Program Overview
SPARX is a computer intervention for depression that incorporates fantasy role-playing in a video game environment.
SPARX combines fantasy and traditional Maori design elements to deliver cognitive behavioral therapy (CBT) techniques (i.e., relaxation skills, problem solving, challenging and replacing negative thoughts, social skills) to adolescents. Over seven modules, the “Guide” presents mood and safety assessments, instructs users on dealing with depression, and reviews CBT skills and assigns homework at the end of each module. Users create an avatar and use CBT skills to defeat GNATs (Gloomy Negative Automatic Thoughts).
Modified versions of SPARX have been created for sexual minority adolescents (Rainbow SPARX) and for addressing general mental health (SPARX-R).
Commercially available for residents of New Zealand here.
Delivery:
Computer-based
Gamification
Theoretical Approach:
Cognitive Behavioral Therapy (CBT)
Target Outcome:
Reduced depression symptoms
Ages:
Adolescents (11-17)
Target Outcome:
Reduced depression symptoms
Ages:
Adolescents (11-17)
Genders:
Male
Female
Races/Ethnicities:
Caucasian
Maori
Pacific Islander
Aboriginal
Other
Settings:
Schools
Remote Access
Geographic Locations:
Urban
Rural
Country:
New Zealand
Australia
Language:
English
Evaluations
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Summary: Researchers recruited 32 adolescents enrolled in schools or transitional programs for adolescents with behavioral problems in New Zealand and randomized them to immediate (n=20) or delayed intervention (n=12) groups. Eligible participants were mildly to moderately depressed, but not suicidal. The intervention was 5-weeks. Participants had access to the program through school computers. Participants completed assessments of depression, anxiety, hopelessness, and quality of life at baseline, 5 weeks, and 10 weeks. Overall, 69% of participants completed the SPARX program and 81% completed 4 or more modules. At week 5, participants in the immediate intervention group had larger decreases in depression symptoms, and were more likely to be in remission from depression (i.e., <30 on Children’s Depression Rating Scale-Revised) than those in the delayed group. Improvements in depression symptoms were maintained at 10 weeks, though between-group differences were no longer significant. There were no significant between-group differences in other outcomes.
Take Away: SPARX is feasible for adolescents. Preliminary evidence supports the potential efficacy of the program for treatment of depression.
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Summary: Researchers recruited 187 adolescent patients with diagnosed depression by referral from primary care clinics and school-based counseling programs in New Zealand. Participants were randomized to receive SPARX or care as usual (CAU). CAU consisted of face-to-face counseling or medication; 13% of the CAU group was placed on a waitlist and received no active treatment. Participants completed assessments of depression, anxiety, hopelessness, and quality of life, at baseline, post-intervention (8 weeks), and 3 months follow-up. 60% of participants in the intervention group completed SPARX and 86% completed at least 4 modules after 3 months. Participants who received SPARX reported significantly greater change in obsessive-compulsive disorder symptoms than CAU participants. There were no significant between-group differences on other outcomes. Relative to less adherent participants, SPARX participants who were adherent to treatment (e.g. completed at least 4 SPARX sessions) experienced significantly greater reductions in hopelessness and symptoms of generalized anxiety and were more likely to achieve remission of depression (i.e., Children’s Depression Rating Scale-Revised score <30) than CAU participants. Treatment effects were greater for participants with more severe depression.
Take Away: SPARX and traditional face-to-face treatments have comparable effects on depressive symptoms for adolescents.
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Summary: Researchers recruited 16 adolescents by referral from two community support agencies to participate in focus groups to evaluate the acceptability of SPARX for rural Australian adolescents. Researchers conducted semi-structured interviews with five gender-specific focus groups. Researchers introduced the SPARX program to focus groups and asked questions to assess acceptability. Participants were also asked whether they played computer games and were categorized as “gamers” (n=13) or “non-gamers” (n=3). Three major themes emerged from focus groups. Participants appreciated that they could personalize the game by choosing their own avatars. SPARX also allowed them to personalize their own depression treatment by choosing where and when to use the program, and who to include in the treatment process. Engagement was another emergent theme. While gamers found SPARX very engaging, non-gamers reported that they would be unlikely to use SPARX. Participants felt engagement could be improved with the ability to change the gender of the guide. The third theme related to stigma. Participants noted that the stigma surrounding depression served a major barrier to seeking help, especially for boys. Thus, the ability to use SPARX privately was a major benefit.
Take Away: For adolescents in rural Australia, SPARX is an acceptable treatment for depression, particularly for those who already played computer games.
