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A smartphone game designed to support people with depression, offered together with optional online therapy modules and on-demand therapist support, reduced depression and anxiety symptoms among adults who were already taking antidepressants, according to a randomized controlled trial in Sweden. Participants who received nine weeks of access to the program also reported better adherence to their medication than those on a waitlist, but their quality of life did not differ. The paper was published in the Journal of Affective Disorders.
Depression is a common mental disorder affecting approximately 300 million people worldwide. It reduces quality of life and creates substantial economic costs. Antidepressant medications are a common treatment for depression, but many patients continue to experience depressive symptoms despite taking them. Another major problem is that many patients do not take their prescribed medications regularly.
Internet-based cognitive behavioral therapy (ICBT) has emerged as an accessible treatment option. Research shows that it can be as effective as face-to-face cognitive behavioral therapy in reducing depressive symptoms. Researchers are increasingly interested in combining antidepressant medications with digital psychological interventions delivered through smartphones.
One promising approach involves serious games. These games use elements of video games to encourage behaviors that support mental health. They may improve motivation and medication adherence by rewarding healthy behaviors and helping users establish daily routines. For example, a smartphone game called Fig: The Game for Depression rewards users for following routines related to medication, sleep, meals, and physical activity.
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Study author Josefin Brehmer of Linköping University and colleagues wanted to examine whether Fig, offered alongside ICBT modules and therapist support available on demand, could improve mental health and medication adherence in adults who were taking antidepressants but still had depressive symptoms. They conducted a randomized controlled trial.
Study participants were 148 adults in Sweden who were receiving antidepressant medication and still had depressive symptoms. They were recruited through social media and paid advertisements. Their average age was 40 years, and 82% were women. About half (52%) were employed, 16% were students, and 17% were on extended sick leave.
Most participants (64%) reported having received a psychiatric diagnosis earlier, and most had previously undergone psychological treatment. According to a diagnostic interview, 66% were currently experiencing a major depressive episode, and 72% had recurrent depression.
Participants were randomly assigned to one of two groups. Both groups were offered the same nine-week intervention, called FIGARO, which consisted of access to Fig, optional access to 25 ICBT modules, and a therapist they could contact as needed. The treatment group received access immediately, while the waitlist control group received the same intervention two weeks after the end of the intervention period.
Fig is a smartphone-based game designed to be used twice daily alongside usual medical care. It encourages healthy routines including medication adherence, sleep, meals, and physical activity. The game rewards adherence by allowing players to develop and customize virtual worlds and provides educational dialogues, mood tracking, and a diary to promote self-reflection and reinforce healthy behaviors.
Before and after the intervention, participants completed assessments of depression (the self-rated Montgomery-Åsberg Depression Rating Scale), anxiety (the Generalized Anxiety Disorder 7-item scale), medication adherence (the 8-item Morisky Medication Adherence Scale), and quality of life (the 12-item Brunnsviken Brief Quality of Life Scale). They also completed brief weekly symptom check-ins during the study. Participants were screened for alcohol and substance use and reported demographic information and their history of psychological treatment.
Results showed that 79% of participants in the treatment group installed the Fig game, and those who did completed 81 game sessions on average. About 32% contacted their therapist during the study period, and 28% completed at least one therapy worksheet. Compared with the waitlist group, the treatment group showed moderately greater reductions in depression and anxiety symptoms at the end of the intervention period.
About 51% of the treatment group improved their depression scores by at least 30%, compared with 19% of the waitlist group, although only 16% of the treatment group improved by at least 50%. Medication adherence also improved in the treatment group, with a small-to-moderate effect, but quality of life did not differ between the groups. The depression and anxiety results held up when the researchers used different methods to account for participants who dropped out, while the medication adherence finding weakened and was no longer statistically significant under the most conservative assumption.
How much participants used the game or the online therapy platform was not linked to how much they improved. Most participants who answered a satisfaction survey (69%) said they were fairly or very satisfied with the treatment.
“This trial provides preliminary evidence that access to a multicomponent digital intervention, comprising the CE-marked [i.e., certified under European Union medical device regulations] serious game Fig, optional ICBT modules and therapist support on demand, can produce short-term improvements in depressive symptoms, anxiety symptoms and medication adherence relative to a waitlist among adults receiving antidepressant medication with residual depressive symptoms,” the study authors concluded.
The study contributes to the scientific understanding of digital treatments for depression. However, the authors note that 41% of participants in the treatment group did not complete the post-treatment assessments, compared with 18% in the control group. Additionally, participants knew which group they were in, and all outcomes were self-reported. Finally, 21% of treatment group participants never installed the Fig game.
Because the comparison group was a waitlist, the researchers could not rule out effects of expectations or other nonspecific factors, and the effects cannot be attributed to the game alone rather than to the full package of game, therapy modules, and therapist support. The study assessed only short-term effects, and participants recruited through advertisements may be more motivated than typical patients.
The trial was registered after recruitment had begun, though the authors state that the registered outcomes did not change. The study was funded by Mindforce Game Lab, the developer of Fig, which the authors say was not involved in data collection, analysis, interpretation, or writing.
The paper, “A smartphone-based serious game to improve mental health and medication adherence in adults with depression: A randomised controlled trial,” was authored by Josefin Brehmer, Matilda Berg, Gabriel Astudillo, Tomas Lindegaard, Amalie Englund Find, Per Carlbring, Mikael Ludvigsson, and Gerhard Andersson.
