Meeting the complex needs of patients with chronic common mental health disorders (CMHDs) may be the greatest challenge facing organized medical practice. On the basis of a well-established and proven theoretical foundation for controlled respiration as a behavioral intervention for CMHDs, as well as preliminary evidence that gamification can improve health outcomes through increasing patient engagement, this randomized controlled pilot study evaluated the feasibility and clinical efficacy of a mobile health game called “Flowy” (www.flowygame.com) that digitally delivered breathing retraining exercises for anxiety, panic, and hyperventilation symptom management.
Materials and Methods:
We designed an unblinded, Web-based, parallel-group randomized controlled trial focusing on feasibility, clinical efficacy, and design proof of concept. In the intervention condition (n = 31), participants received free access to “Flowy” for 4 weeks. In the control condition (n = 32), participants were placed on a waitlist for 4 weeks before being offered free access to “Flowy.” Online measurements using psychological self-report questionnaires were made at 2 and 4 weeks post-baseline.
Results:
At trial conclusion, participants found “Flowy” acceptable as an anxiety management intervention. “Flowy” engaged participants sufficiently to endorse proactive gameplay. Intent-to-treat analysis revealed a reduction in anxiety, panic, and self-report hyperventilation scores in both trial arms, with the intervention arm experiencing greater quality of life. Participants perceived “Flowy” as a fun and useful intervention, proactively used “Flowy” as part of their care, and would recommend “Flowy” to family and friends.
Conclusions:
Our results suggest that a digital delivery of breathing retraining exercises through a mobile health game can manage anxiety, panic, and hyperventilation symptoms associated with CMHDs.
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References
1.
MathersC, FatDM, BoermaJT; World Health Organization. The Global Burden of Disease: 2004 Update. Geneva: World Health Organization; 2008.
2.
PillingS, WhittingtonC, TaylorC, KendrickT. Identification and care pathways for common mental health disorders: Summary of NICE guidance. BMJ, 2011; 342:d2868.
3.
World Health Organization. Integrating the Response to Mental Health Disorders and Other Chronic Diseases in Health Care Systems. Geneva: World Health Organization; 2014.
4.
SkapinakisP, LewisG, DaviesS, et al.Panic disorder and subthreshold panic in the UK general population: Epidemiology, comorbidity and functional limitation. Eur Psychiatry, 2011; 26:354–362.
5.
Institute for Health Metrics and Evaluation. Financing Global Health 2010: Development Assistance and Country Spending in Economic Uncertainty. Seattle, WA: Institute for Health Metrics and Evaluation; 2010.
6.
Department of Health. No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. Supporting Document—The Economic Case for Improving Efficiency and Quality in Mental Health. London: Department of Health; 2011.
7.
BeamishPM, GranelloPF, GranelloDH, et al.Outcome studies in the treatment of panic disorder: A review. J Counsel Dev, 1996; 74:460–467.
8.
ClarkDM. A cognitive approach to panic. Behav Res Ther, 1986; 24:461–470.
9.
LeyR. The efficacy of breathing retraining and the centrality of hyperventilation in panic disorder: A reinterpretation of experimental findings. Behav Res Ther, 1991; 29:301–304.
10.
LeyR. Pulmonary function and dyspnea/suffocation theory of panic. J Behav Ther Exp Psychiatry, 1998; 29:1–11.
11.
LumLC. Hyperventilation and anxiety state. J R Soc Med, 1981; 74:1–4.
MueserKT, LuW, RosenbergSD, WolfeR. The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis. Schizophr Res, 2010; 116:217–227.
14.
RapeeRM, AncisJR, BarlowDH. Emotional reactions to physiological sensations: Panic disorder patients and non-clinical Ss. Behav Res Ther, 1988; 26:265–269.
15.
RapeeRM, BrownTA, AntonyMM, BarlowDH. Response to hyperventilation and inhalation of 5.5% carbon dioxide-enriched air across the DSM-III-R anxiety disorders. J Abnorm Psychol, 1992; 101:538–552.
16.
KimS, WollburgE, RothWT. Opposing breathing therapies for panic disorder: A randomized controlled trial of lowering vs raising end-tidal PCO2. J Clin Psychiatry, 2012; 73:931–939.
17.
Sanchez-MecaJ, Rosa-AlcazarAI, Marin-MartinezF, Gomez-ConesaA. Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clin Psychol Rev, 2010; 30:37–50.
18.
