Figure 2). Exergames Versus Conventional Exercises Outcome data were not available for all or nearly all participants in 21 studies, and there was evidence that the findings were not In 9 studies, the effect of exergames was compared with that of biased by missing outcome data in only 5 studies. The reasons conventional exercises on the severity of depressive symptoms for missing outcome data could not be related to the true value [43-51]. Although 1 study did find a statistically significant of the outcome in 18 studies. As a result, 17 studies were judged difference in the severity of depressive symptoms between the as having a low risk of bias in the “missing outcome data” groups [45], the remaining 8 studies did not [43,44,46-51]. domain. Specifically, Song and Park [45] compared the effect of exergames (Kinect Sport, Kinect Sport Season 2, Kinect All included studies assessed the outcome of interest (ie, Adventure, and Kinect Gunstringer) with that of conventional depression level) using appropriate measures and used exercises (ergometer bicycle training) on the severity of measurement methods comparable across intervention groups. depressive symptoms (measured using the BDI) among patients However, the assessor of the outcome was blinded in only 9 with stroke. The study found a statistically significant difference studies. For this reason, only these studies were rated as low (P<.05) in depressive symptoms between the groups, favoring risk of bias in the “measuring the outcome” domain (Figure 2). exergames over ergometer training. Another study assessed the In 17 studies, a prespecified analysis plan (ie, protocol) was not effect of exergames (Wii Fit Plus) on the severity of depressive published. Only 4 studies reported outcome measurements symptoms (measured using the HADS-D) among patients with different from those specified in the analysis plan. There is no unilateral peripheral vestibular loss [47]. The study did not find evidence that all included studies selected their results from any statistically significant difference (P=.49) in the severity many results produced from multiple eligible analyses of the of depressive symptoms between the exergame group and data. Accordingly, the risk of bias due to the selection of the conventional exercise group [47]. Schumacher et al [46] assessed reported results was considered low in 4 studies (Figure 2). the effects of exergames (Wii Fit and Wii-Sports) and conventional exercises on depression symptoms (measured In the last domain “overall bias,” the risk of bias was considered using the HADS-D) among hematopoietic stem cell high in 20 studies as they were judged as having a high risk of transplantation recipients and found no significant difference bias in at least one domain; 6 studies were judged to have some (P=.07) between both groups in the severity of depressive concerns in the domain of overall bias as they had some symptoms. A study by Ozdogar et al [51] examined the effects concerns in at least one of the domains and were not at high of exergames (Kinect Sports Rivals) and conventional exercises risk for any domain. The remaining study was judged to be at on the severity of depressive symptoms among patients with low risk of bias for the domain of overall bias given that it was multiple sclerosis, and there was no significant difference rated to be at low risk of bias for all domains. Reviewers’ (P>.05) in the severity of depressive symptoms between the 2 judgments about each “risk of bias” domain for each included groups. A study examining the effect of exergames study are presented in Multimedia Appendix 4. (Kinect-RehabPlay) on the severity of depressive symptoms Results of Studies (measured using the BDI) among patients with coronary artery disease in comparison with conventional exercises found no Types of Serious Games significant difference in the severity of depressive symptoms As mentioned earlier, we identified 5 types of serious games between the 2 groups [49]. In another study [48], no significant based on the therapeutic modality that they deliver in the difference in the severity of depressive symptoms (measured included studies. The first type is exergames, which refer to using the Center for Epidemiologic Studies Depression Scale video games that require physical exercises (eg, fitness and in patients with diabetes and end-stage renal disease) was balance exercises) in order to be played. The second type is detected between the exergame group and conventional exercise computerized CBT games, which are video games that provide group. Tollár et al [50] compared the effect of exergames CBT for the users. The third type is exposure therapy games, (Reflex Ridge, Space Pop, Just Dance) with that of conventional which are video games that apply exposure principles to reduce exercises (ergometer bicycle training) on the severity of anxiety in users with phobias. The fourth type is brain training depressive symptoms (measured using the BDI) among patients games, which are video games that are based on cognitive with Parkinson disease. The study showed no statistically interference tasks to reconsolidate traumatic memories. The last significant difference (P=.27) in the severity of depressive type is REBT- and REBE-based games, which are video games symptoms between the 2 groups. A study assessed the effects that enable users to replace irrational beliefs (eg, demandingness, of exergames (Wii-Sports) and conventional exercises on the intolerance, and frustration) with rational beliefs (eg, severity of depressive symptoms (measured by HADS) among unconditional acceptance and tolerance). Results of the included https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al patients with a high risk of cardiovascular diseases [43]. No Results of 7 studies were meta-analyzed as shown in Figure 3 statistically significant difference between the groups was [45-49,51]. No statistically significant difference (P=.12) in the reported in the study [43]. In the last study, no significant severity of depressive symptoms was found between the difference in the severity of depressive symptoms (measured exergame group and conventional exercise group (SMD –0.32, using the Geriatric Depression Scale [GDS] in patients with 95% CI –0.71 to 0.08). There was substantial heterogeneity in Parkinson disease) was detected between the