‘I Can’t Get No Satisfaction’… Experience in the treatment, satisfaction, and professional support of young depressed people using SPARX

Sasha Del Vecchio1, Silvia Mammarella1, Laura Giusti1, Massimo Casacchia1, Rita Roncone1

1Department of Life, Health and Environmental Sciences, University of L’Aquila.

Summary. Aim. Depression in young people is common and can lead to poor long-term outcomes. Digital therapies are a promising means of promoting access to care. Currently, among the digital treatments for depression in adolescents recognized by the NICE guidelines, there is SPARX (Smart, Positive, Active, Realistic, X-factor), based on Cognitive Behavioral Therapy, CBT. This narrative review aimed to evaluate: 1) Who were the depressed young people who used SPARX and what was their experience with the treatment? 2) Were users satisfied with the SPARX treatment? Did the youth’s perceived level of satisfaction with using SPARX impact completion rates? 3) What was the role of professionals (researchers, consultants, teachers) in the SPARX studies? Has their support in running SPARX affected completion rates? Methods. A narrative review of the English literature was performed. The articles were searched in Pubmed, SCOPUS, and Web of Science databases (from 2012 to 2023) with keywords such as ‘SPARX,’ depression’ and ‘young adult’. Results. Of 557 papers, 18 were included in our review. The young people who used SPARX were students or adolescents from special help-seeker populations at risk or with mild to moderate depression. The highest satisfaction levels were present in users of primary health services, such as general practice and counseling services. The support of the school counselor and experts in mental health clinicians was instrumental in impacting user satisfaction and completion rates. The personalization of the game in terms of user culture - symbols, language, norms, values, and artifacts; the customization of the avatar, the gender identity; the narrative structure; the presence of a guide character (virtual therapist); the CBT homework seemed to represent crucial SPARX characteristics related to satisfaction and completion rates. Discussion and conclusions. Our narrative review provides an overview of the main results of using SPARX with interesting considerations that may suggest improvements for broader use and diffusion of this digital treatment.

Key words. Adolescent, cognitive-behavioral treatment, depression, gamification, SPARX, treatment adherence, young adult.

“I Can’t Get No Satisfaction”… Esperienza nel trattamento, soddisfazione e supporto professionale di giovani depressi che utilizzano SPARX.

Riassunto. Scopo. La depressione nei giovani è comune e può comportare esiti non soddisfacenti a lungo termine. Le terapie digitali rappresentano uno strumento promettente per l’accessibilità alle cure nel campo della salute mentale. Attualmente le Linee Guida NICE includono SPARX (Smart, Positive, Active, Realistic, X-factor) tra i trattamenti cognitivo-comportamentali digitali per il trattamento della depressione negli adolescenti. Questa revisione narrativa mira a valutare: 1) “Chi sono i giovani depressi che utilizzano SPARX e qual è la loro esperienza con il trattamento?” 2) “Gli utenti sono soddisfatti del trattamento SPARX? Il livello di soddisfazione percepito dai giovani ha influito sui tassi di completamento?” 3) “Qual è stato il ruolo dei professionisti negli studi SPARX? Il loro supporto ha influito sui tassi di completamento?”. Metodi. È stata eseguita una revisione narrativa della letteratura in lingua inglese. Gli articoli sono stati ricercati nei database Pubmed, SCOPUS e Web of Science (dal 2012 al 2023) con parole chiave “SPARX, “depressione” e “giovani adulti”. Risultati. Su 557 lavori, 18 sono stati inclusi nella revisione. I giovani che hanno utilizzato SPARX erano studenti o adolescenti provenienti da popolazioni a rischio o help-seekers con depressione da lieve a moderata. I più alti livelli di soddisfazione erano presenti negli utenti dei servizi sanitari di base, come i servizi di medicina generale e di counseling. Il supporto dello psicologo scolastico e dei professionisti della salute mentale sembra determinante nell’influenzare la soddisfazione degli utenti e i tassi di completamento del trattamento. L’adesione a SPARX includeva anche la personalizzazione del gioco, in termini culturali e di identità di genere, una struttura narrativa, l’inclusione di una guida virtuale, i “compiti a casa” assegnati nel percorso terapeutico. Discussioni e conclusioni. La revisione narrativa condotta fornisce una panoramica dei principali risultati dell’utilizzo di SPARX con interessanti considerazioni che possono suggerire miglioramenti per un uso e una diffusione più ampi di questo trattamento digitale.