YoungC, HunteA, NewellJ, ValianP. Coping with panic. In: Cambridgeshire and Peterborough NHS Foundation Trust, ed. Improving Access to Psychological Therapies 2011, Vol. 4. Cambridge, United Kingdom: Cambridgeshire and Peterborough NHS Foundation Trust; 2011: 27–28.
19.
SaxenaS, SetoyaY. World Health Organization's comprehensive mental health action plan 2013–2020. Psychiatry Clin Neurosci, 2014; 68:585–586.
20.
SahaS, BeachMC, CooperLA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc, 2008; 100:1275–1285.
CottonR, IrwinJ, WilkinsA, YoungC. The Future's Digital: Mental Health and Technology. London: NHS Confederation Mental Health Network; 2014.
24.
World Health Organization. mHealth: New Horizons for Health Through Mobile Technologies. Geneva: World Health Organization; 2011.
25.
McCurdieT, TanevaS, CasselmanM, et al.mHealth consumer apps: The case for user-centered design. Biomed Instrum Technol, 2012;(Suppl):49–56.
26.
CafazzoJA, CasselmanM, HammingN, et al.Design of an mHealth app for the self-management of adolescent type 1 diabetes: A pilot study. J Med Internet Res, 2012; 14:e70.
27.
DeterdingS, DixonD, KhaledR, NackeL. From game design elements to gamefulness: defining “gamification.” In: Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments. Tampere, Finland: ACM Press; 2011.
28.
ZichermannG, CunninghamC. Gamification by Design: Implementing Game Mechanics in Web and Mobile Apps. Sebastopol, CA: O'Reilly Media, Inc.; 2011.
29.
HeronKE, SmythJM. Ecological momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol, 2010; 15:1–39.
30.
BrownSJ, LiebermanDA, GermenyBA, et al.Educational video game for juvenile diabetes: Results of a controlled trial. Med Inform (Lond), 1997; 22:77–89.
31.
KatoPM, ColeSW, BradlynAS, PollockBH. A video game improves behavioral outcomes in adolescents and young adults with cancer: A randomized trial. Pediatrics, 2008; 122:e305–e317.
32.
KatoPM, BealeIL. Factors affecting acceptability to young cancer patients of a psychoeducational video game about cancer. J Pediatr Oncol Nurs, 2006; 23:269–275.
33.
StinsonJN, JibbLA, NguyenC, et al.Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer. J Med Internet Res, 2013; 15:e51.
34.
BinghamPM, BatesJH, Thompson-FigueroaJ, LahiriT. A breath biofeedback computer game for children with cystic fibrosis. Clin Pediatr (Phila), 2010; 49:337–342.
35.
BinghamPM, LahiriT, AshikagaT. Pilot trial of spirometer games for airway clearance practice in cystic fibrosis. Respir Care, 2012; 57:1278–1284.
36.
DavisMA, QuittnerAL, StackCM, YangMC. Controlled evaluation of the STARBRIGHT CD-ROM program for children and adolescents with cystic fibrosis. J Pediatr Psychol, 2004; 29:259–267.
37.
Asthma Advisory Committee Meeting. Asthma Self-Management Application Project. In: University of Western Ontario Centre for Global e-Health Innovation, Queen's University. The Lung Association. 2014. www.on.lung.ca/document.doc?id=2109 (accessed July29, 2015).
38.
KrishnaS, FranciscoBD, BalasEA, et al.Internet-enabled interactive multimedia asthma education program: A randomized trial. Pediatrics, 2003; 111:503–510.
39.
Developing Breathe: A Self-Management Web App for Asthma. Ottawa: Centre for Global eHealth Innovation, University Health Network; 2013.
40.
GardeA, UmedalyA, AbulnagaSM, et al.Assessment of a mobile game (“MobileKids Monster Manor”) to promote physical activity among children. Games Health J, 2015; 4:149–158.
41.
LinJ-H. “Just Dance”: The effects of exergame feedback and controller use on physical activity and psychological outcomes. Games Health J, 2015; 4:183–189.
42.
MollerCA, MajewskiS, StandishM, et al.Active fantasy sports: Rationale and feasibility of leveraging online fantasy sports to promote physical activity. JMIR Serious Games, 2014; 2:e13.
43.
SatoK, KurokiK, SaikiS, NagatomiR. Improving walking, muscle strength, and balance in the elderly with an exergame using Kinect: A randomized controlled trial. Games Health J, 2015; 4:161–167.
44.
