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 Table of Contents  
SPECIAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 284-289

Gamifying education and mental health


1 Department of Psychiatry, St. John's Medical College and Hospital, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Dr. Suhas Chandran
Department of Psychiatry, St. John's Medical College and Hospital, St. John's National Academy of Health Sciences, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_92_18

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  Abstract 


Objectives: This article explores the advantages of using gamification in mental health, in addition to its potential use in training psychiatry residents by coupling it with the concept of digital andragogy, resulting in a prospective efficient teaching model for graduate and postgraduate medical education. Materials and Methods: Databases such as PubMed and Google Scholar were searched for articles using the keywords such as digital andragogy, gamification, innovation in medical education, medical education, and mental health. Results: Using leader boards, rewards, and a host of innovative testing methods, gamification offers increased student engagement and satisfaction along with improved objective academic results emphasizing competency-based medical education. It has also been used in the management of various psychiatric conditions, especially depression, eating disorders, schizophrenia, depression, autism spectrum disorders, substance use, dementia, and traumatic brain injury. It has been shown to alter user behavior positively, leading to better control over illness and improved quality of life among these patients. Conclusion: Gamification is an extremely efficient method, positively impacting the academic performance when used by students. While it cannot replace traditional methods, they can be blended into an efficient teaching model. It can also be used in the management of several medical and psychiatric conditions in a creative and effective manner, although further research is needed to evaluate this potential.

Keywords: Digital andragogy, gamification, medical education, mental health, psychological theories


How to cite this article:
Chandran S, Prakrithi S N, Kishor M. Gamifying education and mental health. Arch Med Health Sci 2018;6:284-9

How to cite this URL:
Chandran S, Prakrithi S N, Kishor M. Gamifying education and mental health. Arch Med Health Sci [serial online] 2018 [cited 2019 May 26];6:284-9. Available from: http://www.amhsjournal.org/text.asp?2018/6/2/284/248673




  Introduction Top


Just as technology has become omnipresent, gaming has also permeated various aspects of daily life. Games are extremely popular all over the world and among individuals of all age groups. The concept of games and gaming is increasingly being used in different contexts. It has been actively utilized in education, where game thinking and game-like experiences are being used to advance and improve different facets of individual learning by increasing motivation, recall, and retention. “Gamification” is defined as the use of game design elements in nongame contexts. The basis for this is the idea of “gamefulness,” which should be distinguished from “playfulness.” Playfulness defines the behaviors and experiences involved in open, exploratory play (paidia, a Greek word which translates to “childish play”) and gamefulness involves rule-bound, goal-oriented play (ludus, a Latin word which means sport or training). Gamification is explained by the amalgamation of the following three components: gamefulness, which is the behavioral quality; gameful interaction, how the individual reacts to the game; and gameful design, which is the designing process of using game elements in nongame settings.[1]

“Serious games” and gamification are sometimes mistaken for each other. “Serious games” or “Applied games” are defined as games developed to provide additional advantages other than entertainment.[2] Here, the use of the game for recreation itself is primary, and the other aspect is given as a secondary advantage, which may be in the form of education and employee orientation among others. Gamification, on the other hand, involves only the use of game elements (leaderboards, levels of difficulty, and unlocking prizes) in various nongame contexts such as marketing, to primarily increase employee productivity, or to encourage pro-social behavior, like following traffic rules or even crowdsourcing. A gamification-based approach for mental health is still very much in its infancy. However, a few early studies indicate potential benefits for psychological and behavioral changes or symptom relief in schizophrenia, autism spectrum disorders (ASDs), attention-deficit hyperactive disorders (ADHDs), and others, which will be further elaborated in this article.


  Psychological Theories behind Gamification Top


Considering the broad scope of gamification, the psychological theories and the cognitive processes through which it brings about a positive change are numerous. The crux of certain basic elements is summarized. Landers et al.[3] have described the application of various learning theories to develop effective gamification. According to the theory of gamified learning, gamification should target two types of behaviors:

  • Behaviors that affect learning, like meta-cognition (thinking about how to learn leads to better student grades). From this, it follows that games which increase meta-cognition will have increased effectiveness in improving academic performance, an example for which is a study planner application
  • Behaviors that make existing instruction more effective (like student engagement). This entails packaging bland information into attractive learning modules with audiovisual interaction, rather than presenting dry data on a screen.


Classical and operant conditioning: Gamification strives to create a beneficial association between positive stimuli from the game and studying via reinforcement and punishment, using rewards and negative scoring as appetitive and noxious stimuli.

Token economy: Gamification also uses the principle of token economy, based on operant conditioning, where smaller incentives are given for shorter tasks, which the users can collect and utilize for availing perks in the game or save and collect more of them for gift cards which have higher value, teaching users about self-control and planning ahead.

