Can We Use Gamification in Mobile Mental Health Interventions?

Research Paper Title

Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial.


40% of all general practitioner (GP) appointments are related to mental illness, although less than 35% of individuals have access to therapy and psychological care, indicating a pressing need for accessible and affordable therapy tools.

The ubiquity of smartphones offers a delivery platform for such tools. Previous research suggests that gamification-turning intervention content into a game format-could increase engagement with prevention and early-stage mobile interventions.

This study aimed to explore the effects of a gamified mobile mental health intervention on improvements in resilience, in comparison with active and inactive control conditions. Differences between conditions on changes in personal growth, anxiety and psychological wellbeing, as well as differences in attrition rates, were also assessed.


The eQuoo app was developed and published on all leading mobile platforms.

The app educates users about psychological concepts including emotional bids, generalisation, and reciprocity through psychoeducation, storytelling, and gamification.

In total, 358 participants completed in a 5-week, 3-armed (eQuoo, “treatment as usual” cognitive behavioural therapy journal app, no-intervention waitlist) randomized controlled trial. Relevant scales were administered to all participants on days 1, 17, and 35.


Repeated-measures ANOVA revealed statistically significant increases in resilience in the test group compared with both control groups over 5 weeks.

The app also significantly increased personal growth, positive relations with others, and anxiety. With 90% adherence, eQuoo retained 21% more participants than the control or waitlist groups.

Intervention delivered via eQuoo significantly raised mental well-being and decreased self-reported anxiety while enhancing adherence in comparison with the control conditions.


Mobile apps using gamification can be a valuable and effective platform for well-being and mental health interventions and may enhance motivation and reduce attrition.

Future research should measure eQuoo’s effect on anxiety with a more sensitive tool and examine the impact of eQuoo on a clinical population.


Litvin, S., Saunders, R., Maier, M.A. & Luttke, S. (2020) Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial. PLoS One. 15(9), pp.e0237220. doi: 10.1371/journal.pone.0237220. eCollection 2020.

Could a Robot Improve the Way We Treat OCD?

A robot that mimics obsessive compulsive disorder (OCD) could help us understand the condition (Lewis et al., 2019).

OCD involves obsessive worrying that compels people to carry out rituals like repeated handwashing, and generates anxiety if they cannot complete these compulsions.

Researchers recreated this in a robot they programmed to achieve three goals:

  • Eat;
  • Avoid bumping into things; and
  • Groom.

The robot eats by touching light patches on the floor, replenishing its energy. It grooms by going to, and bumping into, a solid post – a behaviour that causes damage and runs down its energy if performed excessively.

To recreate a compulsive drive, the robot’s target grooming level was set beyond what it could
achieve, prompting the robot to run out of energy 95% of the time.

Treatment for OCD often involves exposing someone to the things that trigger their obsessive thoughts and preventing them from responding.

In future, showing people with OCD how the robot might improve may help them accept such stressful
treatment (Lewis et al., 2019).

There is some concern that the robot’s quirks might reinforce the idea that the condition is all down to weird behaviours, instead of distressing, obsessive thoughts. We have been studying people for years, though, so maybe robots do have a role.


Lewis, M., Fineberg, N. & Canamero, L. (2019) A Robot Model of OC-Spectrum Disorders: Design Framework, Implementation, and First Experiments. Computational Psychiatry. 3, pp.40-75.

Online CBT and Bereaved Persons

Research Paper Title

Online cognitive-behavioural therapy for traumatically bereaved people: study protocol for a randomised waitlist-controlled trial.


The traumatic death of a loved one, such as death due to a traffic accident, can precipitate persistent complex bereavement disorder (PCBD) and comorbid post-traumatic stress disorder (PTSD) and depression.

Waitlist-controlled trials have shown that grief-specific cognitive-behavioural therapy (CBT) is an effective treatment for such mental health problems.

This is the first study that will examine the effectiveness of online CBT (vs waitlist controls) in a sample exclusively comprised of people bereaved by a traumatic death.

The primary hypothesis is that people allocated to the online CBT condition will show larger reductions in PCBD, PTSD and depression symptom levels at post-treatment than people allocated to a waitlist. The researchers further expect that reductions in symptom levels during treatment are associated with reductions of negative cognitions and avoidance behaviours and the experience of fewer accident-related stressors. Moreover, the effect of the quality of the therapeutic alliance on treatment effects and drop-out rates will be explored.