FishMT, RussonielloCV, O'BrienK. The efficacy of prescribed casual videogame play in reducing symptoms of anxiety: A randomized controlled study. Games Health J, 2014; 3:291–295.
45.
LeutwylerH, HubbardEM, DowlingGA. Adherence to a videogame-based physical activity program for older adults with schizophrenia. Games Health J, 2014; 3:227–233.
46.
RoepkeAM, JaffeeSR, RiffleOM, et al.Randomized controlled trial of SuperBetter, a smartphone-based/Internet-based self-help tool to reduce depressive symptoms. Games Health J, 2015; 4:235–246.
47.
ShepherdM, FlemingT, LucassenM, et al.The design and relevance of a computerized gamified depression therapy program for indigenous Māori adolescents. JMIR Serious Games, 2015; 3:e1.
48.
GutierrezB, KaatzA, ChuS, et al.“Fair Play”: A videogame designed to address implicit race bias through active perspective taking. Games Health J, 2014; 3:371–378.
49.
ChuSKW, KwanACM, ReynoldsR, et al.Promoting sex education among teenagers through an interactive game: Reasons for success and implications. Games Health J, 2015; 4:168–174.
50.
D'CruzJ, Santa MariaD, DubeS, et al.Promoting parent–child sexual health dialogue with an intergenerational game: Parent and youth perspectives. Games Health J, 2015; 4:113–122.
51.
DriesmansK, VandenboschL, EggermontS. Playing a videogame with a sexualized female character increases adolescents' rape myth acceptance and tolerance toward sexual harassment. Games Health J, 2014; 4:91–94.
52.
JozkowskiKN, EkbiaHR. “Campus Craft”: A game for sexual assault prevention in universities. Games Health J, 2014; 4:95–106.
53.
GoriniA, MarzoratiC, CasiraghiM, et al.A neurofeedback-based intervention to reduce post-operative pain in lung cancer patients: Study protocol for a randomized controlled trial. JMIR Res Protoc, 2015; 4:e52.
54.
KottinkAIR, PrangeGB, KrabbenT, et al.Gaming and conventional exercises for improvement of arm function after stroke: A randomized controlled pilot study. Games Health J, 2014; 3:184–191.
55.
Lozano-QuilisJ-A, Gil-GómezH, Gil-GómezJ-A, et al.Virtual rehabilitation for multiple sclerosis using a Kinect-based system: Randomized controlled trial. JMIR Serious Games, 2014; 2:e12.
56.
ProffittR, SevickM, ChangC-Y, LangeB. User-centered design of a controller-free game for hand rehabilitation. Games Health J, 2015; 4:259–264.
57.
SzturmT, ReimerKM, HochmanJ. Home-based computer gaming in vestibular rehabilitation of gaze and balance impairment. Games Health J, 2015; 4:211–220.
58.
GranicI, LobelA, EngelsRCME. The Benefits of Playing Video Games. Nijmegen, The Netherlands: Radboud University Nijmegen; 2013.
59.
BuijinkAW, VisserBJ, MarshallL. Medical apps for smartphones: Lack of evidence undermines quality and safety. Evid Based Med, 2013; 18:90–92.
60.
HaffeyF, BradyRR, MaxwellS. A comparison of the reliability of smartphone apps for opioid conversion. Drug Saf, 2013; 36:111–117.
61.
MisraS, LewisTL, AungstTD. Medical application use and the need for further research and assessment for clinical practice: Creation and integration of standards for best practice to alleviate poor application design. JAMA Dermatol, 2013; 149:661–662.
62.
WolfJA, MoreauJF, AkilovO, et al.Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol, 2013; 149:422–426.
63.
McCartneyM. How do we know whether medical apps work?. BMJ, 2013; 346:f1811.
FerreroNA, MorrellDS, BurkhartCN. Skin scan: A demonstration of the need for FDA regulation of medical apps on iPhone. J Am Acad Dermatol, 2013; 68:515–516.
66.
LewisLT, WyattCJ. mHealth and mobile medical apps: A framework to assess risk and promote safer use. J Med Internet Res, 2014; 16:e210.
67.
DonkerT, PetrieK, ProudfootJ, et al.Smartphones for smarter delivery of mental health programs: A systematic review. J Med Internet Res, 2013; 15:e247.
68.
PiantadosiS. Clinical Trials: A Methodologic Perspective. New York: Wiley; 2005.