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Summary: This qualitative study assessed the acceptability of SPARX to Maori adolescents (n=19) and their parents (n=7). Adolescents and parents were recruited through word of mouth to participate in one of seven focus groups. Participants did not have to be depressed. Participants were shown a prototype of SPARX and asked for feedback about the design and content of SPARX through semi-structured interviews in focus groups and a short survey. Participants felt SPARX could help young people cope with depression. Participants connected with the characters and believed they could engage with them and learn skills. Additionally, they found the program easy to use and motivating. The program included culturally-relevant details, which were appreciated by participants, although some were confused by the hybrid design incorporating both Maori and fantasy design elements. Participants had several ideas for improving SPARX for Maori users. Parents wanted more involvement in the program and their child’s depression treatment, and suggested including a module for families or a booklet with depression education. Participants felt the text should be shortened and simplified or replaced with audio. Participants also proposed including more Maori language to give users a greater sense of ownership. On average, participants who completed the survey (n=19) reported that they liked the graphics (4.2/5), informational content (4/5), and cultural content (4.2/5) of SPARX.
Take Away: Overall, Maori adolescents and parents found SPARX an acceptable and culturally-relevant treatment for depression.
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Summary: Researchers recruited 21 sexual minority (same-sex attracted, bisexual, questioning) adolescents (aged 13-19) using advertisements in high schools and organizations and media catering to sexual minority adolescents to evaluate the acceptability and preliminary effects of Rainbow SPARX. Participants were asked to complete 1-2 modules per week over 2 months. Participants completed assessments of depression, anxiety, hopeless, and quality of life at baseline, post-interventions, and 3 months follow-up. Participants reported completing 6.6 modules on average. 90% reported that they completed at least 4 modules and 81% reported that they completed all modules. Participants completed an assessment of intervention satisfaction at post-treatment. Participants experienced significant reductions in depression symptoms, anxiety, and hopelessness between baseline and post-treatment, and reductions were maintained at 3 months. Most participants reported that Rainbow SPARX would appeal to other adolescents (85%) and that they would recommend it to friends (80%).
Take Away: Rainbow SPARX demonstrated preliminary efficacy for reducing depression in sexual minority adolescents and was acceptable to these adolescents.
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Summary: Researchers conducted a randomized controlled trial comparing efficacy of SPARX alone and as an augment to in-person cognitive behavioral therapy (Op Volle Kracht; OVK) to OVK alone and a wait-list control for preventing depression in adolescent girls. Researchers recruited 208 girls (aged 11-16) with elevated depression symptoms from 7 secondary schools in the Netherlands. Participants were randomly assigned to receive a Dutch translation of SPARX (n=51), 8 sessions of OVK (n=50), SPARX and OVK combined (n=56), or a wait-list control group (n=51). Participants completed intervention sessions (SPARX, OVK, or both) weekly. OVK involves 16 1 hour-long lessons; in this study, the first 8 sessions were administered to participants by a trained psychologist during or after school. Sessions of OVK and SPARX were completed weekly. The control group rated their depression symptoms each week and could choose to receive either intervention at study-end. Participants completed an assessment of depression symptoms at baseline and post-intervention and 3, 6, and 12 months follow-up. Participants in the 3 intervention groups completed an assessment of intervention satisfaction at post-intervention. Participants in all groups experienced significant reductions in depression symptoms between baseline and 1 year follow-up. Change in depression symptoms over time did not differ by group allocation and depression symptoms were similar between groups at 1 year follow-up. Participants reported OVK was more attractive to adolescents and useful in daily life than SPARX. Researchers theorize that the potential for SPARX to prevent deterioration of depression symptoms may have been limited by the translation to Dutch and inclusion of Maori cultural elements.
Take Away: SPARX produced similar changes in depression in adolescent girls as OVK and no intervention.
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Summary: Researchers invited alternative education centers in Ireland (N=110) to participate in a pilot evaluation of SPARX-R. Alternative education centers provide vocational training and qualifications for young people (aged 15-20) who had left school early. Alternative education centers were randomized to administer SPARX-R to participating students for 7 weeks or to administer no intervention. Researchers recruited 146 students from 16 alternative education centers. Participants completed assessments of depression, anxiety, mental wellbeing, coping styles, and emotion regulation at baseline and post-intervention. Participants who received SPARX-R also completed an assessment of intervention acceptability. Participants who received SPARX-R completed 5.3 modules on average; 87% of participants completed at least 4 levels and 30% completed all modules. Attrition was high (54.8%). Researchers analyzed data only from participants that completed the post-intervention assessment (n=66) and found no significant treatment effects for depression, anxiety, or mental wellbeing. SPARX-R participants experienced significantly greater improvements in the expressive suppression subscale of emotion regulation relative to the control group. Most participants who received SPARX-R (83.3%) reported practicing at least one skill from SPARX-R. On average, SPARX-R participants rated their satisfaction with SPARX-R a 6 out of 10.
