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Abstract

This study aimed to examine the effects of playing an action video game, Boson X, on anxiety and depression compared to journaling. From South Korea, 42 undergraduate students were randomly assigned to gaming (n = 21) and journaling (n = 21) groups. The intervention continued for 6 weeks. Changes in anxiety and depression levels were checked at 3-week intervals for 9 weeks, including pre-, mid- (week 3), post- (week 6), and follow-up points (week 9). The results revealed that university students’ anxiety and depression in both the gaming and journaling groups were significantly reduced over time. Additionally, reduced anxiety and depression were retained for another 3 weeks after the intervention ended in both the gaming and journaling groups. This study suggests that playing an action game may offer an alternative approach to reducing anxiety and depression in the Korean context.

Keywords

anxiety depression gaming journaling

Introduction

Anxiety and depression are serious societal concerns in South Korea (Kim et al., 2020; Ko et al., 2020). For example, individuals with anxiety and depression are likely to adapt poorly to their daily lives and workplaces (Adams et al., 2016; Murphy et al., 2007). Anxiety and depression are related to physical maladaptation symptoms (e.g., sleep deprivation, stomachache, tiredness, breathing, appetite, headache, fever, and nausea; Donnelly et al., 2021). Additionally, according to a nationwide Korean study (An et al., 2022), anxiety and depression predict the risk of lifetime suicide attempts. Many researchers have found that individuals with anxiety and depression are more likely to think about and attempt suicide (Donnelly et al., 2021; Hanna & Strober, 2020; Kim et al., 2020).

Unfortunately, many South Koreans experience anxiety and depression. According to the Health Insurance Review and Assessment Service (HIRAS, 2022), the numbers of Koreans with anxiety and depression symptoms in South Korea in 2021 were 933,481 and 865,108, respectively. These numbers show a dramatic increase in patients with anxiety and depression by 32.3% and 35.1%, respectively, compared to the data from 2017. Among the age groups, a steep increase in anxiety and depression symptoms was noticeable in those in their 20s (HIRAS, 2022). In particular, the number of patients with anxiety in their 20s was 59,080 and 110,351 in 2017 and 2021, respectively, demonstrating a 16.9% annual growth rate over five years. Additionally, the number of patients in their 20s with depression increased from 78,016 in 2017 to 177,166 in 2021, with an annual growth rate of 22.8% over 5 years. Thus, addressing anxiety and depression is critical.

Recently, playing action video games has emerged as an alternative approach to reducing anxiety and depression (Kühn et al., 2018; Rupp et al., 2017; Zayeni et al., 2020). Video games have been used in various mental health-related areas, such as trauma, anxiety, and depression (Zayeni et al., 2020). Some researchers have used video games to relieve attention-deficit hyperactivity disorder, anxiety, stress, and depression (Falconer et al., 2016; Kühn et al., 2018; Merry et al., 2012; Morimoto et al., 2014; Rupp et al., 2017; Schoneveld et al., 2016). More recently, the United States Food and Drug Administration approved the efficacy of video games as a digital therapeutic device (Hong et al., 2021).

While these studies have significantly enhanced our understanding of the role of video games in reducing anxiety and depression, there is a notable lack of empirical research in South Korea, largely due to societal biases against gaming and the stigma surrounding mental health treatment. Specifically, gaming is often viewed as a negative or unproductive activity, which can deter individuals from engaging with it as a therapeutic tool. Additionally, cultural stigma surrounding mental health issues leads many individuals with anxiety and depression to postpone seeking treatment, further limiting research opportunities in this area (Kim et al., 2021).

Ironically, South Korea is one of the countries where video games are deeply integrated into daily life, particularly among younger generations. According to the Korean Creative Content Agency (KOCCA, 2023), 71.5% of males and 53.9% of females are game users, with over 80% of individuals in their teens, twenties, and thirties engaging in gaming. In contrast, the percentage of gamers among those in their fifties and sixties ranges from 30% to 45%. Additionally, more than half of Koreans play mobile games, dedicating 25% of their mobile phone usage to gaming (Nam & Kim, 2020). Despite the great potential of video games as an alternative therapeutic approach, very little empirical research has been conducted to investigate their effects on reducing anxiety and depression in South Korea. Thus, this study aimed to examine whether playing a video game contributes to reducing individuals’ anxiety and depression compared to journaling, a well-known approach for achieving similar outcomes in South Korea.

Anxiety and Depression

Anxiety has been practically and conceptually discussed with depression. Anxiety and depression are prevalent, and half of the individuals with anxiety experience depression and vice versa (Adams et al., 2016; Hanna & Strober, 2020; Kalin, 2020). Although anxiety and depression are highly correlated (Dobson, 1985; Eysenck & Fajkowska, 2018), they also have differences (Dobson, 1985). Anxiety is a future-oriented emotion that focuses on threats or danger. In contrast, depression is considered a past-oriented emotion that concentrates on the experienced loss or withdrawal from unachievable desires (Eysenck & Fajkowska, 2018). That is, anxiety and depression have a comorbid clinical relationship, and the cause of anxiety in a person may differ from that of depression.