exergame group the evidence (P=.005; I =67%). The quality of the evidence (Kinect Adventures) and 2 conventional exercise groups was very low, as it was downgraded by 5 levels due to a high (functional training and bicycle exercises) [44]. risk of bias, heterogeneity, and imprecision (Multimedia Appendix 5). Figure 3. Forest plot of 7 studies comparing the effect of exergames with that of conventional exercises on the severity of depressive symptoms. al [54] assessed the effect of exergames (Wii Fit game) on the Exergames Versus No Intervention severity of depressive symptoms (measured using the GDS and In 7 studies, the effect of exergames was compared with that of Goldberg Anxiety and Depression Scale [GADS]) among older no intervention on the severity of depressive symptoms [49-55]. adults. No significant difference in the severity of depressive Although 4 studies showed a statistically significant difference symptoms as measured using the GDS (P=.43) and GADS in the severity of depressive symptoms between the groups (P=.21) was detected between the exergame group and the [50-52,55], 3 studies did not [49,53,54]. Specifically, Kempf control group [54]. Another study examining the effect of and Martin [52] compared the effect of exergames (Wii Fit Plus) exergames (Kinect-RehabPlay) on the severity of depressive with that of no intervention on the severity of depressive symptoms (measured using the BDI) among patients with symptoms (measured using the WHO 5-item Well-Being Index coronary artery disease in comparison with no intervention [WHO-5], Problem Areas in Diabetes [PAID], and Allgemeine found no significant difference (P>.05) in the severity of Depressionsskala [ADS-L]) in patients with type 2 diabetes. depressive symptoms between the 2 groups [49]. The effects of The study found a statistically significant effect of exergames exergames and no intervention on the severity of depressive over no intervention on the severity of depressive symptoms as symptoms (measured by GDS) among older adults were measured using the WHO-5 (P<.001), PAID (P=.007), and compared in another study [53], and no significant difference ADS-L (P=.002) [52]. A study conducted by Ozdogar et al [51] (P=.09) was found in the severity of depressive symptoms examined the effects of exergames (Kinect Sports Rivals) and between the 2 groups [53]. no intervention on the severity of depressive symptoms We meta-analyzed results of 5 studies, as they reported enough (measured using the BDI) among patients with multiple and appropriate data for the analysis [49-52,54]. Of the 5 studies, sclerosis. Interestingly, the study demonstrated a statistically 2 assessed the severity of depressive symptoms using more than significant difference (P<.05) between the groups, favoring no one measure (ie, WHO-5, PAID, and ADS-L [52]; GDS and intervention over exergames [51]. In another study [55], the GADS [54]); therefore, we included the results of all these influence of exergames (Kinect Sports Ultimate Collection, measures in the meta-analysis. The meta-analysis showed a Your Shape Fitness Evolved, Dance Central, Kinect Training) statistically significant difference in the severity of depressive and no intervention on the severity of depressive symptoms symptoms (P=.004) between exergame and control groups, (measured using the BDI) among older women was investigated, favoring exergames over no intervention (SMD –0.39, 95% CI and a statistically significant difference in the severity of –0.65 to –0.12; Figure 4). This difference was also clinically depressive symptoms between groups was detected, favoring important as the overall effect was outside the MCID boundaries exergames over no intervention. Tollár et al [50] compared the (–0.195 to 0.195) and its CI did not cross the “no effect” line effect of exergames (Reflex Ridge, Space Pop, Just Dance) with (zero effect) and both MCID boundaries. The statistical that of no intervention on the severity of depressive symptoms heterogeneity of the evidence was substantial (P=.003; I =68%). (measured using the BDI) among patients with Parkinson The quality of the evidence was very low, as it was downgraded disease. The study showed a statistically significant difference by 6 levels due to a high risk of bias, heterogeneity, and (P<.001) in the severity of depressive symptoms between the imprecision (Multimedia Appendix 5). 2 groups, favoring exergames over no intervention. Jahouh et https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al Figure 4. Forest plot of 5 studies (8 comparisons) comparing the effect of exergames with that of no intervention on the severity of depressive symptoms. depressive symptoms (measured using the Major Depression Exergames Versus Other Active Interventions Inventory) among secondary students was compared with In 3 studies, the effect of exergames was compared with that of placebo, an interactive online program (LIFESTYLE) that active interventions on the severity of depressive symptoms, provides information about several topics unrelated to mental and no statistically significant difference was found between health. The study found a statistically significant difference in the groups [56-58]. To be more precise, the first study examined the severity of depressive symptoms (as measured the effects of an exergame (Just Dance 2015) and physical postintervention, P<.001, and at a 6-month follow-up, P=0.01) education on the severity of depressive symptoms (measured between the groups, favoring SPARX-R over LIFESTYLE [62]. with the Brunel Mood Scale) among elementary students and In contrast, the third study found no statistically significant demonstrated no statistically significant difference (P=.13) in difference between the 2 groups in the severity of depressive the severity of depressive symptoms between the exergame symptoms as measured with the CDRS-R (P=.26) and RADS-2 group and physical education group [56]. The second study (P=.16) [60]. Similarly, the fourth study did not show any compared the effect of exergames (RehabMaster) with that of statistically significant difference (P=.96) in the severity of occupational therapy on the severity of depressive symptoms depressive symptoms between the SPARX group and the control (measured using the Hamilton Depression Rating Scale) among group [64]. Another study examined the effects of a patients with