Expectancy theory – This describes the three motivational processes:

  • Expectancy: Action leading to consequence (doing the task well will lead to winning the game)
  • Instrumentality: Consequence leading to a reward (winning the game will gain appreciation from teachers)
  • Valence: The value given to the reward (recognition by faculty is very important).


Goal setting theory: Gamification models should incorporate SMART (specific, measurable, attainable, realistic, and time-bound) goals to effectively increase motivation and learning.

Self-determination theory: Competency, accomplishment, and the feeling of being connected to people around them are the three needs of self-determination. Intrinsic motivation occurs when these needs are met and extrinsic motivation occurs through incentives such as grades and recognition, which is most useful to get individuals to try out new tasks. Gamification mainly involves extrinsic motivation and makes the student learn new things. Intrinsic motivation develops after the student becomes proficient in the new task.


  Gamification in Mental Health Top


Gamification and game-like elements can be used to design strategies to treat mental illness. It plays an important role in bridging the mental health treatment gap (those with mental illness versus those seeking treatment), through its attractiveness and ease of use and reduces attrition rates. Games are developed specifically for the purpose of treating mental illnesses, (like “Virtual Iraq” for improving post traumatic stress disorder (PTSD) symptoms in war veterans) or other games originally developed for entertainment can be utilized for addressing mental health and are called repurposed games. For example, “Tetris” was investigated successfully in its ability to block flashbacks in PTSD and also reduce craving in substance dependence.[4]

Games in mental health can combine therapeutic processes and drug compliance monitoring. Different types of games offer different advantages such as cognitive training (remediation and rehabilitation) and guided meditation and mindfulness; “Exergames” mainly encourage physical exercise; cognitive behavioral therapy (CBT)-based games transform traditional therapeutic models into game format or introduce game-like elements into it, which offers therapeutic impact; and entertainment games help improving mood through stress reduction. One study which tested the impact of video game-based physical activity in older adults with schizophrenia showed increased engagement and motivation, and as patients became more involved, they developed skills that made it easier to engage in activity.[5] A randomized controlled trial investigating “SPARX,” a CBT-based video game, showed that test subjects had lower scores on depression rating scales and also increased rates of remission when compared to waitlist controls.[6] “Michael's game” is based on CBT for psychotic symptoms, which trains players to find alternate hypotheses to given situations. The study showed a decrease in conviction scores in patients with persistent delusional disorder, when compared to preintervention scores.[7]

Virtual reality and augmented reality offer immersion and interaction with the virtual elements, including audiovisual stimuli. This has been used in the treatment of eating disorders, with simulated real-life situations such as home, supermarket, restaurant, gym, swimming pool, and clothes shopping, called experiential-cognitive therapy, to the effect of improving awareness, body satisfaction, self-esteem, and social skills of the patient, which imparts greater control over eating and diet compared to traditional approaches for managing obesity and eating disorders.[8] Another game called “Videodope” addresses the consequences, adverse health effects, and legal implications of psychoactive substance use, where changes caused by harmful use are depicted on three-dimensional images of the human body, which is followed by a quiz to consolidate the knowledge and insight gained.[9] “Virtual City” uses different tasks associated with therapeutic procedures based inside a game workspace which is formed by a virtual city, with the objectives of the tasks being to improve cognitive and executive functioning in patients of schizophrenia and acquired brain injury.[10] Computer games can act as distractions in boring or painful situations. Virtual worlds can be customized to individual players based on their needs, thereby allowing for desired behaviors to be transferred to and utilized in the real world.[11] The “Challenger App” was designed for the treatment of social anxiety disorder, by completing increasingly challenging interactions with the environment using gamification techniques, by including anonymous social interaction, real-time location awareness, and notifications with personalization.[12]

Games can have a significant role in teaching social cognition to children with ASD. Children are guided through virtual social encounters in a safe environment. There are games such as “Let's Face It!” which teach users to recognize facial expressions, and there are some games which require emotion and facial expressions from the user to keep the game moving, which trains the child to express emotions. Training with game elements significantly improves the motivation, training performance, and working memory of children with ADHD.[13] A gamification-based attention training program showed a significant improvement in ratings at 24 weeks, compared to the baseline score of parent-rated inattentive and hyperactive-impulsive symptoms.[14] Anguera et al. showed that video games could enhance cognitive functions such as sustained attention and working memory and could further be used to assess cognitive abilities across different age groups.[15]

“Virtual ADL + House” is a gamified computerized cognitive test battery, consisting of mini games embedded with different cognitive tests and activities of daily living. It is also used for long-term monitoring and provides alert signs for cognitive decline, with longitudinal data to facilitate clinical diagnosis.[16] “Eldergames,” an interactive tool for preserving cognitive functions impaired by aging, provides social cognitive training by a multiplayer architecture.[17] Some games are designed to quantify and give baseline assessment of cognitive abilities in patients with Alzheimer's disease.

