Video games and depression

There’s a lot of talk these days about the harm or benefit of playing video games, a lot of time ignoring the issue of what kind of video games we’re talking about.

Merry et al. (2012) designed a game for helping adolescents with depression. The game is called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) and is based on the cognitive behavioral therapy (CBT) principles.

CBT has been proven to be more efficacious that other forms of therapy, like psychoanalysis, psychodynamic, transpersonal and so on in treating (or at least alleviating) a variety of mental disorders, from depression to anxiety, form substance abuse to eating disorders. Its aim is to identify maladaptive thoughts (the ‘cognitive’ bit) and behaviors (the ‘behavior’ bit), change those thoughts and behaviors in order to feel better. It is more active and more focused than other therapies, in the sense that during the course of a CBT session, the patient and therapist discuss one problem and tackle it.

SPARX is a simple interactive fantasy game with 7 levels (Cave, Ice, Volcano, Mountain, Swamp, Bridgeland, Canyon) and the purpose is to fight the GNATs (Gloomy Negative Automatic Thoughts) by mastering several techniques, like breathing and progressive relaxation and acquiring skills, like scheduling and problem solving. You can customize your avatar and you get a guide throughout the game that also assess your progress and gives you real-life quests, a. k. a. therapeutic homework. If the player does not show the expected improvements after each level, s/he is directed to seek help from a real-life therapist. Luckily, the researchers also employed the help of true game designers, so the game looks at least half-decent and engaging, not a lame-worst-graphic-ever-bleah sort of thing I was kind of expecting.

To see if their game helps with depression, Merry et al. (2012) enrolled in an intervention program 187 adolescents (aged between 12-19 years) that sought help for depression; half of the subjects played the game for about 4 – 7 weeks, and the other half did traditional CBT with a qualified therapist for the same amount of time.  The patients have been assessed for depression at regular intervals before, during and after the therapy, up to 3 months post therapy. The conclusion?

SPARX “was at least as good as treatment as usual in primary healthcare sites in New Zealand” (p. 8)

Not bad for an RPG! The remission rates were higher for the SPARX group that in treatment as usual group. Also, the majority of participants liked the game and would recommend it. Additionally, SPARX was more effective than CBT for people who were less depressed than the ones who scored higher on the depression scales.

And now, coming back to my intro point, the fact that this game seems to be beneficial does not mean all of them are. There are studies that show that some games have deleterious effects on the developing brain. In the same vein, the fact that some shoddy company sells games that are supposed to boost your brain function (I always wandered which function…) that doesn’t mean they are actually good for you. Without the research to back up the claims, anybody can say anything and it becomes a “Buyer Beware!” game. They may call it cognitive enhancement, memory boosters or some other brainy catch phrase, but without the research to back up the claims, it’s nothing but placebo in the best case scenario. So it gives me hope – and great pleasure – that some real psychologists at a real university are developing a video game and then do the necessary research to validate it as a helping tool before marketing it.

sparx1-copy

Oh, an afterthought: this paper is 4 years old so I wondered what happened in the meantime, is it on the market or what? On the research databases I couldn’t find much, except that it was tested this year on Dutch population with pretty much similar results. But Wikipedia tells us that is was released in 2013 and is free online for New Zealanders! The game’s website says it may become available to other countries as well.

Reference: Merry SN, Stasiak K, Shepherd M, Frampton C, Fleming T, & Lucassen MF. (18 Apr 2012). The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. The British Medical Journal, 344:e2598. doi: 10.1136/bmj.e2598. PMID: 22517917, PMCID: PMC3330131. ARTICLE | FREE FULLTEXT PDF  | Wikipedia page | Watch the authors talk about the game

By Neuronicus, 15 October 2016

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Younger children in a grade are more likely to be diagnosed with ADHD

AHDH immaturity - Copy.jpgA few weeks ago I was drawing attention to the fact that some children diagnosed with ADHD do not have attention deficits. Instead, a natural propensity for seeking more stimulation may have led to overdiagnosing and overmedicating these kids.