stroke. The study found no statistically significant computerized CBT game (Pesky Gnats: The Feel Good Island) difference (P=.56) in the severity of depressive symptoms and no intervention on the severity of depressive symptoms between the exergame group and occupational therapy group (measured using the Glasgow Depression Scale for people with [57]. The third study compared the effect of exergames with a learning disability) among patients with anxiety, depression, that of robot-assisted training on the severity of depressive or intellectual disability [63]. No statistically significant symptoms (measured using the HADS) among patients with difference (P=.25) in the severity of depressive symptoms was stroke and did not find any statistically significant difference detected between the groups [63]. Välimäki et al [65] compared between the groups [58]. the effect of a computerized CBT game (CogniFit) with that of no intervention on the severity of depressive symptoms Computerized CBT Games (measured using the Patient Health Questionnaire-9 [PHQ-9]) Computerized CBT games were the intervention in 8 studies among patients with traumatic brain injury and found no [59-66]. Computerized CBT games were compared with no statistically significant difference (P=.76) between the groups. intervention, video games, and conventional CBT. The results In the last study in this comparison, the effects of a computerized of these comparisons are summarized in the following sections. CBT game (ZeroPhobia) and no intervention on the severity of depressive symptoms (measured using the PHQ-9) among Computerized CBT Games Versus No Intervention patients with acrophobia were investigated [61]. No statistically In 7 studies, the effect of computerized CBT games was significant difference (P=.12) in the severity of depressive compared with that of no intervention on the severity of symptoms was found between the 2 groups [61]. depressive symptoms [59-65], and 4 of these studies assessed the effect of a computerized CBT game (SPARX) on the severity Results of these 7 studies were meta-analyzed, as shown in of depressive symptoms among patients with depression Figure 5. Because 2 of these studies assessed the severity of [59,60,64]. The first study found a statistically significant effect depressive symptoms using 2 different measures (CDRS-R and of the computerized CBT game over no intervention on the RADS-2), we included the results of both measures of each severity of depressive symptoms as measured using the study in the meta-analysis. The overall effect was statistically Children’s Depression Rating Scale-Revised (CDRS-R; P=.001) significant (P=.003) indicating that computerized CBT games but not the Reynolds Adolescent Depression Scale (RADS-2; are more effective than no intervention in alleviating depressive P=.08) [59]. In the second study [62], the effect of a symptoms: (SMD –0.20, 95% CI –0.34 to –0.07). This computerized CBT game (SPARX-R) on the severity of difference was also clinically important as the overall effect https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al was outside the MCID boundaries (–0.10 to 0.10) and its CI did evidence was not a concern (P=.26; I = 20%). The quality of not cross the “no effect” line (zero effect) and both MCID the evidence was very low, as it was downgraded by 3 levels boundaries. For this outcome, MCID boundaries were calculated due to the high risk of bias and impression (Multimedia as ±0.5 times the SMD value (–.20). The heterogeneity of the Appendix 5). Figure 5. Forest plot of 7 studies (9 comparisons) comparing the effect of CBT games with that of no intervention on depression. severity of depressive symptoms between the groups, favoring Computerized CBT Games Versus Active Interventions REBT- and REBE-based games over conventional REBE Välimäki et al [65] compared the effect of a computerized CBT (P=.03) and no intervention (P<.001). game (CogniFit) with that of entertainment video games on the severity of depressive symptoms (measured using the PHQ-9) Discussion among patients with traumatic brain injury and found no statistically significant difference (P=.36) between the groups. Principal Findings Another study compared the effect of a computerized CBT game This review assessed the effectiveness of serious games on the (MindLight) with that of an entertainment video game (Triple severity of depressive symptoms as reported by RCTs. Although Town) on the severity of depressive symptoms (Child 27 RCTs were included in the current review, 16 studies were Depression Inventory 2) among patients with autism spectrum included in the meta-analysis. Very low-quality evidence from disorder and anxiety [66]. No statistically significant difference 7 RCTs showed no statistically significant effect of exergames (P>.05) in the severity of depressive symptoms was detected on the severity of depressive symptoms as compared with between the groups [66]. A study carried out by Poppelaars et conventional exercises. Furthermore, 3 studies that compared al [64] assessed the effects of a computerized CBT game the effect of exergames with that of other active interventions (SPARX) and a conventional CBT program on the severity of (eg, occupational therapy and robot-assisted training) on the depressive symptoms (measured using the RADS-2) among severity of depressive symptoms and were not included in the patients with depression. The study did not detect a statistically meta-analyses found no statistically significant difference significant difference (P=.58) in the severity of depressive between the groups. These findings indicate that exergames are symptoms between the groups. as effective as active interventions, which are usually delivered and supervised by health care providers (eg, physiotherapists, Other Types of Serious Games occupational therapists, and psychologists). One study compared the effect of an exposure therapy game (Spider App) with that of an entertainment video game (Bubble Very low-quality evidence from 5 RCTs showed a statistically Shooter) on the severity of depressive symptoms (measured and clinically significant effect of exergames on the severity of using the BDI-II) among patients with arachnophobia [67]. No depressive symptoms when compared with no intervention. statistically significant difference (P=.95) in the severity of Findings