In biofeedback-based games, visual feedback of the physiological changes is provided while patients practice relaxation techniques. These games teach relaxation skills along with continuous indication of autonomic arousal through feedback sensors and have been noted to have better outcomes compared to waitlist controls.[4] “Playmancer platform,” a serious video game specifically designed to treat impulse control disorders, uses biofeedback to model physiological and emotional reactions, and significant changes were observed in several measures of impulsivity, anger expression, and other psychopathological symptoms.[18]

Neurofeedback techniques, where patients monitor their own neural activity in magnetic resonance imaging (MRI) scanners while performing tasks, are being used in the treatment of schizophrenia. Patients were made to play a game requiring the landing of a rocket using their own mental strategies, with no external instructions. After four attempts, they were able to reduce neural activity in part of the brain, and later able to control their brain activity even without the use of MRI imaging, therefore allowing for the potential to apply these lasting strategies on a daily basis.[11]

Gamification has been successfully used to address substance dependence. A board game called “Pick-Klop” was developed specifically to improve smoking cessation rates, self-efficacy, and modify attitudes toward smoking and tobacco dependence treatments by illustrating lapse-relapse processes and relapse prevention strategies, with the help of cards such as ‘question’, ‘surprise’, and ‘temptation’. This game has been shown to significantly decrease the number of cigarettes smoked per day compared to the psycho-education group and the waitlist control group.[19]

“BoosterBuddy” is a mobile application, which provides evidence-informed mental health self-management tools with gamification-oriented design, where users complete real-life wellness activities called Quests, to awaken a companion character in the game called Buddy, and they help their buddy by helping themselves. Quests involve real-life self-management and behavioral activation tasks and are graded to match the user's needs, such as crisis response, symptom management, self-care, community engagement, and medication reminders. It facilitates improvement of hedonic deficits and perceived ability and promotes personal meaning and hope.[20]

Similar concepts can be used for treating depression. Activity scheduling can be conducted through gamification, where points are awarded for every activity completed, and at the end of the day, week, and month, incentives are given. Games can be developed for dyslexic children, where correction of spelling or mathematics or other specific learning disability can be incorporated into the game. For example, asking the child to click letters in sequence for a particular spelling, the letters for which are present jumbled up on the screen, where every correct letter gains points and every wrong letter will cause him to lose points, at the end of which new games can be unlocked.

Patients with ADHD have been found to react differently from controls to reward and feedback, preferring strong reinforcement and immediate feedback. Furthermore, elderly people and children, who might dislike being tested, fare better as the test gets hidden behind gameplay and novel interfaces, which optimizes performance by making them feel more comfortable.[21] The limitations for using gamification for improving mental health are funding and user preferences. Depressed individuals might not have enough motivation to start playing the game in the first place. Some may consider use of games for treatment as inappropriate. The use of gamification for improving mental health is not a new idea and shows some promising results. The current research into effective outcomes is still incomplete and needs further elaboration. Concrete research projects with strong methodologies are required in order to have definitive answers. It is necessary to customize the various approaches toward different target groups in order to achieve maximum effectiveness in utilization of gamification for treatment of various illnesses.


  Using Gamification to Teach Psychiatry to Undergraduate and Postgraduate Students Top


The advantage of gamifying education is that students continue playing games despite the obstacles or blocks encountered, whereas the same students might not study something if they find it hard to master. The difference here is of the level of motivation, interest, and engagement. The competitive nature of games and its appealing graphics minimize the monotony, as a result of which students do not get bored easily and continue playing even when it gets difficult. Amalgamating gaming and learning would offer these advantages, a majority of which traditional studying may not cover. Diverse gamification methods such as mobile phone applications and computer games which involve virtual patient simulation and multimedia classrooms have been created for this purpose. The various techniques used in gamification to invoke behavioral changes are “freedom of choice,” which gives autonomy, and “freedom to fail,” which leads to increase in attempting questions. Furthermore, leaderboards trigger competition, all of which serve the purpose of increased learning.[22] A review by McCoy et al. noted that major advantages were seen in the contexts of learning, engagement, collaboration, and clinical decision-making among the medical students, attributed to the freedom of practicing in risk-free environments. In addition, the educators also benefited from the analytical data, which allowed them to review areas in which the student was deficient, thereby allowing constructive feedback from instructors.[23]