A two-arm (online CBT vs waiting list) open-label parallel randomised controlled trial will be conducted. Participants will complete questionnaires at pretreatment and 12 and 20 weeks after study enrolment.

Eligible for participation are Dutch adults who lost a loved one at least 1 year earlier due to a traffic accident and report clinically relevant levels of PCBD, PTSD and/or depression. Multilevel modelling will be used.

Ethics and Dissemination

Ethics approval has been received by the Medical Ethics Review Board of the University Medical Center Groningen (METc UMCG: M20.252121). This study will provide new insights in the effectiveness of online CBT for traumatically bereaved people.

If the treatment is demonstrated to be effective, it will be made publicly accessible.

Findings will be disseminated among:

  • Lay people (eg, through newsletters and media performances);
  • Our collaborators (eg, through presentations at support organisations); and
  • Clinicians and researchers (eg, through conference presentations and scientific journal articles).


Lenferink, L., de Keijser, J., Eisma, M., Smid, G. & Boelen, P. (2020) Online cognitive-behavioural therapy for traumatically bereaved people: study protocol for a randomised waitlist-controlled trial. BMJ Open. doi: 10.1136/bmjopen-2019-035050.

Are Lifestyle Factors Advantageous as First-Line Interventions in Mental Health?

Research Paper Title

The Effect of Exercise on Mental Health: A Focus on Inflammatory Mechanisms.


A growing body of research suggests that neuropsychiatric disorders are closely associated with a background state of chronic, low-grade inflammation.

This insight highlights that these disorders are not just localised to dysfunction within the brain, but also have a systemic aspect, which accounts for the frequent comorbid presentation of chronic inflammatory conditions and metabolic syndromes.

It is possible that a treatment resistant subgroup of neuropsychiatric patients may benefit from treatment regimens that target their associated proinflammatory state.

Lifestyle factors such as physical activity (PA) and exercise (i.e. structured PA) are known to influence mental health. In turn, mental disorders may limit health-seeking behaviours – a proposed “bidirectional relationship” that perpetuates psychopathology. PA is renowned for its positive physical, physiological and mental health benefits.

Evidence now points to inflammatory pathways as a potential mechanism for PA in improving mental illness. Relevant pathways include:

  • Modulation of immune-neuroendocrine and neurotransmitter systems;
  • The production of tissue-derived immunological factors that alter the inflammatory milieu; and
  • Neurotrophins that are critical mediators of neuroplasticity.


In this paper, the researchers focus on the role of PA in positively improving mental health through potential modulation of chronic inflammation, which is often found in individuals with mental disorders.

In a related paper by Edirappuli and colleagues (2020), they will focus on the role of nutrition (another significant lifestyle factor) on mental health.


Thus, inflammation appears to be a central process underlying mental illness, which may be mitigated by lifestyle modifications.


Lifestyle factors are advantageous as first-line interventions due to their cost efficacy, low side-effect profile, and both preventative and therapeutic attributes.

By promoting these lifestyle modifications and addressing their limitations and barriers to their adoption, it is hoped that their preventative and remedial benefits may galvanize therapeutic progress for neuropsychiatric disorders.


Venkatesh, A., Edirappuli, S.D., Zaman, H.P. & Zaman, R. (2020) The Effect of Exercise on Mental Health: A Focus on Inflammatory Mechanisms. Psychiatira Danubina. 32(Suppl 1), pp.105-113.

The Nurse-Patient Relationship: Aggressive Behaviour in a Mental Health Setting

Research Paper Title

Aggressive Behaviour: Nurse-Patient Relationship in Mental Health Setting.


Mental disorder is known to be as a loss of existential paradigm; individual’s functioning is lacking in all areas. Therefore, it is difficult to point out what the patients exactly need because their needs are set on a broad range of a difficult boundary.

The level of care that follows will be complex and multifactorial because nursing will challenge the interaction with the individual as a whole: behaviours and relations with family members.

At this stage exploring interpersonal conflicts, with past and present aggression behaviours will be crucial.