Video Games for Anxiety and Depression

A video game is defined as a game played on an electronic or digital device, such as a computer or mobile device (Halbrook et al., 2019). It is associated with various devices from joysticks to virtual reality gearsets, genres from puzzles to role-playing games, and types from entertainment to medical purposes, such as psychological treatment and diagnosis (Halbrook et al., 2019; Scholten et al., 2016; Schoneveld et al., 2016). Defining types of video games used in counseling is challenging due to the diverse and evolving nature of video games and their applications in diverse therapeutic settings. The variety of games—ranging from hand-held games to immersive virtual reality experiences—means that each can serve different therapeutic purposes, making it difficult to categorize them uniformly. A wide range of video games is used in research as interventions to reduce anxiety and depression. A literature review of empirical studies that use video games to reduce anxiety and depression is conducted separately with each anxiety and depression. The following comprehensive literature review summarizes empirical studies on the efficacy of video games in alleviating anxiety and depression, addressing each condition separately.

Studies have investigated the effects of video gaming on anxiety (Scholten et al., 2016; Schoneveld et al., 2016; Patel et al., 2006). For example, Patel et al. (2006) examined the effects of gaming on young patients (aged 4–12 years) in reducing anxiety before their office visit for outpatient surgery. Youth patients were assigned to one of the following three conditions: handheld gaming available to the public, medicine, and parental care. The results showed that youth patients’ anxiety was relieved more under the video game condition than under the medicine and parental care conditions, even if the handheld gaming was not designed to reduce anxiety. Scholten et al. (2016) examined the effects of video game type on anxiety levels in adolescents aged 11 to 15 years. This study employed two immersive 3D video games: a typical action video game, Rayman 2: The Great Escape, and a biofeedback video game, Dojo, and found that both types reduced anxiety in adolescents. In another study, Schoneveld et al. (2016) compared the effectiveness of neurofeedback and regular video games in children aged 7 to 13 with high anxiety levels. They found that although two types of games helped reduce anxiety, a neurofeedback video game, Mind Light, was more effective in lowering anxiety levels than a commercially successful video game, Max and the Magic Marker. Overall, playing a video game helped relieve anxiety.

Next, the efficacy of video games on depression was studied in various age groups by focusing on particular games, such as action and adventure games, which can pose physical challenges (i.e., hand coordination with eyes in the limited reaction time) of players, and digital therapeutic games, which were specially devised for treating depression (Keefe et al., 2022; Morimoto et al., 2014). For example, research on the effectiveness of the action video game Boson X on depression was conducted in adults aged 18 to 65 (Kühn et al., 2018). The game group showed a significant reduction in depression compared with the control group, which surfed websites. With older adults with depression aged 60 to 89, Morimoto et al. (2014) compared the neuroplasticity-based computerized cognitive remediation-geriatric depression treatment, that is, a simple game and medicine, escitalopram. The simple game was significantly more effective in relieving depression than medicine. In addition, the effectiveness of therapeutic interventions was compared for relieving depression among adolescents aged 12 to 19 with depression symptoms (Merry et al., 2012). The therapeutics for the comparison were an interactive fantasy game, SPARX, and treatment, that is, face-to-face therapy. Keefe et al. (2022) explored the efficacy of different types of games in relieving depressive symptoms among adults aged 22 to 55 with major depression disorders and compared the digital therapeutic game AKL-T03 with a matching-task game devised for the experiment. Both games significantly relieved depression symptoms. However, sustained attention in the digital therapeutic group was significantly enhanced compared to the control group, and cognitive deficits improved more in the experimental group than in the control group.

The studies reviewed indicate that video gaming can be an effective intervention for reducing anxiety and depression across different age groups (Keefe et al., 2022; Kühn et al., 2018; Morimoto et al., 2014). For anxiety, research demonstrates that gaming conditions, including handheld and immersive 3D games, significantly alleviate anxiety levels in children and adolescents, with neurofeedback games showing particularly strong results (Scholten et al., 2016; Schoneveld et al., 2016; Patel et al., 2006). Similarly, in addressing depression, action and digital therapeutic games have proven effective, often outperforming traditional treatments like medication and face-to-face therapy (Kühn et al., 2018; Merry et al., 2012; Patel et al., 2006). Notably, games designed specifically for therapeutic purposes, such as SPARX and AKL-T03, not only relieve depressive symptoms but also enhance cognitive functions like sustained attention (Keefe et al., 2022; Merry et al., 2012). Overall, these findings highlight the potential of video gaming as a viable intervention for alleviating anxiety and depression, offering both immediate and sustained mental health benefits.

Journaling for Anxiety and Depression

Journaling, an act of keeping records of individuals’ thoughts, insights, and feelings as they navigate daily life, is one of the least expensive and most effective approaches to reducing anxiety and depression (Sohal et al., 2022). Gratitude, positive, and expressive journaling are three types of journaling often used to reduce anxiety and depression. Gratitude journaling involves regularly writing down things for which one is grateful (Southwell & Gould, 2017). This practice helps individuals focus on positive aspects of their lives, fostering a sense of appreciation and contentment. Positive journaling focuses on writing about positive experiences and emotions (Suhr et al., 2017). It aims to shift attention away from negative thoughts and towards positive aspects of life, thereby enhancing mood and overall well-being. Expressive journaling involves writing about stressful, traumatic, or emotional experiences (Baikie et al., 2012). It allows individuals to explore and process their deepest thoughts and feelings about difficult events, leading to emotional release and greater self-understanding. Each type of journaling offers unique benefits and can be chosen based on individual needs and therapeutic goals.