Parole chiave. Adesione al trattamento, adolescenti, depressione, gamification, giovani adulti, SPARX, terapia cognitivo-comportamentale.

Introduction

Due to the recent pandemic related to Covid-19, there has been an increase in depressive and anxiety disorders in the world population. Recently, the 2022 World Health Organization Mental Health Report1 reported a rise in depression of 28% compared to pre-pandemic data.

A similar trend was found among young people2, with the adolescent population representing the most affected by emotional disorders3,4. Rapid physical, psychological, and social changes and a period of greatest vulnerability to the onset of mental disorders characterize adolescence. Adolescents are becoming adults and more willing to make crucial decisions and life choices. Despite suffering severe psychological distress, they find it challenging to ask and to get or to adhere to psychological or psychiatric treatments. According to the literature, approximately a third of adolescents do not complete the recommended psychosocial or psychopharmacological therapies5-8. Many factors have been identified to overcome barriers to treatment adherence. Factors that positively impact compliance with adolescents treatment can be divided into factors mainly related to the therapeutic setting and the external social context6. Among the former, effective physician-patient communication was identified9; positive beliefs about and, therefore, acceptance of the prescribed treatment; non-judgmental setting; more contact with mental health professionals and better-planned appointments; involving adolescents in the development of their mental health care; suitable and planned patient psychoeducation; taking into account patient expectations; establish active physician–user cooperation. Furthermore, among the factors implicated in the social context, it was highlighted how higher levels of education and the family’s socio-economic status seem to be positively correlated with the adhesion of adolescents. On the contrary, low solidarity among the family or close friends negatively influenced treatment adherence6.

Digital Mental Health (DMH) appears to be a promising solution to improve access to mental health services10,11 and to overcome barriers of adherence and stigma12. DMH is a term used to indicate all technologies used in the mental health field to make diagnoses, monitor the subject’s clinical conditions, and support the healthcare professionals’ decisions and interventions13. DMH interventions can overcome many barriers, such as inhibiting help-seeking, accessibility in rural contexts, and reducing the burden on service providers. Drop-out subjects and non-completions are commonly reported in the literature, and adherence to digital health programs is also low in adolescents14,15.

According to the complexity of these issues, different factors negatively impact the engagement and interaction with online programs, including lack of time, access and technical issues, no perceived need for help, program relevance, inappropriate content or repetitiveness, doubt regarding program effectiveness, preferences for face-to-face help, concerns about privacy and anonymity, or perceiving the program to be boring or activities laborious, a poorly designed or delivered product16,17. Among the barriers to adherence to treatment, an important role is played by the severity of the disease and how adherence is operationalized in the various studies. An improvement could be providing personalized interventions according to the individual’s severity of illness, allowing participants to select the order of module completion or the choice of session scheduling with customized reminders. Furthermore, designers could incorporate various activities into DMH programs, including multiple-choice quizzes and case-enhanced learning strategies that use educational stories to illustrate problem-solving15.

Gamification (e.g. use of avatars, challenges, prizes, scores, etc.) and the use of Serious Games, is based on the e-learning approach. Several studies demonstrate that digitalized CBT programs, which use the paradigm exposed above, acquire a greater attractive, engaging and effective potential than those that do not use them. Gamification-based DMH interventions show their usefulness, for example in ADHD, autism spectrum disorders, eating disorders, post-traumatic stress, impulse control disorders, depression, schizophrenia, dementia and even in healthy aging18. Although there is much evidence on the effectiveness of serious games, to date there are many improvements to be made to understand how to enhance the compliance of these treatments.