RounsavilleBJ, CarrollKM, OnkenLS. A stage model of behavioral therapies research: getting started and moving on from stage I. Clin Psychol Sci Pract, 2001; 8:133–142.
71.
BalasEA, BorenSA. Managing clinical knowledge for healthcare improvements. In: van BemmelJH, McCrayAT, eds. Yearbook of Medical Informatics 2000. Stuttgart: Schattauer; 2000: 65–70.
72.
BrownCH, KellamSG, KaupertS, et al.Partnerships for the design, conduct, and analysis of effectiveness, and implementation research: Experiences of the Prevention Science and Methodology Group. Adm Policy Ment Health, 2012; 39:301–316.
73.
GlasgowRE, LichtensteinE, MarcusAC. Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health, 2003; 93:1261–1267.
74.
CollinsLM, MurphySA, StrecherV. The Multiphase Optimization Strategy (MOST) and the Sequential Multiple Assignment Randomized Trial (SMART): New methods for more potent eHealth interventions. Am J Prev Med, 2007; 32(5 Suppl):S112–S118.
75.
MohrCD, SchuellerMS, RileyTW, et al.Trials of intervention principles: Evaluation methods for evolving behavioral intervention technologies. J Med Internet Res, 2015; 17:e166.
76.
MohrDC, CheungK, SchuellerSM, et al.Continuous evaluation of evolving behavioral intervention technologies. Am J Prev Med, 2013; 45:517–523.
77.
WyattJ. Assessing and improving evidence based health informatics research. Stud Health Technol Inform, 2010; 151:435–445.
78.
EysenbachG; CONSORT-EHEALTH Group. CONSORT-EHEALTH: Improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res, 2011; 13:e126.
79.
EysenbachG. CONSORT-EHEALTH: Implementation of a checklist for authors and editors to improve reporting of web-based and mobile randomized controlled trials. Stud Health Technol Inform, 2013; 192:657–661.
80.
SpitzerRL, KroenkeK, WilliamsJB, LoweB. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med, 2006; 166:1092–1097.
81.
NormanSB, CissellSH, Means-ChristensenAJ, SteinMB. Development and validation of an Overall Anxiety Severity and Impairment Scale (OASIS). Depress Anxiety, 2006; 23:245–249.
82.
TaylorS, ZvolenskyMJ, CoxBJ, et al.Robust dimensions of anxiety sensitivity: Development and initial validation of the Anxiety Sensitivity Index-3. Psychol Assess, 2007; 19:176–188.
83.
ShearMK, RucciP, WilliamsJ, et al.Reliability and validity of the Panic Disorder Severity Scale: Replication and extension. J Psychiatr Res, 2001; 35:293–296.
84.
van DixhoornJ, DuivenvoordenHJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res, 1985; 29:199–206.
85.
EndicottJ, NeeJ, HarrisonW, BlumenthalR. Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure. Psychopharmacol Bull, 1993; 29:321–326.
86.
NormanCD, SkinnerHA. eHEALS: The eHealth Literacy Scale. J Med Internet Res, 2006; 8:e27.
87.
EverlyGS, LatingJM. A Clinical Guide to the Treatment of the Human Stress Response, 3rd ed. New York: Springer; 2013.
88.
CohenJ. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
89.
KumarS, NilsenWJ, AbernethyA, et al.Mobile health technology evaluation: The mHealth Evidence Workshop. Am J Prev Med, 2013; 45:228–236.
90.
DeciEL, RyanRM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum; 1985.
91.
PrzybylskiAK, DeciEL, RigbyCS, RyanRM. Competence-impeding electronic games and players' aggressive feelings, thoughts, and behaviors. J Pers Soc Psychol, 2014; 106:441–457.
92.
ChaoYY, SchererYK, WuYW, et al.The feasibility of an intervention combining self-efficacy theory and Wii Fit exergames in assisted living residents: A pilot study. Geriatr Nurs, 2013; 34:377–382.
93.
KatoPM, ColeSW, BradlynAS, PollockBH. A video game improves behavioral outcomes in adolescents and young adults with cancer: A randomized trial. Pediatrics, 2008; 122:e305–317.
94.
LyonsEJ, HatkevichC. Prevalence of behavior changing strategies in fitness video games: Theory-based content analysis. J Med Internet Res, 2013; 15:e81.
95.
SchneiderKL, FerraraJ, LanceB, et al.Acceptability of an online health videogame to improve diet and physical activity in elementary school students: “Fitter Critters.”. Games Health J, 2012; 1:262–268.
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