The aim of this paper is to investigate the professional experience in a work context where the patient’s clinical condition poses a daily challenge from a physical and emotional perspective.

Narrative investigation is performed here in order to explore the psychological load of the professional’s psychological experience and its implication in facing aggressive situations.

Moreover, this investigation highlights the importance of some professional and personal resources that can be made available to the operator.


These tools could improve the understanding of the subjective experience of acute events guiding the individual through an exploration of the phenomenology of what happened decreasing the intimate stress load.


A constant updating, the knowledge of de-escalation techniques and sharing the experience in dedicated settings could be important allies in the management of risk events.


Moriconi, S., Balducci, P.M. & Tortorella, A. (2020) Aggressive Behavior: Nurse-Patient Relationship in Mental Health Setting. Pyschiatria Danubina. 32(Suppl 1), pp.207-209.

Eating Disorders: Linking Self, Other, & Gaze

Research Paper Title

The Pathogenic and Therapeutic Potential of the Gaze of the Other in the Clinic of “Eating Disorders”.


Building on the optical-coenaesthetic disproportion model of so-called eating disorders, this paper provides a framework for the psychotherapy of people affected by these conditions.

This model characterises “eating disorders” as disorders of embodiment and identity, where a sense of unfamiliarity with one’s own flesh, experienced as shifting and incomprehensible, leads to an impairment in the constitution of the Self and thus of one’s own identity.

Since there is a deficit of the coenaesthetic experience of the embodied Self, greater importance is assumed by body perception conveyed from without. To these persons, their corporeality is principally given as a body-object “to be seen” from a third-person perspective, rather than as a body-subject “to be felt” from a first-person perspective.

The Other’s look serves as an optical prosthesis to cope with dis-coenaesthesia and as a device through which these persons can define themselves. They are unable to accept the hiatus between “being a body” and “having a body,” constitutively present in every human being, forcibly trying to recouple it, and finally ending up objectifying themselves to succeed.

The external foundation of the Self thus takes the form of a constriction one can never be completely free of. Psychotherapy should thus accompany persons affected by eating disorders in their encounter with the miscarried dialectic between feeling oneself from within and seeing oneself from without through the gaze of the Other, so keenly feared by people desperately in search of self-control.

Tactfully, the clinician accompanies the patient in taking a stance towards their symptom as the outcome of this miscarried dialectics, which is one premise for overcoming it.

The clinician’s gaze becomes the herald of recognition, allowing the patient to feel accepted in terms of their individuality. Feeling themselves touched by a gaze that waives its alienating potential in order to signify acceptance reactivates the identity-forming dialectics. Their body is thus revealed as the receiver of gazes, but also rediscovers its own possibility for self-determination starting out from these gazes.

This intersubjective resonance between the clinician’s gaze and the patient reactivates the identity-making dialectics between body-subject and body-object, creating the relational premises for overcoming the symptom.


Esposito, C.M. & Stanghellini, G. (2020) The Pathogenic and Therapeutic Potential of the Gaze of the Other in the Clinic of “Eating Disorders”. Psychopathology. 1-7. doi: 10.1159/000509625. Online ahead of print.

The Challenges & Opportunities for Counselling & Psychotherapy in the Aftermath of COIV-19.

Research Paper Title

Counselling and psychotherapy post-COVID-19.


The researchers consider how the prolonged, complex and uncertain aftermath of the COVID-19 crisis will present challenges and opportunities for counselling and psychotherapy.

Increased mental strain on populations, individuals and professionals is likely to be compounded by further constraints in therapeutic resources.

Nevertheless, emerging needs and priorities will offer ground for systems thinking in linking the application of a range of therapeutic frameworks, theories to address global challenges, integration of counselling and psychotherapy into new sectors, service models for the most vulnerable, use of digital approaches, support mechanisms for professionals and interdisciplinary research.


Vostanis, P & Bell, C.A. (2020) Counselling and psychotherapy post-COVID-19. Counselling and Psychotherapy Research. doi: 10.1002/capr.12325. Online ahead of print.

COVID-19 and the Role of Primary Care in Suicide Prevention

Research Paper Title

Role of Primary Care in Suicide Prevention During the COVID-19 Pandemic.