in this review are comparable to other reviews. depressive symptoms was detected between the groups [67]. Specifically, a recently published meta-analysis of 5 RCTs Butler et al [68] examined the effects of brain training games conducted by Yen and Chiu [37] showed an overall statistically and psychotherapy on the severity of depressive symptoms significant effect (P<.001) of exergames on depression. (measured using the BDI) among patients with posttraumatic Additionally, another recent meta-analysis of 8 RCTs conducted stress disorder. No statistically significant difference (P=.95) by Li et al [19] showed a significant effect of exergames on in the severity of depressive symptoms between the 2 groups depression. However, both reviews [19,37] compared the effect was detected [68]. In another study, the effect of REBT- and of exergames with the effects of different active and inactive REBE-based games on the severity of depressive symptoms interventions through one meta-analysis, while our review (measured using the Early Adolescent Temperament conducted 2 separate meta-analyses to compare exergames with Questionnaire-Revised) among patients with stroke was conventional exercises and no intervention respecting the compared with conventional REBE and no intervention [69]. uniqueness of these 2 interventions. Further, in contrast to our The study found a statistically significant difference in the https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al review, 5 of the 8 studies included in the review by Li et al were validity than any other study design [70] and owing to practical not RCTs (quasi-experimental or pre-post one-group trials) [19]. constraints, it was not feasible to translate all non-English studies. Very low-quality evidence from 6 RCTs showed a statistically and clinically significant effect of computerized CBT games Most included studies recruited patients without depression; on the severity of depressive symptoms when compared with thereby, the effect of serious games on the severity of depression no intervention. In contrast, 3 studies that compared the effect symptoms was not significant. Further, the overall risk of bias of computerized CBT games with those of active interventions was high in most included studies, and the quality of evidence (eg, video games and conventional CBT) on depressive for the meta-analyses was very low. Accordingly, findings in symptoms and were not included in the meta-analyses found this review must be interpreted with caution. no statistically significant difference between the groups. This Research and Practical Implications insignificant effect can be attributed to the fact that conventional CBT is comparable to the active interventions, thereby Research Implications comparing the effect of 2 comparable interventions usually Although the severity of depression was one of the measured produces no significant difference, which indicates that outcomes in all included studies, only 5 studies recruited patients computerized CBT games are at least as effective as these active with depression. This might lead to underestimating the effect interventions. None of the previous reviews [18,19,35-37] of serious games. Therefore, future studies need to recruit assessed the effect of computerized CBT games on depression. participants with depression to assess the effectiveness of serious games on depression. Strengths and Limitations The therapeutic modalities provided by serious games in most Strengths included studies were either exercises or CBT. Further, serious This review bridged the gaps of previous reviews by focusing games were not designed specifically to alleviate depression in on all types of serious games, including only RCTs, targeting about half of the studies. Thus, there is a pressing need to assess all age groups, searching technical databases, assessing the the effectiveness of serious games that are designed specifically quality of evidence, and synthesizing the data statistically. to alleviate depression and deliver other therapeutic modalities Therefore, it is more comprehensive than previous reviews such as art therapy, psychotherapy, relaxation-based exercises, [18,19,35-37]. As we followed highly recommended guidelines psychoeducation, rational emotive behavioral therapy, and (ie, PRISMA) to conduct this review, it can be considered a exposure therapy, and the list goes on. robust and high-quality review. Most included studies were carried out in high-income countries; The risk of publication bias in this review is minimal, as we thereby, our findings may not be generalizable to low-income searched the most popular databases in information technology countries. Researchers should conduct more studies to assess and health fields; conducted backward and forward reference the effectiveness of serious games in low-income countries. We list checking; used a comprehensive search query; searched excluded many studies that assessed the effectiveness of serious grey literature databases; and did not restrict our search to a games on other mental disorders such as anxiety and dementia. certain country, year, setting, population, and comparator. Further systematic reviews need to be carried out to investigate The risk of selection bias in this review is minimal because 2 the effectiveness of serious in alleviating other mental disorders. reviewers independently performed the study selection, data The overall risk of bias was high in most included studies mainly extraction, risk of bias assessment, and quality of evidence due to issues in the randomization process, deviations from the evaluation with a very good interrater agreement for all intended outcomes, and selection of the reported result. Further, processes. The quality of the evidence was appraised to enable several studies were not included in the meta-analysis due to the reader to draw more accurate conclusions. When possible, missing outcome data. For this reason, we encourage researchers we synthesized data statistically, and this improved the power to follow recommended guidelines or tools (eg, RoB 2 [40]) of studies and increased the estimates of the likely size of the when conducting and reporting RCTs to avoid such biases. effect of serious games on depression. This review hopefully augurs the possible potential of serious Limitations games in mental health