The effectiveness of journaling on anxiety has been investigated by comparing various diaries, such as gratitude, positive, and expressive (Baikie et al., 2012; Ducasse et al., 2019; Southwell & Gould, 2017). Southwell and Gould (2017) studied the effects of gratitude on anxiety and its symptoms. As the intervention, the research participants used a gratitude diary, writing about their experiences of gratitude for 3 weeks. The participants wrote in their diaries before sleeping for at least 3 days per week. The results showed that anxiety and sleep difficulty were significantly improved post-experiment. The researchers found that the gratitude diary remained effective for another 3 weeks post-intervention. One comparison study (Baikie et al., 2012) explored the long-lasting influences of expressive, gratitude, and control writing groups on anxiety. Participants in the expressive writing group wrote about their emotional issues, those in the gratitude writing group described their positive experiences, and those in the control writing group wrote about their daily lives. Each group completed four writing tasks over 2 weeks. This study discovered that anxiety was relieved for at least 4 months after the experiment in all three groups.

In addition, many empirical studies have examined the efficacy of journaling interventions for depression (Ducasse et al., 2019; Giovanetti et al., 2019; Reinhold et al., 2018; Robertson et al., 2019; Suhr et al., 2017). For example, the role of positive writing in depression has been explored with patients in a rehabilitation hospital (Suhr et al., 2017). The study was conducted with positive writing and control groups for 4 weeks. The positive writing group wrote a diary for at least 3 days per week, whereas the control group was not treated. This study found significant relief from depression in the positive writing group compared to the non-treatment group. Robertson et al. (2019) investigated the efficacy of expressive writing in relieving depression in first-year college students. Participants were grouped into mild, moderate, and severe depression symptoms based on their initial diagnosis and completed expressive writing for 3 days. All three groups showed significant reductions in depression at six months by comparing with the initial diagnosis. Moreover, their physical illness was significantly reduced compared to that of the control group, which completed non-emotional writing tasks. One meta-analysis explored the long-term effects of expressive writing on the relief of depression symptoms (Reinhold et al., 2018). Expressive writing had no significant long-term effects on healthy adults. However, the number of expressive writings was significantly associated with relief for those with depression symptoms.

The collective findings from various studies indicate that journaling—whether through gratitude, positive, or expressive writing—is an effective intervention for reducing anxiety and depression. Gratitude journaling has been shown to significantly improve anxiety and sleep difficulties, with lasting effects, while expressive and positive writing have demonstrated long-term benefits in alleviating symptoms of depression and enhancing physical health (Baikie et al., 2012; Robertson et al., 2019; Southwell & Gould, 2017). Although expressive writing did not show significant long-term effects for healthy adults, it proved beneficial for those with depression (Reinhold et al., 2018). Overall, these studies underscore the therapeutic value of journaling in managing mental health issues such as anxiety and depression.

Comparison of Gaming Intervention to Journaling

Gaming and journaling, both increasingly popular interventions in counseling for anxiety and depression, offer distinct strengths and limitations. Gaming excels in its high engagement factor, intrinsic motivation, and ability to provide extensive practice opportunities without losing interest (Granic et al., 2014; Kowal et al., 2021; Pine et al., 202). Its appeal, particularly to younger populations, makes it an effective “stealth” approach for delivering mental health interventions, especially for those reluctant to seek traditional help (Fleming et al., 2017). Games can also be personalized, adjusting to individual needs and maintaining an optimal balance of challenge and reinforcement. However, gaming interventions come with potential drawbacks, including the risk of overuse or addiction, limited face-to-face interaction, and possible technical barriers for some individuals. Additionally, measuring therapeutic progress through gaming can be challenging.

On the other hand, journaling offers strengths in promoting self-reflection, stress reduction, and problem-solving skills (Graf et al., 2008; Lundgren et al., 2018; Reinhold et al., 2018). It is highly flexible, can be adapted to various therapeutic approaches, and requires minimal resources, making it accessible to a wide range of individuals (Reinhold et al., 2018). Journaling also aids in memory improvement and can be done anywhere, anytime (Graf et al., 2008). However, some individuals may struggle with maintaining a consistent journaling practice, and there is a lack of immediate feedback compared to interactive interventions like gaming. Furthermore, journaling may present challenges for those with limited writing skills or language proficiency, and some may have privacy concerns about their written thoughts and feelings (Lundgren et al., 2018).

Potential Challenges to Implement Video Gaming Intervention in South Korea

To implement video games as an intervention for reducing anxiety and depression in South Korea, at least three challenges should be considered: technology access and literacy, cultural stigma toward gaming as a mental health treatment, and issues related to game addiction. First, technology access and literacy must be taken into account. Although South Korea has an advanced technological infrastructure, disparities in access still exist, particularly among lower-income families and in rural areas (Jun, 2021). Access to high-quality gaming platforms or VR equipment necessary for certain therapeutic games may be limited. Additionally, not all individuals are comfortable with or familiar with gaming technology, which is especially relevant for older adults or those who are not accustomed to digital interfaces (Jun, 2021; Wilson et al., 2023). Second, cultural stigma surrounding gaming should be considered. In South Korea, gaming is sometimes viewed negatively, particularly when associated with addiction or escapism. This stigma can extend to therapeutic use, where gaming might be perceived as an inappropriate or less serious method of treatment compared to traditional therapies (Seo et al., 2022). Third, issues related to game addiction must be addressed. South Korea faces a significant problem with gaming addiction, which has been recognized by both the government and the media (Seok et al., 2018). This complicates the use of gaming as a therapeutic tool, as it might inadvertently contribute to or reinforce existing addiction problems if not managed carefully (Kwon et al., 2015).