In this innovative scenario of DMH, we investigate the serious game SPARX (Smart, Positive, Active, Realistic, X factor), based on Cognitive Behavioral Therapy, CBT practices19, one of the most used active RCT interventions20. This intervention is included in the Digital CBT for mild depression for young people aged 12 to 18 by the National Institute of Health and Care Excellence (NICE)21. There are different versions of SPARX, although each version is articulated in seven modules (30-40 min each), including 1) Psychoeducation about depression and an introduction to the cognitive behavioral therapy model; 2) Activity scheduling and behavioral activation; 3) Dealing with strong emotions and interpersonal skills (assertiveness, listening, and negotiation); 4) Problem-solving and cognitive restructuring; 5) Cognitive restructuring; 6) Cognitive restructuring and interpersonal skills; 7) Recap of all skills, mindfulness (tolerating distress) and relapse prevention (knowing when to ask for help). SPARX is based on a 3D fantasy world, where it is possible to choose and customize its avatar and to interact with a ‘guide’ who plays the role of therapist. The modules are articulated as game levels, and a maximum of two levels per week is suggested.

This narrative review aims to identify the existing literature on SPARX for depressed youth populations, their experience of the treatment, and their satisfaction. Considering the role of therapists, the review also intended to clarify their role when involved in the study design. Special attention was reserved to identify elements influencing the SPARX treatment’s completion rate.

Methods

Research questions

Three main research questions (RQ) were addressed:

1. Who were the young, depressed people who used SPARX and what was their experience with the treatment?

2. Were the users satisfied with the SPARX treatment? Did the level of satisfaction for perceived SPARX utilization by young people impact completion rates?

3. What was the role of professionals (researcher, counselor, teacher) in the SPARX studies? Did their support in SPARX execution influence the completion rates?

Study design

Three reviewers (RR, SM, SDV) searched PubMed, SCOPUS, and Web of Science databases using the search terms reported in figure 1.




Researchers explored the term ‘SPARX’ and then narrowed the searches to depressive symptoms with the term ‘depression’ and the age group of interest, ‘young adults’. From the search carried out for the term ‘SPARX’, 441 results emerged; 106 studies were found from the terms ‘SPARX and Depression’; 10 scientific works were found with the terms ‘SPARX and Young Adult’, for a total of 557 scientific studies. Among these, 40 works were duplicated in the various searches, for a total of 517 studies that were analyzed. Among the exclusion criteria we identified the studies in which ‘SPARX’ represents a mobile APP on learning rural and agricultural concepts; The SPARX Trial which refers to a multicenter, randomized, controlled, single-blinded, study designed to test the feasibility of using high-intensity exercise to modify symptoms of Parkinson Disease; all those scientific works that dealt with the SPARC protein involved in inflammatory processes were excluded; SPARX works of low quality and in which only the protocol without results was reported were excluded.

Results

After evaluating the search terms ‘SPARX’, ‘SPARX AND Depression’, and ‘SPARX AND Young Adult’, the searches yielded 557 articles across the databases, analyzing the records by title and abstract. Exclusion criteria were applied, and 18 studies were recruited from 2012-2023. Among these studies, nine presented quantitative data, eight qualitative data, and one combined quantitative and qualitative data included in our work.

Who were the young, depressed people who used SPARX and what was their experience with the treatment?

Characteristics of Quantitative and Qualitative Studies using SPARX

Table 1 (Supplementary material available in the online version of the paper) summarizes the characteristics of the included quantitative studies.

Six studies were conducted in New Zealand22-27, one in The Netherlands24, one in Australia28, one in Ireland29, and one in Canada30. All studies included adolescents in the age range of 12-19.

Out of ten quantitative studies, six are RCT studies22,23,28-31, two are real-world studies26,27, one study is a cohort study25, and one is an observational study24.

Regarding the features of the sample in these studies, one study recruited a clinical population affected by depressive symptoms who asked for help from health services23; one study was conducted in a hospital youth inpatient unit24; two studies evaluated students with depressive symptoms in a school prevention context28,31 or isolated communities30; two studies in ‘alternative school settings’22,29. Two studies were conducted in the transgender or intersex adolescent population26,27 based on a Rainbow SPARX version developed for adolescents with depressive symptoms who are also sexually attracted by the same sex, both sexes, or who were questioning their sexuality (i.e., sexual minority youth)32. One study included a population of adolescent male offenders due to crime25.

The samples included in the studies show a wide heterogeneity. From a clinical point of view, the severity of psychopathology ranges from acute psychosis24 to depression23 and to prevention of depression risk28. The considered studies privilege culturally specific, community-led prevention programs with limited access to mental health resources, as for Maori22 and Inuit young suffering people30, gender minorities26,27 and ‘special’ population, as alternative school settings students22,29 and young offenders25.