  Consolidating Digital Andragogy into Gamification Models Top


Andragogy is defined as the art and science of teaching adults, where importance is given to critical thinking and practical application. Blackley and Sheffield[24] noted that the traditional techniques of andragogy do not fit the 21st century learner, who has entirely different methods of knowledge access, and instead suggested the concept of “Digital Andragogy,” as technology has inundated all aspects of modern life, including the way students perceive and access educational materials. They define digital andragogy as, “the practice of educators to equip and encourage adult learners to choose and use the affordances of accessible digital technologies to personalise their learning and facilitate their interactions with peers and tutors.” They also noted that successful digital andragogy would impart the four cardinal 21st century learning skills, i.e., critical thinking, communication, collaboration, and creativity. Furthermore, it would also incorporate the “adult learning traits,” which are self-concept (being more self-directed and independent), learning from past experiences, and change in learning orientation from subject based to problem based. This necessitates a certain level of freedom, as they choose the type of course work for themselves. Teamwork helps students learn to communicate and collaborate. Opportunities are also given to develop different skill sets and contextual creativity. The authors conducted a study comparing digital andragogy to traditional teaching and found that breaking down course content into smaller chunks and allowing flexibility of schedule, along with quick assessments with instant personalized feedback showed improved academic results and student satisfaction.

The concept of gamification lends itself suitably to the successful application of digital andragogy in medical education. These gamified course modules can have video lectures, audio clips, slide shows, quizzes, clinical case scenarios, virtual patient simulations, website links with resources for further detailed reading, and various tasks and assignments integrated into the game. Moreover, it enhances analytical thinking, and the immediate answers and explanations provided will motivate students to read more extensively. As the student progresses further, new levels with better rewards will be unlocked, enticing the student to continue playing. A step-wise increase in complexity, coupled with greater incentives, can motivate the student to learn more than what he would have when the only objective was passing end of term assessments.

The students direct themselves through the course set, therefore improving self-concept. Students can learn working on their own as well as working as part of a team. An example would be creating a simulation where the treatment of a patient requires a multidisciplinary team of doctors, who discuss with each other to arrive at a management plan for the patient, which will include investigations, pharmacotherapy, or psychotherapy. A “disease team” instead of a virtual patient can also be added, where the team decides the symptoms, signs, treatment response, and side effects in response to the treating team's management, resulting in a number of possible outcomes. In the current era of massive multiplayer online role playing games, this scenario can be easily played out in cyberspace, thereby honing the collaborative and communicative skills of the students and leading to better understanding of the disease process itself. The varied tasks make sure that the student uses his/her creativity in multiple domains. An advanced quiz can be conducted based on the material the student is required to learn after practicing the initial modules, i.e., on the newer material read from the sources outside of the app or game.

Apart from andragogy, gamification can also be used for teaching specific skill sets to psychiatry residents. The videos can include tutorials on how to conduct psychotherapy, with a few guiding examples of different scenarios. Spot identification of physical signs, facial cues, and body language through pictures or video clips will sharpen the observation skills of the student and sensitize him/her to pick up the same in real-life situations, which can provide pointers about what the patient is thinking and how receptive the patient is to intervention. Patients with psychoactive substance dependence are known to be notoriously difficult to treat. Using gamification to teach brief motivational interview techniques to students where multiple patient responses to different motivational statements are presented to the interviewer will sensitize students to similar situations that arise in real life. The student is rewarded whenever the virtual patient is convinced to progress a bit further in the stages of recovery. The student can also identify, investigate, treat, and follow-up symptoms or side effects in sample cases. He/she is awarded points for every correct decision, and points are deducted for every wrong decision (ordering unnecessary investigation or mistakes in treatment). Besides, the student will become proficient in applying the knowledge and skills amassed in the virtual space into real-life situations, which will better equip them to handle with confidence events or cases which the student may not have had the opportunity to encounter in real life.

Gamification is an extremely efficient method to increase student engagement, memory, retention, and recall, thereby significantly impacting the academic performance when used by students. John Dewey, the American psychologist and educational reformer, once said that “If we teach today, as we taught yesterday, we then rob students of tomorrow.” The additional incentive produced by winning gives impetus for further learning, unlike traditional teaching methods. It is a concept hardly explored currently in our country, and we must inculcate it into our medical education, and thereby give students another opportunity to improve their various skill sets by virtual experience, in addition to building team spirit and a sense of healthy competition.


  Conclusion Top


Gamification cannot replace conventional methods of teaching, but traditional teaching strategies can be improved by blending the core principles used in gamification. Constant reinvention is the only way of moving forward, to ensure that we are not out of the running, and the most efficient approach to achieve this using innovative strategies to better ourselves by more effective learning. The current digitalization wave along with the new tech-savvy generation will also aid in easy dissemination of this method into the enhancement of mental health in a large target group. The development of effective games for addressing mental health issues should, therefore, take into account the user preferences, appeal, the therapeutic methods needed for different conditions, and the intended outcomes after treatment. Creative and effective implementation of gamification can thereby be used in the management of several medical and psychiatric conditions successfully.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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