Research Questions

This study’s purpose was to examine the effectiveness of action gaming in reducing anxiety and depression. An action game such as Boson X was chosen as an intervention for gaming. Boson X was selected because it was originally developed to help reduce anxiety and depression. It is user-friendly, making it accessible even for beginners, and it ensures high technological accessibility by being available on both PC and mobile platforms while requiring minimal memory. For comparison, we used an expressive journaling group, as it is a well-known low-cost intervention for reducing anxiety and depression. This method allows individuals to write about stressful, traumatic, or emotional experiences during the COVID-19 pandemic. More specifically, the following two research questions guide this study:

1 Is playing an action game as effective as expressive journaling in reducing anxiety?

2 Is playing an action game as effective as expressive journaling in reducing depression?

Method

Participants

To recruit participants, a research recruitment letter was posted on the website of the university where this study was conducted, and 75 students volunteered to participate. For participation, the following inclusion criteria were set: the participants should (a) be over 20 years old, (b) have a personal smartphone, and (c) have depression symptoms defined as either mild or moderate according to the Beck Depression Inventory (BDI-II) score (see the Research Instrument section). Using the exclusion criteria (i.e., participants should not have symptoms of a psychiatric or neurological disorder, such as schizophrenia, or other psychotic disorders), 26 participants were excluded. Subsequently, the remaining 49 participants were randomly assigned to one group in the gaming group and the other group in the journaling group. However, seven students withdrew from the study. The final number of participants in the gaming and journaling groups was 21 each. Thus, 42 university students participated in the study.

To examine the differences between the gaming and journaling groups, an independent sample t-test and chi-square test of independence were performed with sociodemographic variables (see Table 1). No significant differences were found in the variables, that is, age (t = −0.48, p > .05), gender (χ² = 1.00, p > .05), household type (χ² = 0.53, p > .05), and gaming frequency (χ² = 2.33, p > .05). The results demonstrated no significant differences in sociodemographic characteristics between the gaming and journaling groups.

Table 1.

Sociodemographic Information Between Gaming and Journaling Groups.

Sociodemographic variables		Gaming group (N = 21)	Journaling group (N = 21)	Statistics
Age		25.2 (4.6)	25.9 (4.3)	t ₍₄₀₎ = −0.48, p > .05
Gender	Female	11 (52.4)	11 (52.4)	χ² = 1.00, p > .05
Gender	Male	10 (47.6)	10 (47.6)	χ² = 1.00, p > .05
Household type	One-person household	7 (33.3)	10 (47.6)	χ² = 0.53, p > .05
Household type	Group household	14 (66.7)	11 (52.4)	χ² = 0.53, p > .05
Gaming frequency	Never	2 (9.5)	1 (4.8)	χ² = 2.33, p > .05
	Everyday	7 (33.3)	7 (33.3)
	4–5 days per week	1 (4.8)	0 (0.0)
	2–3 days per week	6 (28.6)	6 (28.6)
	1–4 days per month	4 (19)	4 (19.0)
	1–11 times per year	1 (4.8)	3 (14.3)

Group Conditions

Two group conditions—gaming and journaling—were used in this study. Descriptions of each condition are provided below.

Gaming Group

Participants in the gaming group daily played Boson X for half an hour for 6 weeks. They had to report their daily gaming time, such as the starting and ending times, on Google Docs. Boson X has been downloaded more than 10,000 times since its release in 2013 and has regular updates. It is accessible on both PC and mobile phones. Boson X (see Figure 1) is a fast-paced action game in which the player controls a character from a third-person perspective with a camera fixed behind it through a tunnel. The character moves automatically through a tunnel, and the player must overcome obstacles by pressing one of three keys (up, left, and right on the keyboard). If the player steps onto a missing tile, the character is forced to restart the level. As the game progresses and the levels rise, users must respond faster and more precisely.

Figure 1.

Action video game Boson X screenshots.

Journaling Group

Participants in the journaling group wrote three times a week for 6 weeks. The journal format was loosely structured. Participants were instructed to respond to the two questions in their daily journals via Google Docs with at least seven sentences per journal entry. The two questions were, “What did you do today?” and “How did you feel today?” An example of a daily journal written by a participant is presented below:

The social distancing level owing to COVID-19 has been raised to level 2, and some things that I usually do freely have been restricted. The gym I used to go to every morning was closed. All the appointments with friends scheduled for today and tomorrow were canceled. I felt frustrated as I continued to experience things that were out of my control. How long should I wear a mask and reduce my interactions with people? Many people may be having a more challenging time than I am owing to the coronavirus situation, but I am also very frustrated and challenged by the current situation.

Research Instrument

We used self-reported questionnaires and observer-rated assessments to measure anxiety and depression. The General Anxiety Disorder-7 (GAD-7) and the Hamilton Anxiety Rating Scale (HARS) were used to measure anxiety. The BDI-II and the Hamilton Depression Rating Scale (HDRS) were used to assess depression. Detailed information on each measurement is provided below.