According to intervention treatment, five studies administered SPARX without external psychological supports24,26,27,30,31; one study included school counselors’ support in recruiting young users23, and in two studies researchers gave their support and supervision to subjects included from alternative education settings22,29. One study administered SPARX supported by teachers28; one evaluated the impact of SPARX-R 1.0 and the compulsory rehabilitation program MYND supported by social workers25.

Of the nine qualitative studies included in the present review and described in table 2 (available online), four studies carried out focus groups on a population of adolescents not belonging to ‘special populations’18,33-35, two studies carried out focus groups including LGBTQ+ adolescents36,37. Two studies carried out focus groups and semi-structured interviews considering clinicians’ opinions (counselors, clinical psychologists, nurses, etc.)18,38.

Only one article conducted focus groups evaluating the point of view of family members39, while two studies reported focus groups on communities with limited access to mental health resources (Maori)39,40. Regarding the mean topic discussed in the different focus groups, two studies considered the issues related to the satisfaction and usefulness of SPARX33,35,40, and two focus groups evaluated SPARX satisfaction with sexual minority issues36,37. Two focus groups with clinicians included patient satisfaction and technical, structural, and monitoring implementations of SPARX18,38. Family members participated in a focus group investigating their opinions on SPARX’s contents and cultural style39. Fleming et al.34 conceptualized their focus group on the perceived usefulness of SPARX in preventive terms of depression (e.g., anger, stress, etc.).

Were the users satisfied with the SPARX treatment? Did the level of satisfaction for perceived SPARX utilization by young people impact completion rates?

Only five studies evaluated the level of SPARX satisfaction of participants through the administration of a short self-report questionnaire17,23,24,29,31, comparing them with levels of completion rates levels (tables 3 and 4).

Concerning the level of satisfaction users express, what emerges from these studies is unclear.

In Merry et al.23, SPARX participants expressed high satisfaction levels, although statistically significantly lower than youth receiving TAU (face-to-face counseling). The good results of the study appeared to be attributed to school counseling services and the recruitment of youth clinics in both study arms. The professionals providing psychological interventions in the TAU arm were experienced counselors, establishing an excellent therapeutic alliance with young users.

The level of satisfaction monitored was also high in the inpatient ward study of Bobier et al.24, although only 10% completed the SPARX program. One patient stated that she preferred individual talking therapy to computer treatment, while another said that SPARX made her feel worse.

In Poppelaars et al.31, although the two programs (SPARX and OVK) generated the same satisfaction rate (not very high), OVK was perceived as more attractive and more helpful in daily life, despite the completion rates. These data probably relate to the fact that no cultural adaptations were made for Dutch adolescents in SPARX.

Even the study by Kuosmanen et al.29 showed a low level of satisfaction expressed by the SPARX-R group; only 30% of the sample completed virtual therapy. Staff members reported that young users felt more comfortable when the researcher was present, suggesting the need for professional mental health support to monitor student reactions and provide prompt support.

The SPARX-R version, providing practical skills for young people when depressed, down, angry, or stressed, received a modest satisfaction rating. More than half of the participants considered the program helpful for a young person struggling. However, only a third indicated they would recommend the program to a friend. A minority found the program uncomfortable, and a quarter stated that they were concerned about privacy. No clear patterns emerged when comparing user satisfaction ratings and completion rates. Most participants evaluated most levels as easy to use, enjoyable, and valuable29.

It remains unclear whether young, depressed people are satisfied with SPARX if we assume that satisfaction would impact completion. There may be a full completion both with high levels of satisfaction and with low levels of satisfaction, suggesting that other factors may be involved in the appreciation of the SPARX intervention. The study published by Merry et al.23 is the only one that presents high satisfaction levels with high completion rates. Instead, in Poppelaars et al.31, low levels of satisfaction present high completion rates, probably related to the fact the participants were offered a modest financial reward to participate in the post-test and follow-ups. In Bobier et al.24, satisfaction levels were high. Still, completion rates were low because the population was recruited in a hospital inpatient unit, and the subjects presented different clinical pictures. The ‘special’ sample of students, not depressed but at risk of depression and leaving school early and attending an alternative education (AE) program, reported low levels of SPARX satisfaction and completion rates29. This finding could be justified by the difficulty in recognizing the real challenges of these young, troubled people.