Primary care providers have an important role in suicide prevention, knowing that among people who die by suicide, 83% have visited a primary care provider in the prior year, and 50% have visited that provider within 30 days of their death, rather than a psychiatrist.

The psychosocial impact of the coronavirus disease 2019 pandemic poses increased risk for suicide and other mental health disorders for months and years ahead.

This article focuses on screening tools, identification of the potentially suicidal patient in the primary care setting, and a specific focus on suicide prevention during widespread, devastating events, such as a pandemic.


Nelson, P.A. & Adams, S.M. (2020) Role of Primary Care in Suicide Prevention During the COVID-19 Pandemic. The Journal for Nurse Practitioners. doi: 10.1016/j.nurpra.2020.07.015. Online ahead of print.

What are the Challenges of Mental Healthcare during COVID-19?

Research Paper Title

Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19.


The USA is in the midst of the COVID-19 pandemic.

The researchers assess the impact of COVID-19 on psychiatric symptoms in healthcare workers, those with psychiatric comorbidities, and the general population.

They highlight the challenges ahead and discuss the increased relevance of telepsychiatry.


The researchers analysed all available literature available as of 25 March 2020, on PubMed, Ovid Medline, and PsychInfo.

They utilised the MeSH term “covid AND (psychiatry OR mental health)” and included all articles.

Duplicates were removed resulting in 32 articles, of which 19 are cited. Four additional references are included to examine suicide data. During the review process, an additional 7 articles were identified which are also included.


Frontline healthcare workers are currently experiencing increased psychiatric symptoms and this is more severe in females and nurses. Non-frontline healthcare workers, as well as the general population, are experiencing vicarious traumatisation.

People with psychiatric comorbidities, and the general population, face increased psychiatric symptom burden. Migrant workers, the elderly, children, and the homeless may be disproportionately impacted. Suicide rates may be impacted.


The COVID-19 pandemic has resulted in a severe disruption to the delivery of mental healthcare.

Psychiatric facilities are facing unprecedented disruptions in care provision as they struggle to manage an infected population with comorbid psychiatric symptoms.

Telepsychiatry is a flawed but reasonable solution to increase the availability of mental healthcare during COVID-19.


Gautam, M., Thakrar, A., Akinyemi, E. & Mahr, G. (2020) Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19. SN Comprehensive Clinical Medicine. 1-6. doi: 10.1007/s42399-020-00348-3. Online ahead of print.

Can We Use Telehealth to Reach Underserved Veterans?

Research Paper Title

The Impact of Co-occurring Anxiety and Alcohol Use Disorders on Video Telehealth Utilisation Among Rural Veterans.


Co-occurring anxiety and alcohol use disorders lead to poorer treatment outcomes for both disorders.

Compounding risk for poor outcomes related to these disorders, individuals living in rural areas face barriers receiving evidence-based mental health treatment.

Video to home telehealth (VTH) has been implemented broadly within the Veterans Health Administration to improve access to care for rural veterans. However, VTH may not be utilised equally across disorders and comorbidities, including co-occurring anxiety and alcohol use disorders, potentially contributing to gaps in care that are not available in person.


A cohort of veterans who received at least one VTH mental health visit between fiscal years 2016-2019 was compiled from VA administrative data.

Multilevel linear growth curve models were used to examine growth in VTH use over time among veterans with anxiety only, alcohol use disorder only, and co-occurring disorders.


Fixed effects were significant for both time and diagnosis group and a significant interaction between time and group.

For each subsequent fiscal year, the percentage of total MH visits that were VTH increased for all groups but less so for those with co-occurring anxiety and alcohol use diagnoses.


Despite VTH being an important tool to reach underserved rural veterans, rural veterans with AUD and co-occurring anxiety and AUD are at risk for not receiving care using this modality.

Findings suggest that veterans with co-occurring anxiety and AUD are especially at risk for being underserved, given that a major goal of VTH is to increase access to mental health services.


Ecker, A.H., Amspoker, A.B., Hogan, J.B. & Lindsay, J.A. (2020) The Impact of Co-occurring Anxiety and Alcohol Use Disorders on Video Telehealth Utilization Among Rural Veterans. Journal of Technology in Behavioral Science. 1-6. doi: 10.1007/s41347-020-00150-x. Online ahead of print.