GAD-7

The GAD-7 is a 7-item self-report measure that assesses the severity of generalized anxiety disorders (Spitzer et al., 2006). The Korean version of the GAD-7 used in this study was obtained from Ahn et al. (2019). Using a 4-point Likert scale (0 = not at all; 3 = nearly every day), participants were asked to report the frequency of anxiety symptoms (i.e., feeling nervous, anxious, or on the edge and worrying too much about different things) over the previous 2 weeks. The total score ranges from 0 to 21, with higher scores indicating more severe GAD symptoms. The Cronbach’s alpha for the current participants ranges from .81 to .92.

HARS

The HARS is a 14-item observer rating scale that measures anxiety level and symptom distribution (Hamilton, 1959). The HARS describes anxiety levels, including psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety), using a 5-point Likert scale (0 = not present) to 4 (severe). Example items include “anxious mood” and “tension” for psychic anxiety, and “gastrointestinal symptoms” or “cardiovascular symptoms” for somatic anxiety. The total score ranges from 0 to 56 points, with higher scores indicating greater severity of symptoms. The Cronbach’s alpha for the current participants ranges from .88 to .90.

BDI-II

The BDI-II is a self-report questionnaire consisting of 21 items that assess the degree of depression symptoms (i.e., sadness, pessimism, and past failure) presented over 2 weeks. The BDI was initially developed by Beck et al. (1961) and revised into BDI-II (Beck et al., 1996) in response to changes in the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for diagnosing depression symptoms. Each item is rated on a 4-point scale from 0 to 3 (0 = not at all; 3 = nearly every day), with summation scores ranging from 0 to 63. Higher total scores indicate more severe depression symptoms. A total score ranging from 0–10, 11–19, 20–29, and more than 30 indicates no, mild, moderate, and severe depression, respectively. The Cronbach’s alpha for the current sample ranges from .78 to .88.

HDRS

The HDRS, which consists of 17 items, is an observer rating scale. It was developed to assess the severity of depression symptoms (Hamilton, 1960). This study used the Korean version of the HDRS, which was adopted and validated by Yi et al. (2005). For each depression symptom, nine items (e.g., depressed mood, feeling of guilt, and suicide) were scored 0 to 4 (0 = absent; 4 = incapacitating), and eight items (insomnia, retardation) were scored 0 to 2 (0 = absent; 2 = severe). Total scores range from 0 to 52, with higher scores indicating more severe depression symptoms. The Cronbach’s alphas for the current sample range from .82 to .90.

Research Procedure

The campus institutional review board at the university where the current study was conducted approved this study. All participants were informed of the research goal and their rights as participants. The study was conducted for 9 weeks, from July to September 2020, during the COVID-19 pandemic. The 42 students were randomly assigned to either the gaming (n = 21) or the journaling (n = 21) group. Before the study, the GAD-7 and BDI-II self-report instruments were administered to measure anxiety and depression, respectively. In individually scheduled meetings with participants, two clinical psychologists administered the HARS and the HDRS to measure anxiety and depression, respectively, without knowing the conditions to which each participant was assigned. Both the self-reporting and two observer rating scales were administered four times: at baseline, in the middle of the intervention (week 3), at the end of the intervention (week 6), and 3 weeks after the intervention (week 9).

Results

Effects of Gaming on Reducing Anxiety Compared to Journaling

Baseline Between Gaming and Journaling Group

To check the baseline differences in anxiety between the gaming and journaling groups, independent sample t-tests were conducted with pre-point scores on the GAD-7 and HARS. The results showed no significant differences between the two groups in the GAD-7, t(40) = −1.092, p = .281, and HARS, t(40) = 0.666, p = .509, demonstrating that the levels of anxiety in the two groups were the same (see Table 2).

Table 2.

Mean and Standard Deviations of Anxiety and Depression for Each Group.

Measures	Group	n	Pre		Mid		Post		Follow
Measures	Group	n	M	SD	M	SD	M	SD	M	SD
Anxiety
GAD-7	Gaming	21	4.33	2.60	3.67	3.79	2.33	2.18	3.24	3.55
GAD-7	Journaling	21	5.24	2.77	3.57	3.14	2.62	2.20	1.86	1.74
HARS	Gaming	21	12.57	5.75	9.05	5.84	8.33	7.21	8.48	8.40
HARS	Journaling	21	11.43	5.37	9.52	5.50	5.91	4.36	5.33	4.15
Depression
BDI-II	Gaming	21	19.24	7.94	11.86	5.74	9.43	5.60	9.76	6.27
BDI-II	Journaling	21	20.05	8.41	11.05	6.04	8.33	6.42	7.1	4.76
HDRS	Gaming	21	13.52	5.60	9.76	5.24	7.57	5.60	7.24	6.16
HDRS	Journaling	21	11.24	4.63	10.43	5.11	7.24	4.81	5.52	4.08

Effects of Interventions on Anxiety Change Over Time

To examine group differences in anxiety changes over time, a 2 (group: gaming, journaling) × 3 (time point: pre-, mid-, post-) repeated measures multivariate analysis of variance (MANOVA) was conducted using GAD-7 and HARS scores as dependent variables. The analysis revealed no significant interaction between group and time point, F(2, 39) = 5.82, p = .564, η²_p = .029; no significant main effect of group, F(1, 40) = 1.21, p = .278, η²_p = .029; but a significant main effect of time point, F(2, 39) = 19.83, p < .001, η²_p = .504.