disorders, but it also underlines that this The intervention of interest in this review was restricted to field, albeit full of potential, is still in its infancy. More studies serious games delivered on any digital platform and used as a are needed to prove the significant role of serious games in therapeutic intervention. Thus, this review cannot comment on alleviating depression. the effectiveness of nondigital serious games and those used Practical Implications for other purposes such as monitoring, screening, or diagnosis. The outcome of interest in this review was depression; therefore, Overall, this study showed that serious games can be effective we cannot comment on the effectiveness of serious games on in alleviating depression in comparison with no intervention, other mental health outcomes. and they can be comparable to other traditional therapeutic interventions for alleviating depressive symptoms. However, The review was restricted to RCTs written in the English findings in this review must be interpreted with caution because language; therefore, many studies were excluded because they the overall risk of bias was high in most included studies, the were quasi-experiments or written in other languages. This quality of evidence in the meta-analyses was very low, few restriction was necessary because RCTs have higher internal https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al studies recruited patients with depression, and serious games should be exploited to alleviate depression in low-income in half of the studies were purpose-shifted. Therefore, we can countries. only recommend health care providers consider offering serious Gaming and mental health have traditionally been two distinctly games as an adjunct to existing interventions until further, more separate fields and come with their own unique pedagogy and robust evidence is available. praxis. The potential of utilizing the advantages inherent to As mentioned before, serious games in more than half of the gaming, as described earlier, from its reach to its transformative studies were not designed to specifically alleviate depression potential in mental health holds a lot of promise in theory. and did not deliver other therapeutic modalities such as art However, to achieve this potential, experts from the two therapy, REBT, and psychoeducation. This may be attributed disciplines need to work together in order to understand the to the lack of such serious games in real life. Accordingly, there unique strengths and limitations of each field when designing is a need to develop more serious games that are designed to serious games. specifically alleviate depression and deliver other therapeutic Conclusion modalities. Overall, serious games can be better than no intervention in The most common platforms used for playing the games were alleviating depression and as effective in alleviating depression computers and video game consoles and their accessories, which as other active interventions (eg, conventional CBT, exposure are relatively more expensive and less accessible than therapy, conventional exercise). However, definitive conclusions smartphones that were the platform for serious games in only regarding the effectiveness of serious games could not be drawn 1 study. The number of smartphone users in the world exceeded in this review because the overall risk of bias was high in most 6.4 billion in 2021 [71], which forms about 82% of the global included studies, the quality of the meta-analyzed evidence was population (7.8 billion) [72]. We encourage developers to very low, and few studies recruited patients with depression. develop serious games that can be played through smartphones. Therefore, we can only recommend health care providers consider offering serious games as an adjunct to existing Most studies were carried out in high-income countries, and interventions until further, more robust evidence is available. this may indicate the lack of serious games in low-income To have sufficient evidence, future studies should assess the countries. People in low-income countries may be more in need effectiveness of serious games that are designed specifically to of serious games than those in high-income countries because alleviate depression and deliver other therapeutic modalities, low-income countries have a greater shortage of mental health recruit participants with depression, and avoid biases by professionals than high-income countries (0.1 per 1,000,000 following recommended guidelines for conducting and reporting people vs 90 per 1,000,000 people) [73,74]. Serious games RCTs (eg, RoB 2). Conflicts of Interest None declared. Multimedia Appendix 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. [DOCX File , 33 KB-Multimedia Appendix 1] Multimedia Appendix 2 Search strategy. [DOCX File , 31 KB-Multimedia Appendix 2] Multimedia Appendix 3 Data extraction form. [DOCX File , 26 KB-Multimedia Appendix 3] Multimedia Appendix 4 Reviewers’ judgements about each “risk of bias” domain for each included study. [DOCX File , 45 KB-Multimedia Appendix 4] Multimedia Appendix 5 Grading of Recommendations Assessment, Development and Evaluation (GRADE) Profile for comparison of serious games to control or conventional exercises for depression. [DOCX File , 19 KB-Multimedia Appendix 5] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al References 1. Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, et al. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol 2014 Apr;43(2):476-493 [FREE Full text] [doi: 10.1093/ije/dyu038] [Medline: 24648481] 2. Depression. World Health Organization. URL: https://www.who.int/news-room/fact-sheets/detail/depression [accessed 2022-01-09] 3. Rehm J, Shield KD. Global burden of disease and the impact of mental and addictive disorders. Curr Psychiatry Rep 2019 Feb 07;21(2):10. [doi: 10.1007/s11920-019-0997-0] [Medline: 30729322] 4. Roland J, Lawrance E, Insel T, Christensen H. The digital mental health revolution: Transforming care through innovation and scale-up. World Innovation Summit for Health. 2020. URL: https://www.wish.org.qa/reports/ the-digital-mental-health-revolution-transforming-care-through-innovation-and-scale-up/ [accessed 2021-01-09] 5. Hall-Flavin DK. What does the term "clinical depression" mean? Mayo Clinic. 