Feeling anxious, depressed, fearful, or unable to focus? Is your memory getting fuzzy? Medication might help. Therapy might help. And someday soon—according to neuroscientists, game designers, and drug makers—you might be prescribed a videogame that helps as much as (or more than) either. Here are a few of the innovative companies that are fusing game mechanics with principles of cognitive psychology to create a new paradigm for digital healing.
In September 2013, a group led by Adam Gazzaley, a cognitive neuroscience researcher at UCSF, published a landmark paper in the prestigious scientific journal Nature. A study they had conducted showed that playing a specially designed driving game called Neuroracer arrested age-related cognitive decline in senior citizens, improving memory, attention, and the ability to multitask.
Boston-based game maker Akili Interactive Labs—with Gazzaley as an advisor and funding from drug maker Shire—is developing a tablet-based game based on the Neuroracer platform, called EVO. Rather than driving and noticing road signs, in EVO players explore foreign worlds, collecting stars, gems, and alien specimens. The game is currently being deployed in about a half dozen clinical trials, testing its effectiveness for improving function in kids with ADHD (in collaboration with Shire) and autism, treating depression (with the National Institutes of Health), and detecting early signs of Alzheimer’s disease (with Pfizer).
On the surface, these conditions may seem to have little connection. But there is a common thread, says Eddie Martucci, Akili’s vice president of research and development: "All of these populations have strong deficits in executive function and the processing of cognitive interference, or ‘noise.’" While Akili’s prototype game is designed for universal appeal—"ADHD kids love it, and compliance in the 70-plus depression group is also sky high," Martucci says—future iterations will update visuals and other game elements to appeal to specific groups of users. Akili’s creative team includes veterans of Lucas Digital Arts and Electronic Arts.
Unlike consumer "brain fitness" games such as Lumosity’s, which make vague claims about "training" memory and attention but don’t need to prove they’re actually doing anything, Akili wants full FDA approval and acceptance by the medical mainstream. "We’re building medical devices, going after very deep neurological or psychological disorders that have multimillion-dollar drug models," says Martucci. "Doctors are willing and open-minded, but at the end of the day, if they’re going to recommend games to patients, they need more clinical validation. Over the next few years, you’ll see lots of studies coming out, and we’ll see disease solutions that include prescriptions for pills as well as highly engaging games."
According to a 2013 CDC report, 11% of all school-age children in the U.S.—or more than 6 million kids between ages 4 and 17—have been diagnosed with ADHD. About 66% of those with an ADHD diagnosis have prescriptions for stimulants such as Adderall and Ritalin. CDC director Thomas Frieden has called the situation "disturbing," and the "overmedicated kids" meme poses a public-relations problem for drug companies. Given kids’ natural affinity for videogames, using them as a component of ADHD therapy—alone, or in combination with medication—is a no-brainer for forward-thinking drug companies.
One of the first extensive studies of games for this population took place in Holland last year, a collaboration between Rotterdam-based game developer Ranj and Janssen Pharmaceutica, a Dutch subsidiary of Johnson & Johnson. The game, called Plan-It Commander, provides 40 hours of play in an adventure-game format. A series of mini games target specific behaviors to change—planning and organization, time management, and social interactions. The game becomes more complex and difficult as the player accomplishes development goals.
"Drug-based therapy for ADHD is focused on primary symptoms like concentration and impulsivity," says Tom Aelbrecht, director of Janssen’s venture and incubation center. "Secondary issues like time management and social interactions aren’t targeted by medication. We needed something to tackle those issues—not to replace medication but to have another tool. Children are very susceptible to the idea of a serious game."
Results of the study have recently been submitted for publication, and a Dutch version of the game became commercially available in June 2013. Although ADHD isn’t an area of strategic priority for Janssen, Greg Panico, a spokesperson for the company’s neurological drugs group, says the game project "is illustrative of our group’s R&D work, focusing on integrated solutions that combine drugs with other therapies," for conditions such as Alzheimer’s and schizophrenia.
Rather than developing its own games, Cambridge, Massachusetts-based Pear Therapeutics has a different business model: pairing game developers with drug makers and marketing the resulting drug-software "eFormulations." Imagine picking up your medication and finding a software code on the package that directs you to a complementary game.