Follow-up repeated-measures analyses of variance (ANOVAs) revealed significant reductions in anxiety levels across time points on GAD-7, in both the gaming group, F(2, 40) = 3.98, p = .026, η²_p = 0.17, and the journaling group, F(2, 40) = 7.84, p = .001, η²_p = 0.28 (see Table 2). Pairwise comparisons with Bonferroni correction revealed significant differences in GAD-7 between the pre-point (M = 4.33, SD = 2.60) and the post-point (M = 2.33, SD = 2.18, p = .013) in the gaming group. For the journaling group, significant differences were found between the pre-point (M = 5.24, SD = 2.77) and mid-point (M = 3.57, SD = 3.14, p = .043) and between the pre-point (M = 5.24, SD = 2.77) and post-point (M = 2.62, SD = 2.20, p = .005). These results indicate that participants’ self-reported anxiety levels measured with GAD-7 significantly decreased between pre- and post-points in both groups.

Additional repeated-measures ANOVAs revealed significant reductions in anxiety levels across time points on HARS, in both the gaming group, F(2, 40) = 5.35, p = .009, η²_p = 0.21, and the journaling group, F(2, 40) = 17.34, p < .001, η²_p = 0.66 (see Table 2). Pairwise comparisons with Bonferroni correction revealed significant differences in HARS between the pre-point (M = 12.57, SD = 5.75) and the mid-point (M = 9.05, SD = 5.84, p = .041), as well as between the pre-point and post-point (M = 8.33, SD = 7.21, p = .031) in the gaming group. In the journaling group, significant difference was found between the pre-point (M = 11.43, SD = 5.37) and the post-point (M = 5.91, SD = 4.36, p < .001). These results collectively demonstrate that participants’ anxiety levels significantly decreased over time, regardless of intervention type or measurement approach (self-reported vs. observer-rated; see Figure 2).

Figure 2.

Anxiety change over time.

Anxiety Between Post and Follow-up

To check the continuity of reduced anxiety at the follow-up point, paired-sample t-tests were conducted with the GAD-7 and the HARS separately in each group. In the gaming group, insignificant differences in the GAD-7, t(20) = −1.694, p = .106, and the HARS, t(20) = −0.101, p = .920 were found, demonstrating that reduced anxiety continued for another 3 weeks. In the journaling group, insignificant differences in GAD-7, t(20) = 1.925, p = .069, and the HARS, t(20) = 1.023, p = .319, were found, demonstrating that reduced anxiety continued for another 3 weeks (see Figure 2).

Effects of Gaming on Reducing Depression Compared to Journaling

Baseline Between Gaming and Journaling Group

To check the baseline differences in depression between the gaming and journaling groups, independent sample t-tests were conducted with pre-point scores on the BDI-II and HDRS. The results showed no significant differences between the two groups in BDI-II, t(40) = −0.321, p = .750, and HDRS, t(40) = 1.442, p = .157, indicating that the levels of depression between the two groups were the same.

Effects of Interventions on Depression Change Over Time

To examine group differences in depression changes over time at pre-, mid-, and post-points, a 2 (group: gaming, journaling) × 3 (time point: pre-, mid-, post-) repeated measures multivariate analysis of variance (MANOVA) was conducted, using BDI-II and HDRS scores as dependent variables. The analysis revealed no significant interaction between group and time point, F(2, 39) = 0.15, p = .857, η²_p = .008; no significant main effect of group, F(1, 40) = 0.05, p = .831, η²_p = .001; and a significant main effect of time point, F(2, 39) = 33.50, p < .001, η²_p = .632.

Follow-up repeated-measures analyses of variance (ANOVAs) revealed significant reductions in depression levels across time points on BDI-II, in both the gaming group, F(2, 40) = 27.03, p < .001, η²_p = 0.58, and the journaling group, F(2, 40) = 18.24, p < .001, η²_p = 0.48 (see Table 2). Pairwise comparisons with Bonferroni correction revealed significant differences in BDI-II between the pre-point (M = 19.24, SD = 7.94) and mid-point (M = 11.86, SD = 5.74, p < .001) as well as between the pre-point (M = 19.24, SD = 7.94) and post-point (M = 9.43, SD = 5.60, p < .001) in the gaming group. For the journaling group, significant differences were found between pre-point (M = 20.05, SD = 8.41) and the mid-point (M = 11.05, SD = 6.04, p = .003) as well as between the pre-point (M = 20.05, SD = 8.41) and the post-point (M = 8.33, SD = 6.42, p < .001). These results indicate that participants’ self-reported depression levels measured with BDI-II significantly decreased between pre- and post-points in both groups.

Additional repeated-measures ANOVAs revealed significant reductions in depression levels across time points on HDRS, in both the gaming group, F(2, 40) = 9.89, p < .001, η²_p = 0.33, and the journaling group, F(2, 40) = 5.91, p = .006, η²_p = 0.23 (see Table 2). Pairwise comparisons with Bonferroni correction revealed significant differences in HDRS between the pre-point (M = 13.52, SD = 5.60) and mid-point (M = 9.76, SD = 5.24, p = .029) as well as between the pre-point (M = 13.52, SD = 5.60) and post-point (M = 7.57, SD = 5.60, p < .001) in the gaming group. In the journaling group, significant differences were found between the pre-point (M = 11.24, SD = 4.63) and the post-point (M = 7.24, SD = 4.81, p = .013). These results collectively demonstrate that participants’ depression levels significantly decreased over time, regardless of intervention type or measurement approach (self-reported vs. observer-rated; see Figure 3).