What was the role of professionals
(researcher, counselor, teacher) in the SPARX studies? Did their support in SPARX execution influence the completion rates?

Five quantitative studies considered the role of the professionals within SPARX in supporting the intervention22,23,25,28,29 and six qualitative studies dealt the topic ‘the importance of the therapist’ within the various focus groups17,32,35,38,39,41 (table 3, available online).

In two studies, the support was provided by the same researchers22,29, in one study by teachers28, in one study by a school counselor23. In one study, the researchers involved a social worker25.

Merry et al.23 showed how the role of counselors was helpful in recruiting subjects who could benefit from SPARX. The school counselors knew teenagers and suggested this treatment based on the more appropriate clinical indications. They could facilitate access to treatment for young people who may be reluctant to have more conventional therapy, showing how such a role of a counselor in recruitment leads to high completion rates and satisfaction (tables 3 and 4, available online).

The therapist involved in the Fleming et al. study22 was a Ph.D. candidate with experience as a clinician in adolescent health and mental health services, weekly visiting or telephoning the students in their classroom. He addressed any safety concerns or problems that may have arisen or supported students using the program. The fact that the intervention was offered during class time may have contributed to the high completion rates in SPARX (69%).

The Australian study by Perry et al.28 does not include health professionals. Indeed, the SPARX-R intervention was completed over 5 to 7 weeks in class under teacher supervision, reporting a satisfactory completion rate. The Authors underlined the success of what could be defined as the first step in a stepped-care approach to mental health interventions, whereby young people within the school setting are provided with access to a universal, skills-oriented intervention, with those who require additional support being stepped up to a more intensive one.

The Irish study by Kuosmanen et al.29 included both researchers at the program’s start and a staff member who moderated the program. The researcher visited centers and addressed technical issues. The staff members were provided with a Program Manual and Study Instructions with detailed information on the day-to-day rollout of the study and the completion of the online assessment questionnaires. Also, the staff delivering the program was given a list of each student’s SPARX login details in case they forgot them.

The protocol of Fleming et al.25 was more articulated than that of other considered studies since SPARX-R was an add-on component. The professionals involved were social workers working at a compulsory day-based rehabilitation program for offenders (Mentoring Youth New Directions; MYND) for the study period, all of whom participated in the study. Each participant worked with their social worker to determine specific activities and goals.

Both Kuosmanen et al.29 and Fleming et al.25 reported low completion rates (table 4, available online). The samples considered in their study concerned ‘troubled teens’ exhibiting high levels of mental distress and legal/social-economics difficulties that presumably needed more support from a professional in a face-to-face mode or from online peer support.

As regards the six qualitative works that dealt with the ‘therapist’ topic within the various focus groups, it was highlighted that the majority of them considered the presence of the clinical therapist crucial both in the recruitment and in the monitoring of the SPARX treatment, not only to increase satisfaction and completion rates, but also to improve the therapeutic alliance (table 3, available online).

In particular, in the focus groups including both clinicians and adolescents, it emerged that the presence of a clinician is relevant both in the face-to-face mode17 and through online active monitoring of the progress of the SPARX treatment38.

In two focus groups conducted on LGBT and non-LGBT adolescents, enrollment in the program32 and the support for dealing with emotional problems and talking about emotions35 were effectively promoted by the figure of a clinical counselor.

Instead, a therapist’s support did not seem necessary to learn the skills of the SPARKS treatment in the study involving Maori parents/caregivers and adolescents39. Moreover, the presence of the therapist seemed to generate embarrassment for young people and create resistance to treatment41.

Discussion

The authors investigated the population who used SPARX, their experience, and their perceived satisfaction with this online treatment as a serious game for depression. They also identified which type of professionals were involved in the SPARX treatment and whether their support could impact satisfaction levels and compliance rates.