2017 May 13. URL: https://www. mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770 [accessed 2022-01-09] 6. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Publishing; 7. Haller H, Anheyer D, Cramer H, Dobos G. Complementary therapies for clinical depression: an overview of systematic reviews. BMJ Open 2019 Aug 05;9(8):e028527 [FREE Full text] [doi: 10.1136/bmjopen-2018-028527] [Medline: 31383703] 8. Riccelli R, Passamonti L, Cerasa A, Nigro S, Cavalli SM, Chiriaco C, et al. Individual differences in depression are associated with abnormal function of the limbic system in multiple sclerosis patients. Mult Scler 2016 Jul;22(8):1094-1105. [doi: 10.1177/1352458515606987] [Medline: 26453680] 9. Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med 2017 Dec;195:42-49 [FREE Full text] [doi: 10.1016/j.socscimed.2017.11.008] [Medline: 29132081] 10. Park S, Oh HS, Oh D, Jung SA, Na K, Lee H, et al. Evidence-based, non-pharmacological treatment guideline for depression in Korea. J Korean Med Sci 2014 Jan;29(1):12-22 [FREE Full text] [doi: 10.3346/jkms.2014.29.1.12] [Medline: 24431900] 11. Dias L, Barbosa J, Vianna H. Gamification and serious games in depression care: A systematic mapping study. Telematics and Informatics 2018 Apr;35(1):213-224 [FREE Full text] [doi: 10.1016/j.tele.2017.11.002] 12. Chatham RE. Games for training. Commun. ACM 2007 Jul;50(7):36-43. [doi: 10.1145/1272516.1272537] 13. Hwang H, Bae S, Hong JS, Han DH. Comparing effectiveness between a mobile app program and traditional cognitive behavior therapy in obsessive-compulsive disorder: evaluation study. JMIR Ment Health 2021 Jan 19;8(1):e23778 [FREE Full text] [doi: 10.2196/23778] [Medline: 33464208] 14. Charlier N, Zupancic N, Fieuws S, Denhaerynck K, Zaman B, Moons P. Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis. J Am Med Inform Assoc 2016 Jan;23(1):230-239 [FREE Full text] [doi: 10.1093/jamia/ocv100] [Medline: 26186934] 15. Wiemeyer J, Kliem A. Serious games in prevention and rehabilitation—a new panacea for elderly people? Eur Rev Aging Phys Act 2011 Dec 08;9(1):41-50. [doi: 10.1007/s11556-011-0093-x] 16. Wang R, DeMaria S, Goldberg A, Katz D. A systematic review of serious games in training health care professionals. Simul Healthc 2016 Feb;11(1):41-51. [doi: 10.1097/SIH.0000000000000118] [Medline: 26536340] 17. Zayeni D, Raynaud J, Revet A. Therapeutic and preventive use of video games in child and adolescent psychiatry: a systematic review. Front Psychiatry 2020;11:36 [FREE Full text] [doi: 10.3389/fpsyt.2020.00036] [Medline: 32116851] 18. Li J, Theng Y, Foo S. Game-based digital interventions for depression therapy: a systematic review and meta-analysis. Cyberpsychol Behav Soc Netw 2014 Aug;17(8):519-527 [FREE Full text] [doi: 10.1089/cyber.2013.0481] [Medline: 24810933] 19. Li J, Theng Y, Foo S. Effect of exergames on depression: a systematic review and meta-analysis. Cyberpsychol Behav Soc Netw 2016 Jan;19(1):34-42. [doi: 10.1089/cyber.2015.0366] [Medline: 26716638] 20. Matthyssens L, Vanhulle A, Seldenslach L, Vander Stichele G, Coppens M, Van Hoecke E. A pilot study of the effectiveness of a serious game CliniPup® on perioperative anxiety and pain in children. J Pediatr Surg 2020 Feb;55(2):304-311 [FREE Full text] [doi: 10.1016/j.jpedsurg.2019.10.031] [Medline: 31761458] 21. Radkowski R, Huck W, Domik G, Holtmann M. Serious Games for the Therapy of the Posttraumatic Stress Disorder of Children and Adolescents. In: Shumaker R, editor. Virtual and Mixed Reality - Systems and Applications. VMR 2011. Lecture Notes in Computer Science, vol 6774. Berlin, Germany: Springer; 2011:44-53. 22. Jones M, Denisova A, Mitchell S, Owen T. Acceptability of a plasticity-focused serious game intervention for posttraumatic stress disorder: user requirements analysis. JMIR Serious Games 2019 Apr 16;7(2):e11909 [FREE Full text] [doi: 10.2196/11909] [Medline: 30990461] 23. Barajas AO, Osman HA, Shirmohammadi S. A Serious Game for children with Autism Spectrum Disorder as a tool for play therapy. 2017 Presented at: IEEE 5th International Conference on Serious Games and Applications for Health (SeGAH); April 2-4, 2017; Perth, Western Australia URL: https://ieeexplore.ieee.org/document/7939266 [doi: 10.1109/segah.2017.7939266] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 18 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 24. Tang JSY, Falkmer M, Chen NTM, B lte S, Girdler S. Designing a serious game for youth with ASD: perspectives from end-users and professionals. J Autism Dev Disord 2019 Mar;49(3):978-995. [doi: 10.1007/s10803-018-3801-9] [Medline: 30377883] 25. McCallum S, Boletsis C. Dementia Games: A Literature Review of Dementia-Related Serious Games. In: Ma M, Oliveira MF, Petersen S, Hauge JB, editors. Serious Games Development and Applications. SGDA 2013. Lecture Notes in Computer Science, vol 8101. Berlin, Germany: Springer; 2013:15-27. 26. Zhao Y, Feng H, Wu X, Du Y, Yang X, Hu M, et al. Effectiveness of exergaming in improving cognitive and physical function in people with mild cognitive impairment or dementia: systematic review. JMIR Serious Games 2020 Jun 30;8(2):e16841 [FREE Full text] [doi: 10.2196/16841] [Medline: 32602841] 27. Verduin ML, LaRowe SD, Myrick H, Cannon-Bowers J, Bowers C. Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder. J Subst Abuse Treat 2013 Mar;44(3):316-322. [doi: 10.1016/j.jsat.2012.08.006] [Medline: 23009800] 28. Dovis S, Van der Oord S, Wiers RW, Prins PJM. Improving executive functioning in children with ADHD: training multiple executive functions within the context of a computer game. a randomized double-blind placebo controlled trial. PLoS One 2015;10(4):e0121651 [FREE Full text] [doi: 10.1371/journal.pone.0121651] [Medline: 25844638] 29. Hong JS, Kim SM, Aboujaoude E, Han DH. Investigation of a mobile "serious game" in the treatment of obsessive-compulsive disorder: a pilot study. Games Health J 2018 Oct;7(5):317-326. [doi: 10.1089/g4h.2017.0158] [Medline: 30129775] 30. Cruz R. The Modern Economics of the Video Games Industry. University of Miami. URL: https://com.miami.edu/wp-content/ uploads/2021/06/mma_2021_firstplace.pdf [accessed 2022-01-09] 31. Mental health. World Health Organization. URL: https://www.who.int/health-topics/mental-health#tab=tab_1 [accessed 2022-01-09] 32. Eyal N. Hooked: How to build habit-forming products. Brentford, Middlesex, United Kingdom: Portfolio; 2014. 