Another reason for the dramatic increase in ADHD diagnosis over the past couple of decades may stem in the increasingly age-inappropriate demands that we place on children. Namely, children in the same grade can be as much as 1 year apart in chronological age, but at these young ages 1 year means quite a lot in terms of cognitive and behavioral development. So if we put a standard of expectations based on how the older children behave, then the younger children in the same grade would fall short of these standards simply because they are too immature to live up to them.

So what does the data say? Two studies, Morrow et al. (2012) and Chen et al. (2016) checked to see if the younger children in a given grade are more likely to be diagnosed with ADHD and/or medicated. The first study was conducted in almost 1 million Canadian children, aged 6-12 years and the second investigated almost 400,000 Taiwanese children, aged 4-17 years.

In Canada, the cut-off for starting school in Dec. 31. Which means that in the first grade, a child born in January is almost a year older that a child born in December. Morrow et al. (2012) concluded that the children born in December were significantly more likely to receive a diagnosis of ADHD than those born in January (30% more likely for boys and 70% for girls). Moreover, the children born in December were more likely to be given an ADHD medication prescription (41% more likely for boys and 77% for girls).

In Taiwan, the cut-off date for starting school in August 31. Similar to the Canadian study, Chen et al. (2016) found that the children born in August were more likely to be diagnosed with ADHD and receive ADHD medication than the children born in September.

Now let’s be clear on one thing: ADHD is no trivial matter. It is a real disorder. It’s an incredibly debilitating disease for both children and their parents. Impulsivity, inattention and hyperactivity are the hallmarks of almost every activity the child engages in, leading to very poor school performance (the majority cannot get a college degree) and hard family life, plus a lifetime of stigma that brings its own “gifts” such as marginalization, loneliness, depression, anxiety, poor eating habits, etc.

The data presented above favors the “immaturity hypothesis” which posits that the behaviors expected out of some children cannot be performed not because something is wrong with them, but because they are simply too immature to be able to perform those behaviors. That does not mean that every child diagnosed with ADHD will just grow out of it; the researchers just point to the fact that ignoring the chronological age of the child coupled with prematurely entering a highly stressful and demanding system as school might lead to ADHD overdiagnosis.

Bottom line: ignoring the chronological age of the child might explain some of increase in prevalence of ADHD by overdiagnostication (in US alone, the rise is from 6% of children diagnosed with ADHD in 2000 to 11-15% in 2015).

References:

  1. Morrow RL, Garland EJ, Wright JM, Maclure M, Taylor S, & Dormuth CR. (17 Apr 2012, Epub 5 Mar 2012). Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children. Canadian Medical Association Journal, 184 (7), 755-762, doi: 10.1503/cmaj.111619. Article | FREE PDF 
  1. Chen M-H, Lan W-H, Bai Y-M, Huang K-L, Su T-P, Tsai S-J, Li C-T, Lin W-C, Chang W-H, & Pan T-L, Chen T-J, & Hsu J-W. (10 Mar 2016). Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in Taiwanese Children. The Journal of Pediatrics [Epub ahead print]. DOI: http://dx.doi.org/10.1016/j.jpeds.2016.02.012 Article | FREE PDF

By Neuronicus, 14 March 2016

Prostaglandins in the sickness syndrome

63woman-698962_960_720When you’re sick you also feel awful: no appetite, weak, sleepy, feverish, achy, and so on. This is called, appropriately so, the sickness syndrome.

Saper, Romanovsky & Scammell (2012) wrote a beautiful review of the neural circuits underlying this collection of symptoms. In a nutshell, the immune system releases cytokines to fight the inflammation, which in turn stimulate the release of prostaglandins. Prostaglandins bind to various areas in the brain to produce the sickness syndrome symptoms. Below are outlined 4 simplified circuits which the non-specialists can skip entirely.

  1. in median preoptic nucleus which will lead to a cascade involving dorsomedial hypothalamus, rostral medullary raphe and finally the spinal cord to produce fever by activating the brown adipose tissue.
  2. in preoptic area which will lead to the inhibition of the brain’s analgesic system involving the descending projections of the periaqueductal grey to spinal cord, thus promoting achiness.
  3. in the meninges that results in adenosine release which binds in nucleus accumbens and ventrolateral preoptic nucleus which will result, downstream, in inhibiting the arousal system to produce sleepiness.
  4. in arcuate nucleus to inhibit several hypothalamic nuclei involved in promoting feeding, thereby producing anorexia.

