Dr. Mario and the Role of Video Games in Depression

In August 2023, Moritz Bergmann and his co-authors published a study titled “Effects of a video game intervention on symptoms, training motivation, and visuo-spatial memory in depression” (1). By the end of December 2023, media headlines were running with the hype that the researchers had reported that the video game “Super Mario Odyssey” could beat depression.

Don’t we all love it when consumer media misconstrue a scientific study? Well, “Super Mario Odyssey” is not a miracle cure for depression. But the study is certainly interesting – and it raises some great questions about the therapeutic potential of gaming.

Even pre-pandemic, rates of depression were rising in many countries. Antidepressants are a big seller for the pharma industry, but they are not a cure, and some scientific studies question the overall effectiveness – especially for treatment of mild depression. If something as innocuous as a video game could have a potentially therapeutic impact, it’s important to thoroughly explore it.

The study in question comes from psychologists at the University of Bonn, Germany, and assigned 46 participants with major depressive disorder to one of three study groups for six weeks: i) a 3D video gaming group that played the Nintendo Switch game “Super Mario Odyssey” alongside normal clinical care, ii) an active control group that used a computerized training program called CogPack that focuses on exercises for attention, memory, visuomotor skills, linguistic skills, and mathematical skills – again alongside normal clinical care, and iii) a “treat–as–usual” group that only received standard clinical treatment (psychotherapy and/or pharmacotherapy). 

Participants who already had a high level of video game use or prior experience with “Super Mario Odyssey” were excluded.

The study looked at depressive symptoms (as measured by the Beck’s Depression Inventory- II) and visuospatial (working) memory function. Motivation to complete the training over the study period was also assessed in the 3D gaming and CogPack groups.

The 3D gaming group performed very well. In fact, a statistically significant decrease in depressive symptoms was only found in the 3D gaming group (dropping from 100 percent at the start of the study to 57 percent at the end). The 3D gaming group also showed on average higher levels of motivation than the CogPack group. For visuospatial memory functions, all groups showed some improvement, with the CogPack group seeing increases across all variables.

We spoke with lead author Moritz Bergmann, a PhD candidate and clinical psychologist at University Hospital Bonn, to learn more.

This study became very popular with news outlets during December 2023; many headlines touted that Super Mario Odyssey can beat depression. What is the reality?
 

I was astonished by the audience and the attention that our work received during this period. This highlights the public's interest in innovative approaches to mental health, but it also underscores the importance of accurately interpreting scientific studies – especially when they make headlines. Indeed, several media outlets suggested that playing “Super Mario Odyssey” could “beat” depression, a claim that simplifies the complex and serious nature of major depressive disorder (MDD).

Interpreting media headlines about scientific studies, such as those concerning our research, requires caution. It’s important to understand that a video game alone is not a cure for MDD; this serious condition is typically addressed by specialists through established therapies, such as medication and/or psychotherapy. MDD affects a significant portion of the population; over 300 million individuals globally, with lifetime prevalence reaching up to 15.7 percent. The disorder not only impacts individuals but also places a substantial burden on societies. For instance, in Germany, the number of cases has increased by 26 percent between 2009 and 2017 (2). It’s also the second leading contributor to chronic disease burden, resulting in an average of 27.2 work days lost per affected worker per year (3).

In our study, we explored an adjunct treatment combining usual clinical care with video gaming therapy (VGT) using “Super Mario Odyssey.” This approach showed promise in improving depressive symptoms and visuospatial memory performance in patients. This finding aligns with previous research indicating the potential benefits of video gaming therapies for depression (4). To our knowledge, our study was the first to implement VGT for inpatient clinical treatment. It’s crucial to note that we used VGT as an additional, not standalone, treatment. The therapy was supervised by clinical practitioners, who engaged patients in tasks designed to train visuospatial memory, such as drawing maps from the game or identifying locations and significant objects within the game world. These exercises targeted cognitive functions associated with the hippocampus and entorhinal cortex.

Despite these promising results, we must be cautious about generalizing because of limitations; for example, the small sample size (N=46) and the unblinded nature of the study, which could introduce experimenter and expectation biases. Further research with larger sample sizes, blinded designs, and follow-up measurements is essential to validate the findings. That said, the initial results are encouraging, pointing towards new avenues in therapy. As we continue this work, our aim is to not just advance scientific understanding, but offer real-world benefits to those affected by MDD.

How did the study come about? 
 

The beginning of our study was rooted in a paradox in the world of video gaming and cognitive science. Prior research indicated that video game players often exhibit enhanced performance in various cognitive functions, such as attentional and perceptual tasks (5). However, a critical question remained unanswered: Do people with inherently higher cognitive abilities gravitate towards video games as a leisure activity or can video gaming actively improve cognitive functions? In other words, can we find a causal link between video gaming and cognitive performance? This intriguing ambiguity was the cornerstone of our investigation.

As always, this study also began with an exploration of existing literature, where we discovered that, though there were studies establishing a causal link between video gaming and cognitive performance, they were predominantly conducted with healthy participants (6, 7). However, initial research in individuals suffering from MDD also showed improvements in depressive symptoms and various cognitive functions following VGTs (7, 8). This was interesting, suggesting a potential therapeutic avenue in a field often overshadowed by negative perceptions. Video gaming is frequently associated with negative aspects, such as sedentary screen time, exposure to violence, and excessive or problematic gaming. The dominant narrative in news and academic circles focused on these detrimental effects. However, we were inspired to delve deeper into the other side of the coin: the potential positive impacts of video gaming. And that led to our research question: Could we adapt popular video games into interventions that promote mental health and cognitive function?