33. Fleming TM, Bavin L, Stasiak K, Hermansson-Webb E, Merry SN, Cheek C, et al. Serious games and gamification for mental health: current status and promising directions. Front Psychiatry 2016;7:215 [FREE Full text] [doi: 10.3389/fpsyt.2016.00215] [Medline: 28119636] 34. Cheek C, Fleming T, Lucassen MF, Bridgman H, Stasiak K, Shepherd M, et al. Integrating health behavior theory and design elements in serious games. JMIR Ment Health 2015;2(2):e11 [FREE Full text] [doi: 10.2196/mental.4133] [Medline: 26543916] 35. Fleming TM, Cheek C, Merry SN, Thabrew H, Bridgman H, Stasiak K, et al. Juegos serios para el tratamiento o la prevención de la depresión: una revisión sistemática. RPPC 2015 Jan 15;19(3):227. [doi: 10.5944/rppc.vol.19.num.3.2014.13904] 36. Lau HM, Smit JH, Fleming TM, Riper H. Serious games for mental health: are they accessible, feasible, and effective? A systematic review and meta-analysis. Front Psychiatry 2016;7:209 [FREE Full text] [doi: 10.3389/fpsyt.2016.00209] [Medline: 28149281] 37. Yen H, Chiu H. Virtual reality exergames for improving older adults' cognition and depression: a systematic review and meta-analysis of randomized control trials. J Am Med Dir Assoc 2021 May;22(5):995-1002. [doi: 10.1016/j.jamda.2021.03.009] [Medline: 33812843] 38. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009 Jul 21;339(jul21 1):b2700-b2700 [FREE Full text] [doi: 10.1136/bmj.b2700] [Medline: 19622552] 39. Altman DG. Practical statistics for medical research. Boca Raton, FL: CRC press; 1990. 40. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019 Aug 28;366:l4898. [doi: 10.1136/bmj.l4898] [Medline: 31462531] 41. Deeks JJ, Higgins JPT, Altman DG, Cochrane Statistical Methods Group. Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Sussex, UK: John Wiley & Sons; 2008:243-296. 42. Schunemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziou P, Cochrane Applicability and Recommendations Methods Group. Interpreting results and drawing conclusions. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Sussex, UK: John Wiley & Sons; 2008:359-387. 43. Ruivo JMADS, Karim K, O Shea R, Oliveira RCS, Keary L, O Brien C, et al. In-class active video game supplementation and adherence to cardiac rehabilitation. J Cardiopulm Rehabil Prev 2017 Jul;37(4):274-278. [doi: 10.1097/HCR.0000000000000224] [Medline: 28350640] 44. Ferraz DD, Trippo KV, Duarte GP, Neto MG, Bernardes Santos KO, Filho JO. The effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly patients with Parkinson cisease: A pilot randomized controlled single-blinded trial. Arch Phys Med Rehabil 2018 May;99(5):826-833. [doi: 10.1016/j.apmr.2017.12.014] [Medline: 29337023] 45. Song GB, Park EC. Effect of virtual reality games on stroke patients' balance, gait, depression, and interpersonal relationships. J Phys Ther Sci 2015 Jul;27(7):2057-2060 [FREE Full text] [doi: 10.1589/jpts.27.2057] [Medline: 26311925] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 19 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 46. Schumacher H, Stüwe S, Kropp P, Diedrich D, Freitag S, Greger N, et al. A prospective, randomized evaluation of the feasibility of exergaming on patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2018 May;53(5):584-590. [doi: 10.1038/s41409-017-0070-8] [Medline: 29335629] 47. Meldrum D, Herdman S, Vance R, Murray D, Malone K, Duffy D, et al. Effectiveness of conventional versus virtual reality-based balance exercises in vestibular rehabilitation for unilateral peripheral vestibular loss: results of a randomized controlled trial. Arch Phys Med Rehabil 2015 Jul;96(7):1319-1328.e1. [doi: 10.1016/j.apmr.2015.02.032] [Medline: 25842051] 48. Zhou H, Al-Ali F, Kang GE, Hamad AI, Ibrahim RA, Talal TK, et al. Application of wearables to facilitate virtually supervised intradialytic exercise for reducing depression symptoms. Sensors (Basel) 2020 Mar 12;20(6):1 [FREE Full text] [doi: 10.3390/s20061571] [Medline: 32178231] 49. Vieira A, Melo C, Machado J, Gabriel J. Virtual reality exercise on a home-based phase III cardiac rehabilitation program, effect on executive function, quality of life and depression, anxiety and stress: a randomized controlled trial. Disabil Rehabil Assist Technol 2018 Feb;13(2):112-123. [doi: 10.1080/17483107.2017.1297858] [Medline: 28285574] 50. Tollár J, Nagy F, Hortobágyi T. Vastly different exercise programs similarly improve Parkinsonian symptoms: a randomized clinical trial. Gerontology 2019;65(2):120-127. [doi: 10.1159/000493127] [Medline: 30368495] 51. Ozdogar AT, Ertekin O, Kahraman T, Yigit P, Ozakbas S. Effect of video-based exergaming on arm and cognitive function in persons with multiple sclerosis: A randomized controlled trial. Mult Scler Relat Disord 2020 May;40:101966. [doi: 10.1016/j.msard.2020.101966] [Medline: 32045868] 52. Kempf K, Martin S. Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial. BMC Endocr Disord 2013 Dec 10;13:57 [FREE Full text] [doi: 10.1186/1472-6823-13-57] [Medline: 24321337] 53. Rendon AA, Lohman EB, Thorpe D, Johnson EG, Medina E, Bradley B. The effect of virtual reality gaming on dynamic balance in older adults. Age Ageing 2012 Jul;41(4):549-552. [doi: 10.1093/ageing/afs053] [Medline: 22672915] 54. Jahouh M, González-Bernal JJ, González-Santos J, Fernández-Lázaro D, Soto-Cámara R, Mielgo-Ayuso J. Impact of an intervention with Wii video games on the autonomy of activities of daily living and psychological-cognitive components in the institutionalized elderly. Int J Environ Res Public Health 2021 Feb 07;18(4):1 [FREE Full text] [doi: 10.3390/ijerph18041570] [Medline: 33562249] 55. Rica RL, Shimojo GL, Gomes MC, Alonso AC, Pitta RM, Santa-Rosa FA, et al. Effects of a Kinect-based physical training program on body composition, functional fitness and depression in institutionalized older adults. Geriatr Gerontol Int 2020 Mar;20(3):195-200. [doi: 10.1111/ggi.13857] [Medline: 31923924] 56. Andrade A, Cruz WMD, Correia CK, Santos ALG, Bevilacqua GG. Effect of practice exergames on the mood states and self-esteem of elementary school boys and girls during physical education classes: A cluster-randomized controlled natural experiment. PLoS One 2020;15(6):e0232392 [FREE Full text] [doi: 10.1371/journal.pone.0232392] [Medline: 32502164] 57. Shin J, Bog Park S, Ho Jang S. Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: A randomized, controlled study. Comput Biol Med 2015 Aug;63:92-98. [doi: 10.1016/j.compbiomed.2015.03.011] [Medline: 26046499] 58. Adomavičienė A, Daunoravičienė K, Kubilius R, Varžaitytė L, Raistenskis J. Influence of new technologies on post-stroke rehabilitation: a comparison of Armeo Spring to the Kinect system. Medicina (Kaunas) 2019 Apr 09;55(4):98 [FREE Full text] [doi: 10.3390/medicina55040098] [Medline: 30970655] 59. Fleming T, Dixon R, Frampton C, Merry S. A pragmatic randomized controlled trial of computerized CBT (SPARX) for symptoms of depression among adolescents excluded from mainstream education. Behav Cogn Psychother 2012 Oct;40(5):529-541. [doi: 10.1017/S1352465811000695] [Medline: 22137185] 60. Merry SN, Stasiak K, Shepherd M, Frampton C, Fleming T, Lucassen MFG. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012 Apr 18;344(apr18 3):e2598-e2598 [FREE Full text] [doi: 10.1136/bmj.e2598] [Medline: 22517917] 61. Donker T, Cornelisz I, van Klaveren C, van Straten A, Carlbring P, Cuijpers P, et al. Effectiveness of self-guided app-based virtual reality cognitive behavior therapy for acrophobia: a randomized clinical trial. JAMA Psychiatry 2019 Jul 01;76(7):682-690 [FREE Full text] [doi: 10.1001/jamapsychiatry.2019.0219] [Medline: 30892564] 62. Perry Y, Werner-Seidler A, Calear A, Mackinnon A, King C, Scott J, et al. Preventing depression in final year secondary students: school-based randomized controlled trial. J Med Internet Res 2017 Nov 02;19(11):e369 [FREE Full text] [doi: 10.2196/jmir.8241] [Medline: 29097357] 63. Cooney P, Jackman C, Coyle D, O'Reilly G. Computerised cognitive-behavioural therapy for adults with intellectual disability: randomised controlled trial. Br J Psychiatry 2017 Aug;211(2):95-102. [doi: 10.1192/bjp.bp.117.198630] [Medline: 28596245] 64. Poppelaars M, Tak YR, Lichtwarck-Aschoff A, Engels RCME, Lobel A, Merry SN, et al. A randomized controlled trial comparing two cognitive-behavioral programs for adolescent girls with subclinical depression: A school-based program (Op Volle Kracht) and a computerized program (SPARX). Behav Res Ther 2016 May;80:33-42. [doi: 10.1016/j.brat.2016.03.005] [Medline: 27019280] https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 20 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al 65. Välimäki M, Mishina K, Kaakinen JK, Holm SK, Vahlo J, Kirjonen M, et al. Digital gaming for improving the functioning of people with traumatic brain injury: randomized clinical feasibility study. J Med Internet Res 2018 Mar 19;20(3):e77 [FREE Full text] [doi: 10.2196/jmir.7618] [Medline: 29555622] 66. Wijnhoven LA, Creemers DH, Vermulst AA, Lindauer RJ, Otten R, Engels RC, et al. Effects of the video game 'Mindlight' on anxiety of children with an autism spectrum disorder: A randomized controlled trial. J Behav Ther Exp Psychiatry 2020 Sep;68:101548. [doi: 10.1016/j.jbtep.2020.101548] [Medline: 32155470] 67. Haberkamp A, Walter H, Althaus P, Schmuck M, Rief W, Schmidt F. Testing a gamified Spider App to reduce spider fear and avoidance. J Anxiety Disord 2021 Jan;77:102331. [doi: 10.1016/j.janxdis.2020.102331] [Medline: 33166870] 68. Butler O, Herr K, Willmund G, Gallinat J, Kühn S, Zimmermann P. Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder. J Psychiatry Neurosci 2020 Jul 01;45(4):279-287 [FREE Full text] [doi: 10.1503/jpn.190027] [Medline: 32293830] 69. David OA, Cardo  RAI, Matu S. Is REThink therapeutic game effective in preventing emotional disorders in children and adolescents? Outcomes of a randomized clinical trial. Eur Child Adolesc Psychiatry 2019 Jan 10;28(1):111-122. [doi: 10.1007/s00787-018-1192-2] [Medline: 29992353] 70. Bhattacherjee A. Social science research: Principles, methods, and practices. Scotts Valley, CA: CreateSpace Independent Publishing Platform; 2012. 71. Ericsson Mobility Report. Ericsson. 2021 Jun 23. URL: https://www.ericsson.com/en/mobility-report/ mobility-visualizer?f=1&ft=1&r=1&t=8&s=1&u=1&y=2016,2021&c=1 [accessed 2022-01-09] 72. Worldometer. Current World Population. 2021 July 23, 2021. Jul 23. URL: https://www.worldometers.info/world-population/ [accessed 2022-01-09] 73. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012 Dec 15;380(9859):2197-2223. [doi: 10.1016/S0140-6736(12)61689-4] [Medline: 23245608] 74. Oladeji BD, Gureje O. Brain drain: a challenge to global mental health. BJPsych Int 2016 Aug 02;13(3):61-63 [FREE Full text] [doi: 10.1192/s2056474000001240] [Medline: 29093905] Abbreviations ADS-L: Allgemeine Depressionsskala BDI: Beck Depression Inventory CBT: Cognitive behavioral therapy CDRS-R: Children’s Depression Rating Scale-Revised GADS: Goldberg Anxiety and Depression Scale GDS: Geriatric Depression Scale GRADE: Grading of Recommendations Assessment, Development and Evaluation HADS: Hospital Anxiety and Depression Scale MCID: minimal clinically important difference PAID: Problem Areas in Diabetes PHQ-9: Patient Health Questionnaire-9 PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses RADS-2: Reynolds Adolescent Depression Scale RCT: randomized controlled trial REBE: rational emotive behavioral education REBT: rational emotive behavioral therapy RoB 2: Risk-of-Bias 2 SMD: standardized mean difference WHO: World Health Organization WHO-5: WHO 5-item Well-Being Index Edited by N Zary; submitted 24.07.21; peer-reviewed by F Shuweihdi, S Bae; comments to author 10.09.21; revised version received 10.09.21; accepted 26.09.21; published 14.01.22 Please cite as: Abd-Alrazaq A, Al-Jafar E, Alajlani M, Toro C, Alhuwail D, Ahmed A, Reagu SM, Al-Shorbaji N, Househ M JMIR Serious Games 2022;10(1):e32331 URL: https://games.jmir.org/2022/1/e32331 doi: 10.2196/32331 PMID: https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 21 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Abd-Alrazaq et al ©Alaa Abd-Alrazaq, Eiman Al-Jafar, Mohannad Alajlani, Carla Toro, Dari Alhuwail, Arfan Ahmed, Shuja Mohd Reagu, Najeeb Al-Shorbaji, Mowafa Househ. Originally published in JMIR Serious Games (https://games.jmir.org), 14.01.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/1/e32331 JMIR Serious Games 2022 | vol. 10 | iss. 1 | e32331 | p. 22 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious GamesJMIR Publications

Published: Jan 14, 2022

Keywords: serious games; exergames; depression; cognitive behavioral therapy; systematic reviews; meta-analysis

There are no references for this article.