The sickness syndrome and the role prostaglandins play in it has tremendous adaptive role, as it promotes rest and recuperation. So don’t blame them too much. And if you’re really done feeling sick, take some non-steroid anti-inflammatory drugs, like aspirin, who very effectively inhibit the prostaglandins’ synthesis. That’s why NSAIDs work.

Reference: Saper CB, Romanovsky AA & Scammell TE (26 Jul 2012). Neural Circuitry Engaged by Prostaglandins during the Sickness Syndrome. Nature Neuroscience, 15(8):1088-95. doi: 10.1038/nn.3159. Article | FREE Fulltext PDF

By Neuronicus, 21 December 2015

Choose: God or reason

Photo Credit: Anton Darcy
Photo Credit: Anton Darcy

There are two different ways to problem-solving and decision-making: the intuitive style (fast, requires less cognitive resources and effort, relies heavily on implicit assumptions) and the analytic style (involves effortful reasoning, is more time-consuming, and tends to assess more aspects of a problem).

Pennycook et al. (2012) wanted to find out if the propensity for a particular type of reasoning can be used to predict one’s religiosity. They tested 223 subjects on their cognitive style and religiosity (religious engagement, religious belief, and theistic belief). The tests were in the form of questionnaires.

They found that the more people were willing to do analytic reasoning, the less likely they were to believe in God and other supernatural phenomena (witchcraft, ghosts, etc.). And that is because, the authors argue, the people that are engaging in analytic reasoning do not accept as easily ideas without putting effort into scrutinizing them; if the notions submitted to analyses are found to violate natural laws, then they are rejected. On the other hand, intuitive reasoning is based, partly, on stereotypical assumptions that hinder the application of logical thinking and therefore the intuitive mind is more likely to accept supernatural explanations of the natural world. For example, here is one of the problems used to asses analytical thinking versus stereotypical thinking:

In a study 1000 people were tested. Among the participants there were 995 nurses and 5 doctors.
Jake is a randomly chosen participant of this study. Jake is 34 years old. He lives in a beautiful home in a posh suburb. He is well spoken and very interested in politics. He invests a lot of time in his career. What is most likely?
(a) Jake is a nurse.
(b) Jake is a doctor.

Fig. 1 from Pennycook et al. (2012) depicting the relationship between the analytical thinking score (horizontal) and percentage of people that express a type of theistic belief (vertical). E.g. 55% of people that believe in a personal God scored 0 out of 3 at the analytical thinking test (first bar), whereas atheists were significantly more likely to answer all 3 questions correctly (last bar)
Fig. 1 from Pennycook et al. (2012) depicting the relationship between the analytical thinking score (horizontal) and percentage of people that express a type of theistic belief (vertical). E.g. 55% of people that believe in a personal God scored 0 out of 3 at the analytical thinking test (first bar), whereas atheists were significantly more likely to answer all 3 questions correctly (last bar)

First thing that comes to mind, based on stereotypical beliefs about these professions, is that Jake is a doctor, but a simple calculation tells you that there is 99.5% chance for Jake to be a nurse. Answer a) denotes analytical thinking, answer b) denotes stereotypical thinking.

And yet that is not the most striking thing about the results, but that the perception of God changes with the score on analytical thinking (see Fig. 1): the better you scored at analytical thinking the less conformist and more abstract view you’d have about God. The authors replicated their results on 267 additional more people. The findings were still robust and independent of demographic data.

Reference: Pennycook, G., Cheyne, J. A., Seli, P., Koehler, D. J., & Fugelsang, J. A. (June 2012, Epub 4 Apr 2012.). Analytic cognitive style predicts religious and paranormal belief. Cognition, 123(3): 335-46. doi: 10.1016/j.cognition.2012.03.003.  Article | PPT | full text PDF via Research Gate

by Neuronicus, 1 October 2015