Figure 3.

Depression change over time.

Depression Level Between Post and Follow-up Points Within Each Group

To check the continuity of reduced depression to the follow-up point, paired-sample t-tests were conducted with the BDI-II and the HDRS separately in each group. In the gaming group, insignificant differences in BDI-II, t(20) = −.284, p = .779, and HDRS, t(20) = .278, p = .784, were found, demonstrating that reduced anxiety continued for another 3 weeks. In the journaling group, an insignificant difference was found in the BDI-II, t(20) = 1.330, p = .198, indicating that the reduced depression continued for another 3 weeks. Interestingly, however, the HDRS was significantly reduced at the follow-up point compared to the post-point, t(20) = 2.186, p < .05, indicating that journaling was even more effective than gaming in reducing depression.

Discussion

This study aimed to examine the effects of playing an action video game, Boson X on individuals’ anxiety and depression in comparison to journaling. More specifically, we investigated whether playing an action video game is as effective as expressive journaling in reducing anxiety and depression. Overall, the results showed that playing the action video game was effective in reducing the participants’ anxiety and depression as measured by both self-reported and observer-rated scales, with their effectiveness retaining 3 weeks after discharge. Notably, the observed effects of playing the action video game were almost equivalent to those of journaling, a well-known low-cost approach for reducing anxiety and depression.

One critical finding of this study was that playing an action video game, Boson X, reduced anxiety and depression. Our study proves that playing a well-selected game can be a valuable approach to reducing anxiety and depression among people in their 20s in South Korea. This study is meaningful as video games are rarely used in South Korea as a research tool because of the prevalent bias against them, such as gaming being terrible or that games can be a source of addiction and can cause physical and mental health problems, such as depression and anxiety (Seok et al., 2018). However, our study empirically proves that games can be used to relieve participants’ anxiety and depression, especially for those in their 20s who are using games often in their daily lives and have easy access to them.

Our study also suggests that gaming has the potential to serve as an alternative approach for the public in urgent situations such as the COVID-19 pandemic. Owing to the pandemic, participants experienced unwanted social isolation and quarantine to mitigate the spread of the coronavirus infection (Ganesan et al., 2021). Further, as over half of the mental health services across the world were disrupted, many people with anxiety and depression symptoms were unable to receive timely and appropriate treatment (Byrne et al., 2021), which is related to an increased number of mental disorders and suicide attempts and higher suicide rates (Ganesan et al., 2021). Our study was conducted during the COVID-19 pandemic, during which many students reported anxiety and depression and were isolated from family and friends. In an emergency, video gaming can be an alternative approach before patients visit their doctors (Byrne et al., 2021; Ganesan et al., 2021). Our study shows that gaming can be an alternative tool for this effort.

The effects of gaming can occur in two ways. First, playing a game gives individual participants a sense of positive emotions, such as enjoyment and achievement (Kowal et al., 2021). Barr and Copeland-Stewart (2021) reported that playing a video game relieved stress through enjoyment. In a study involving 4 weeks of music-based casual video game training (Li et al., 2022), playing video games decreased symptoms of depression and increased positive emotions, such as joy, cheerfulness, and satisfaction, compared to a control group who did not play video games. According to Kühn et al. (2018), playing Boson X gave participants a sense of achievement when they completed each stage or challenging task. Second, playing action video games helps relieve anxiety and depression by disrupting rumination in some participants (Kowal et al., 2021). Kühn et al. (2018) found that playing Boson X distracted participants from ruminating about depression by requiring them to allocate their cognitive resources to game activities. Another study also discovered that playing 3D video games reduced rumination on repetitive negative thinking, which worsens emotions and cognitive states, among clinically depressed individuals (Bergmann et al., 2023). Patel et al. (2006) reported that playing hand-held video games was an effective distraction intervention for decreasing anxiety among children before surgery. Thus, playing an action video game may help individuals shift their cognitive focus from anxious and depressive thoughts to other thoughts that foster positive emotions, such as enjoyment and a sense of achievement.

Similar to previous findings (Baikie et al., 2012; Lee et al., 2016; Reinhold et al., 2018), our study demonstrates that journaling helps participants reduce their anxiety and depression. Our findings are similar to those of Lee et al. (2016), who compared Korean participants’ anxiety and depression between journaling and non-journaling groups. Lee et al. (2016) found that the daily journaling group showed significant relief from anxiety and depression during, at the end of, and 3 weeks after the experiment. Journaling allows individuals to relieve unnecessary cognitive loads by discharging their feelings, being insensitive to negative emotions, or rational reasoning between their emotions and thoughts. In our study, journaling facilitated participants to write about their anxiety and depression at any time of the day and reflect on their emotions (Baikie et al., 2012; Reinhold et al., 2018). As journaling allows participants to mitigate their anxiety and depression and understand their emotional states, it may help relieve their anxiety and depression (Baikie et al., 2012).

Our study found no significant differences in anxiety and depression between the gaming and journaling conditions and demonstrated the potential of gaming as an approach to reduce anxiety and depression, especially among people in their 20s in South Korea (Sohal et al., 2022). Owing to the widespread use of smart devices (Nam & Kim, 2020), the cost of gaming has decreased. Smart devices allow individuals to install and uninstall games easily when they want (Nam & Kim, 2020). These accessibility traits in games are not significantly different from those in a journal. That is, gaming can be an interchangeable approach with journaling, which is a low-cost and straightforward approach to relieve anxiety and depression.