The population that uses SPARX is heterogeneous, and there are only a few studies conducted on the use of this serious game on users who require help for depressive symptoms. Most studies have been conducted on specific populations with limited access to mental health resources, fully reflecting the aims of digital mental health and considering the use of technology as a fundamental resource to overcome socio-economic and cultural limits to access to care. Special populations, such as offenders or difficult young adolescents, underlined the need to adapt SPARX, as other serious games, to different young languages and backgrounds. These data highlight the importance of tailored interventions that can address the complexity of the depressive experience and the adolescents’ various socio-economic and cultural settings. Our results are in line with other studies that highlighted how user’s characteristics, such as their age, development, gender identity, and the nature and severity of their difficulties, must be taken into consideration to understand better who to provide this intervention34,42. Young users who decide to use a serious game like SPARX will have individual preferences regarding the content and design of technologies and their overall approach (e.g., social media, chatbot). After all, some might prefer to engage only with face-to-face therapy or self-help booklets. Therefore, it seems crucial that young people have a choice, where possible, regarding how they access support43.

The results are ambiguous regarding the satisfaction levels of young people who use SPARX. This narrative review revealed the highest satisfaction levels in young help-seekers to mental health resources. However, satisfaction with the use of SPARX does not appear to be high in young adults with subclinical depression or at risk of depression onset but not yet showing severe emotional suffering. Moreover, these data linked to satisfaction levels do not impact completion rates, suggesting that many other aspects may do it. These findings can be justified by the difficulty of adolescents identifying depression symptoms, often having abnormal experiences referred to as trans-diagnostic psychopathological patterns.

Narrative structure33,35, a Guide character – virtual therapist33,39 and challenges – CBT homework tasks32,17 seemed to contribute in satisfaction and completion rates also. A relevant role in the completion rates is also played by customization of the game in terms of users’ culture - symbols, language, norms, values, and artifacts30,39,40, and user gender identity, reflected through the avatar gender26,27,36. Recent literature supports our data by suggesting that the variability in satisfaction outcomes may be related to differences in the virtual game elements and the suitability of specific gamification components for customers with different demographic characteristics. Indeed, the correlation between satisfaction and completion rate should consider the potential benefits and costs of personalization versus standardization of gamification44.

Although SPARX is a serious game not driven by face-to-face support, different professional figures were involved in the selected studies to support SPARX users. Researchers, school counselors, mental health clinicians, teachers, and social workers were among these. If the role of professional support in addition to the treatment was unclear in adolescents and young adults45, our findings showed that the presence of the school counselor was beneficial in impacting satisfaction and completion rates by recruiting and selecting the users who could benefit most from it. Moreover, it has been proven that monitored settings, such as primary care settings, may increase enrollment in online youth programs46.

The presence of a researcher with clinical experience in mental health, who provides emotional support supplementary to SPARX in face-to-face or online/telephone mode, seemed to impact the percentage of completion rates. Consistently, whereas teachers and researchers gave support without any clinical mental health experience, satisfaction levels remained low along with those of completion rates, underlining the importance of integrating mental health professionals into SPARX. A recent review confirms these data, highlighting how the assistance provided by professionals with clinical training and experience could improve satisfaction levels and completion rates in supporting the utilization of serious games42.

Furthermore, these data found in the present study conducted on SPARX are in line with the data also present in the literature on other serious games; in fact in a recent meta-analysis47 it emerged that the most used serious games for the treatment of depression (including SPARX, Wii Fit, Kinect Sport, MindLight, etc.) present a high number of dropouts and missing data in the follow-up phase and it is important to collect as much data as possible to enhance the use of serious games in clinical practice. It would be interesting to delve deeper and compare in future studies how clinician support and the administration practice could impact on completion rates in different serious games treatments.

Conclusions

To the best of our knowledge, our narrative review, including quantitative and qualitative studies, is the first to analyze and discuss the professional’s role in supporting SPARX, an issue not considered in previous reviews. Following the growing increase in depression among young people, it is necessary to ask how services and therapeutic programs can facilitate access to this population and help them maintain adherence to treatments. DMH and gamification seem to be one way to overcome barriers (eg stigma, costs, accessibility in rural contexts) that prevent young people from asking for help. In particular, gamification could be a promising paradigm for building digital mental health programs that promote stimulating engagement.

More accurate answers could be given to our research questions if further studies will better define the characteristics of the young depressed users who can benefit most from these digital interventions, mainly addressed to primary care contexts, in a sort of ‘precision serious game’ preventive treatment48.

We foresee that future directions should also include optimizing user choice, as typical for Internet applications, and improving integration between digital tools and clinical services.

Conflict of interests: the authors have no conflict of interests to declare.














































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