Our team faced the challenge of translating this concept into a scientific study. We aimed to create a research design that was rigorous yet innovative, balancing scientific integrity with the exploratory nature of our hypothesis. The collaborative effort was a great experience with the aim of establishing a new path in cognitive and mental health research. There may still be endless possibilities that lie at the intersection of technology, psychology, and healthcare.

Why choose Super Mario Odyssey for the 3D gaming group?
 

In selecting a video game for the 3D gaming group in our study, it was crucial to choose one that not only engaged the players but also provided the right kind of cognitive stimulation. Our decision to use “Super Mario Odyssey” was informed by several key factors. Firstly, the nature of action video games (AVGs) made them a suitable choice for our research. AVGs, known for their fast pace, high degree of clutter or distraction, spatial navigation challenges, and motor load, require players to use higher cognitive functions. These functions include visuospatial working memory, planning, and set-shifting. Previous research has demonstrated the positive effects of AVGs on attention allocation and spatial skills (9, 10).

Super Mario Odyssey embodies many of these aspects, being an open-world game filled with plenty of visual stimuli, mini-games requiring rigorous planning, and spatial navigation across various environments. One of its standout features is the ability to switch between allocentric perspectives (viewing maps of the in-game worlds from a bird’s-eye view) and egocentric perspectives (navigating Mario through these worlds). This feature particularly aligned with our research interests as spatial navigation, both egocentric and allocentric, is closely linked to entorhinal and hippocampal functions, which were central to our study’s focus on cognitive training.

Another important consideration was the motivational aspect of the game, as well as its content. It was essential to choose a game that would keep participants engaged throughout the study without exposing them to extreme violence. “Super Mario Odyssey” with its adventure-themed, jump-and-run gameplay, offered a highly motivating experience, while maintaining a relatively violence-free environment.

Were you surprised by the results?
 

We were indeed surprised by the results of our study! The improvements we observed over time in tasks measuring visuospatial working memory functions were notable. These improvements were not exclusive to the group playing Super Mario Odyssey; they were also evident in the active control group.

What particularly stood out was the significant reduction in clinically significant depressive symptoms during follow-up within the 3D video gaming group. This finding suggests that video gaming, particularly when supervised and as part of a broader therapeutic strategy, could be a viable supplementary intervention alongside traditional therapies. The increased motivation to participate in the video gaming therapy further supports this idea, indicating that engaging and interactive interventions can be both effective and well-received by participants.

However, as we stated in our paper, the study did have its limitations, primarily the relatively small sample size (N=46). This factor necessitates a cautious interpretation of the results. It’s clear that more research in this field is essential to further validate and understand these findings.

What are your thoughts on the effects on visuospatial (working) memory in the 3D gaming and CogPack groups?
 

Though there was an improvement in the 3D gaming group on a specific visuo-spatial memory test, it was the control group, engaging with the “CogPack” program, that demonstrated broader improvements in these functions. This outcome was somewhat surprising, as it challenges the assumption that the immersive and spatially complex environment of a 3D video game would naturally lead to more pronounced enhancements in visuospatial memory. The fact that the control group showed broader improvements suggests that there might be aspects of the CogPack program specifically targeting and effectively training visuospatial memory skills. Larger-scale studies will allow us to draw more definitive conclusions and better understand the nuances of these interventions.

Why is it so important to find additional therapeutic interventions for depression?
 

Finding new therapeutic interventions for depression is crucial because of the complex and multifaceted nature of the disorder, as well as the limitations and challenges posed by current treatment approaches. As stated earlier, MDD is a highly individualized disorder, with symptoms and effective treatments varying significantly from person to person. This variability means that a one-size-fits-all approach is often insufficient. New interventions are needed to provide a wider range of options that can be tailored to individual needs, preferences, and specific symptom profiles.

Moreover, current treatments, mainly comprising medication and psychotherapy, have certain limitations. For instance, antidepressant medications can have varying degrees of effectiveness and are often accompanied by side effects that can be challenging for many patients. Some individuals may not respond to certain types of medication, and finding the right drug and dosage can be a lengthy process of trial and error.

Psychotherapy can be effective for many but also has limitations. Accessibility is a major issue, as psychotherapy can be expensive, time-consuming, and not readily available. There is also the stigma associated with seeking mental health treatment, which can deter individuals from pursuing this option. Hence, the ongoing advancements in technology and our understanding of the brain and mental health disorders open up new possibilities for innovative treatments. These could also include digital interventions, like the use of video games in therapy.

Do you think video games deserve more research attention?
 

Over the past two decades, research around the use of video games in therapeutic settings has expanded significantly. However, this body of research is characterized by a diversity in methodologies, which makes generalizations about the effects and applications of video games in mental health treatments challenging. One of the key issues is the variability in study designs, which leads to difficulties in comparing and synthesizing results across different research projects.

Moreover, when it comes to using video games for therapeutic purposes in various mental disorders, the field is still in an early stage. Though there have been promising developments, there is a clear need for more robust and comprehensive studies. These studies should ideally include larger sample sizes and extended follow-up periods to assess the longevity of the benefits. Additionally, the evaluation of transfer tasks (how well the skills or improvements gained from the video games apply to real-world scenarios) is crucial for understanding the practical applications of these interventions.

Another critical area that demands attention is the investigation of the underlying neural mechanisms that are influenced by video game use. To truly understand the impact of video gaming on the brain, advanced functional neuroimaging studies, particularly using high-end tools like for e.g. functional magnetic resonance imaging (fMRI), are essential. These studies could provide valuable insights into how video games affect brain function and structure, which in turn could inform the development of more effective and targeted video game-based therapies.

The fast pace of digital innovation offers an exciting opportunity to use increasingly complex and suitable video games for therapeutic purposes. As the field evolves, it is important that research keeps pace – not only to validate the efficacy of video games as therapeutic tools, but also to understand the basis of how they interact with and affect the human brain.