"There are at least 30 conditions where drug-plus-software apps have a chance to make the drugs more effective," says Corey McCann, Pear’s founder and CEO. "For some patients, the game may be a proxy for drugs. For most, they’ll be part of a multimodal treatment." From a business perspective, eFormulations could also be a boon for drug maker’s bottom lines, because they would likely qualify as new formulations and extend patent protection—and profitability.
Pear’s lead product will be aimed at managing general anxiety disorder through a game that encourages the player to breathe in a rhythmic pattern to stimulate the vagus nerve in the brain. "The standard of care today is to take a benzodiazepine," says McCann. "But a big component of the treatment for anxiety is deep breathing and meditation. Now, you’ll be able first to pull out an app, and if you don’t get relief, to take a benzo and record your symptoms. You can use a smartphone app component to record your anxious symptoms and have a data-centric follow-up conversation with your doctor or therapist."
Treating depression in teens—who are generally more resistant to traditional therapy, and at greater risk for suicide than adults—is another opportunity for using games to improve outcomes, McCann says. Studies of a role-playing game called SPARX, being commercialized in the U.S. by LinkedWellness, have found it to be as effective as in-person cognitive behavioral therapy for this group. McCann envisions an eFormulation that would pair a similar game with antidepressant medication.
"One of the real opportunities for depression and anxiety is to tailor pieces of content to be very specific for different stages of therapy," he says. "You can have different content for the first several weeks, where the medication is less effective, and then change it later. In anxiety, that’s true even to the minute. Anxiety is a very acute event. Even rapidly acting drugs are going to take tens of minutes before you feel relief. Deep breathing produces relief within seconds."
Pear is working with branded and generic drug makers as well as nutritional-supplement companies, and hopes to launch an FDA-approved product with a pharma partner in 2015. "With effectively every new drug for the brain, the traditional path to market is 12 to 15 years and two to three billion dollars," says McCann. "From concept to launch for us, it’s a couple of millions and 18 to 20 months. And there’s a similar opportunity in terms of magnitude for helping patients."
While all these companies are focusing primarily on mobile or PC platforms, new gaming interfaces—most notably, virtual reality (VR) headsets by Oculus Rift and Sony—could enable much deeper immersion in virtual environments, with profound therapeutic benefits. "If you’re dealing with something where the brain doesn’t want to go—like PTSD, or an anxiety disorder such as fear of heights, flying, or crowds—a more three-dimensional experience that stimulates more sensory systems can have more cognitive benefits," says Walter Greenleaf, Pear’s chief science officer and former head of the Center on Aging at Stanford.
VR is already being used clinically for pain management. A team led by Hunter Hoffman at University of Washington, for example, has developed an immersive game called Snow World, where the player is a snowman throwing snowballs in a virtual winter-scape. When burn victims are allowed to play the game while undergoing painful bandage changes, they experience significantly less pain than when taking opiate painkillers alone. Since 2005, Albert "Skip" Rizzo, a clinical psychologist at the University of Southern California, has been using a virtual reality program called Virtual Iraq as a form of exposure therapy for veterans struggling with PTSD.
Until now, though, virtual simulations have been limited to clinical environments with special equipment. With affordable consumer VR headsets, at-home immersive game-therapy sessions could become commonplace. Add to that the rapid emergence of consumer-priced, user-friendly neuro-hardware—such as EEG headsets, made by Emotiv and others, which "read" a user’s brainwaves to interact with software—and you can imagine any number of "sci-fi" scenarios for digital neuro-tuneups. Beyond just "reading" brainwaves, some avid gamers are already using headbands that zap their brain with low doses of current to boost game performance. Imagine waking up, playing a quick game to assess your mental state, and fixing any imbalances with targeted brain stimulation.
There are still substantial technological hurdles to overcome before we can seamlessly wire together our brains, Xbox, VR goggles, and the EEG sensors. But simpler games-as-drugs will be here much sooner. To be sure, the current model for delivering mental-health services—where demand outstrips supply, and the cost of care can be prohibitive—is ripe for disruption. "If we show this works and saves money in the real world," says McCann, "it will be great way to scale the field of psychology."