Take Away: SPARX-R did not improve mental health outcomes for students in alternative education relative to no intervention, with the exception of one subscale of self-reported emotion regulation.
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Summary: Researchers analyzed surveys and feedback from participants (n=28) and staff members (n=6) about perceptions of SPARX-R to among end-users and stakeholders at alternative education centers. Participants completed surveys after individual modules, completed a satisfaction survey post-intervention, and provided written and verbal feedback post-intervention. Staff members also completed surveys and interviews about perceptions of SPARX-R implementation. Participants and staff members reported moderate satisfaction with SPARX-R (5.78/10 and 5/10, respectively). Most participants reported SPARX-R was easy to use (71.4%) and understand (60.7%) and could be helpful to someone in distress (53.6%). Fewer reported SPARX-R was personally relevant (42.9%) or useful (39.2%). About one third of participants reported that they would recommend SPARX-R to a friend. Perceptions of relevance and usefulness were more likely among those at risk for depression. Participants liked the gaming elements of SPARX-R, but found it too easy, boring, and emotionally taxing. Participants reported SPARX-R could help people manage negative thoughts and emotions, but found technical issues frustrating. Staff members reported the content and computerization of SPARX-R was relevant to students, but the delivery of SPARX-R was not age appropriate, too negative, and had technical issues. Staff also expressed a need for structure when delivering SPARX-R. Participants and staff members indicated SPARX-R should be delivered to entire classes, rather than specific students.
Take Away: SPARX-R showed limited acceptability to students and staff at alternative education centers in Ireland. SPARX-R may need to be further tailored to this population.
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Summary: Researchers recruited 540 students in their final year of secondary school at 10 selective (required an entry exam for admission) or semi-selective schools (required an entry exam for admission to an advanced program) in Australia. Participants were randomized by school to receive SPARX-R or an alternative 7-session intervention without mental health-related content (lifeSTYLE). Participants completed 1-2 modules per week during class time over 5-7 weeks. Participants completed assessments of depressive symptoms, anxiety, suicidality, and perceptions of depression-related stigma at baseline, post-intervention, 6-, and 18-months. Researchers also collected final exam scores for participants. The 6-month assessment occurred about 2 weeks before participants completed their final exams. Participants who received SPARX-R experienced significantly greater reductions in depressive symptoms between baseline and post-intervention and between baseline and 6 months. Intervention effects were found for participants who had completed 4 or more SPARX-R modules, but not for participants who had completed fewer than 4 SPARX-R modules. A larger proportion of SPARX-R participants experienced clinically significant improvement in depression, as determined by the Reliable Change Index, than the lifeSTYLE group. Participants in both groups reported significantly lower anxiety and social anxiety at post-intervention than at baseline, but there were no between-group differences.
Take Away: SPARX-R may lead to greater reductions in depression in secondary school students than a comparable intervention that does not address mental health.
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Summary: Researchers recruited 7 Maori students at two schools in New Zealand to complete SPARX to explore the acceptability of SPARX to Maori adolescents. Participants completed assessments of depression symptoms at baseline, 2 months (post-intervention), and 5 months. Participants (n=6) completed interviews at post-intervention about perceptions of intervention content and effects. Interviews were recorded, transcribed, and thematically coded. Participants reported significant reductions in depression symptoms between baseline and 2 months that were maintained at 5 months. Participants felt SPARX was both fun and helpful. Participants reported using the CBT skills taught in SPARX, particularly breathing and cognitive restructuring, and that SPARX helped improve their mood and relationships with others. Participants liked the “Guide” character because he provided a connection to Maori culture and helped them navigate SPARX. Participants also liked the character that represented hope (the Bird of Hope) because they felt the feeling of hope contributed to their improvements in mood. Participants disagreed on whether the puzzles were too easy or moderately difficult and whether there were enough options for character customization.
Take Away: SPARX was acceptable to a small sample of Maori adolescents, but more research with larger samples is needed to improve the generalizability of results.
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“It’s mean!” The views of young people alienated from mainstream education on depression, help seeking and computerized therapy. Fleming TM, Dixon RS, Merry SN. Advances in Mental Health: Promotion, Prevention and Early Intervention. 2012. 10(2): 195-203.
Integrating health behavior theory and design elements in serious games. Cheek C, Fleming T, Lucassen MFG. JMIR Mental Health. 2015. 2(2): e11. doi: 10.2196/mental.4133
Tips and traps: Lessons from codesigning a clinician e-monitoring tool for computerized cognitive behavioral therapy. Sundram F, Hawken SJ, Obs D, et al. JMIR Mental Health. 2017. 4(1): e3. doi: 10.2196/mental.5878