Understanding how gaming and journaling differ could provide valuable insights for future clinical practice. We compared gaming and journaling from three perspectives: engagement, accessibility, and potential risks. In terms of engagement, gaming captivates users through interactive experiences and immediate rewards, which can provide enjoyment, relaxation, and a sense of accomplishment (Kowal et al., 2021; Kühn et al., 2018; Pine et al., 2020; Scholten et al., 2016). Journaling, on the other hand, allows individuals to express and process their emotions (Baikie et al., 2012) and facilitates the development of self-awareness and personal growth through introspection (Baikie et al., 2012; Reinhold et al., 2018). Regarding accessibility, journaling is generally more acceptable due to its minimal requirements, whereas gaming necessitates access to specific technologies and platforms. Lastly, concerning potential risks, gaming poses risks such as addiction and overstimulation. Excessive gaming can lead to neglect of responsibilities, sleep disturbances, and social isolation (Seok et al., 2018). In contrast, journaling may present challenges for some individuals, as sharing sensitive emotions through writing can be difficult or uncomfortable, impacting consistent engagement. Ultimately, the choice between these interventions—or their combined use—should be based on individual preferences, needs, and therapeutic goals. Many therapists are now incorporating both methods, leveraging the strengths of each to provide comprehensive and engaging mental health support.

Limitations and Future Study

One limitation of this study is the absence of a control group. Having a control group in which students engage in neither video gaming nor journaling would provide more accurate results regarding the effectiveness of video gaming. Future research should consider using a control group to better understand the intervention effects on reducing anxiety and depression. Another limitation of the study is the characteristics of the participants, which may only partially represent Koreans in their 20s. All participants were enrolled at a university. To generalize the results to the broader population of Koreans in their 20s, it is essential to recruit a larger and more diverse group of participants, including those without a higher education background. A third limitation is that this study focused solely on the efficacy of action video gaming. To expand the applicability of video gaming, future researchers should consider exploring the efficacy of various types of video games (e.g., emotion regulation, relaxation, mindfulness, or serious games for mental health) on anxiety and depression. Investigating the action mechanisms and therapeutic effects of different game genres will be useful in prescribing intervention methods that consider clients’ symptoms, preferences, accessibility to technology, and intervention objectives. Additionally, it is unclear whether the effects of the game will persist beyond the short-term follow-up period (3 weeks after the post). Longitudinal studies examining the sustainability of gaming interventions for anxiety and depression would provide valuable insights into their long-term efficacy.

Significance of the Study

Despite these limitations, this study is critical for the Korean context. First, limited empirical research has been conducted in Korea to examine the effects of video gaming on anxiety and depression. Our study demonstrates the potential for further research using video gaming as an alternative digital therapy in counseling. Second, this study proved that video gaming had positive effects on reducing anxiety and depression in Korean settings. Considering the high accessibility of video games to the Korean public (Nam & Kim, 2020), game intervention is a promising approach for reducing anxiety and depression in the Korean context, particularly for young adults in their 20s. Recently, several attempts have been made to examine the effects of diverse types of gaming on counseling (Falconer et al., 2016; Hong et al., 2021; Keefe et al., 2022; Morimoto et al., 2014; Poppelaars et al., 2021); our study contributed to this effort. Third, we observed that the participants’ anxiety and depression changed at multiple time points (pre-, mid-, post-, and follow-up, with 3-week intervals at each time point) over 9 weeks. The relatively long observation time provides strong evidence for the efficacy of video gaming in reducing anxiety and depression. Finally, unlike many studies in which only video games or journaling were used as interventions, we employed both interventions in one study. We have found that video gaming has equivalent effects on journaling in terms of reducing anxiety and depression, which is a unique contribution to existing literature.

Footnotes

ORCID iDs

Moon-Heum Cho

Seokwon Hwang

Ye Jin Kim

Dong Hun Lee

Ethical Considerations

The present study was approved by the Institutional Review Board (IRB) from SungKyunKwan University.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF2021S1A3A2A02089682), and by the Korea Creative Content Agency (KOCCA) funded by the Ministry of Culture, Sports and Tourism (KOCCA 20-39, A Study on the Therapeutic Applications of Digital Games)

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The Effects of Playing an Action Video Game on Reducing Anxiety and Depression: A Comparison with Journaling

Abstract

Keywords

Introduction

Anxiety and Depression

Video Games for Anxiety and Depression

Journaling for Anxiety and Depression

Comparison of Gaming Intervention to Journaling

Potential Challenges to Implement Video Gaming Intervention in South Korea

Research Questions

Method

Participants

Group Conditions

Gaming Group

Journaling Group

Research Instrument

GAD-7

HARS

BDI-II

HDRS

Research Procedure

Results

Effects of Gaming on Reducing Anxiety Compared to Journaling

Baseline Between Gaming and Journaling Group

Effects of Interventions on Anxiety Change Over Time

Anxiety Between Post and Follow-up

Effects of Gaming on Reducing Depression Compared to Journaling

Baseline Between Gaming and Journaling Group

Effects of Interventions on Depression Change Over Time

Depression Level Between Post and Follow-up Points Within Each Group

Discussion

Limitations and Future Study

Significance of the Study

Footnotes

ORCID iDs

Ethical Considerations

Funding

Declaration of Conflicting Interests

Data Availability Statement

References