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Background. Using commercial off-the-shelf video games rather than custom-made computer games could have several advantages for reducing stress and anxiety. This means they automatically save some of your game information (such as progress, daily challenges, and current game state) in a special way. Wellness: Women’s Jewelry Making Class Teachers & Assistants Duties: Help clients who are having problems with their Lifeline phones (free cell phones.
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This site and all of our games are not intended for children under the age of 13 and we do not knowingly market to or collect, use or disclose information from children under the age of Two authors FP and AP independently assessed study quality. Faber J, Fonseca LM. The effect of games and simulations on higher education: a systematic literature review. The social side of gaming: How playing online computer games creates online and offline social support.
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A recent systematic review [ 35 ] indicated that casual video games CVGs , characterized by low cognitive loads and generally short time demands such as Tetris and Angry Birds, represent a particularly useful genre for diminishing stress and anxiety. Several other genres of COTS video games appear to be promising for decreasing stress and anxiety in individuals, including exergames [ 85 ] or survival horror games [ 86 ].
Within this context, the aim of this systematic review was to describe the literature on the use of COTS video games for decreasing stress and anxiety.
The secondary objective was to organize the research with respect to critical variables related to video game characteristics ie, genre, platform, time of play.
Papers published in English in peer-reviewed journals were selected and subjected to a check for the above inclusion criteria. This period was chosen as the first reports of the effects of video games on stress and anxiety reduction appeared around the s [ 36 ].
Initially, two of the authors FP and AP checked the titles and abstracts of the identified articles to determine their eligibility. Subsequently, they independently reviewed the full texts of potentially eligible papers. Any disagreements between the two authors FP and AP were discussed until reaching a consensus.
When papers provided insufficient data for inclusion in the analysis, the corresponding authors were contacted to provide additional data. No additional articles emerged via manual searching and reviewing the reference lists of relevant papers. Two authors FP and AP independently extracted data on study characteristics and video game characteristics.
The populations, study design, measures of outcomes, and study outcomes were considered relevant variables according to the approach adopted in previous reviews [ 35 , 37 , 88 , 89 ] to facilitate easily classified and comparable studies in the literature.
An indication of the mean age or age range identified studies performed with children ie, under 12 years old , adolescents years old , young adults years old , middle-aged adults years old , and older adults over 55 years old. The division of these age ranges also followed previous studies [ 90 – 92 ].
Video game genre classification was considered because not all video games are equal from many aspects, and their effects strongly depend on specific characteristics of the game itself [ 93 , 94 ]. Since there is no standard accepted taxonomy of genre, although one of the most commonly adopted is the system proposed by Herz [ 95 ], the above categorization was proposed to be as similar as possible to the Entertainment Software Association ESA classification [ 14 , 96 ] see Table 1.
In addition to the ESA classification genres, AR games were added since they appear to be essential to the main research questions of this review [ 97 ]. Delivery platforms were considered since they represent important information about how computer games can be accessed.
Since new technologies such as mobile devices and virtual reality have recently expanded how games are played, we further considered the delivery devices. Finally, in the studies that indicated play time, this information was included in the analysis, which can offer valuable insights about how and for how long to use COTS to effectively reduce stress and anxiety. The MMAT has high reliability and efficiency as a quality assessment protocol and is capable of concomitantly appraising methodological quality across various types of empirical research [ 99 ].
Two authors FP and AP independently assessed study quality. Disagreements on study quality were resolved by discussion between the two authors. The search strategy retrieved records. Ninety-six full-text copies of the remaining articles were obtained and subjected to further evaluation. Finally, 28 studies remained for inclusion in the review see Figure 1 and Multimedia Appendix 1.
An overall quality score was assigned to each study using the MMAT scoring system [ 98 ]. Studies could be awarded a score of 0, 25, 50, 75, or with indicating the highest quality.
The distribution of MMAT scores among the included studies varied substantially according to study design Table 2. See Multimedia Appendix 2 for details of quality assessment for each study.
None of the 8 studies that used a quantitative nonrandomized methodology accounted for confounders in the design and analysis. Two of these studies did not clearly describe the target population and the sample inclusion and exclusion criteria [ 80 , ]. One study did not adopt appropriate measurements and did not report complete outcome data [ ]. Two of the three studies using a quantitative descriptive methodology did not report establishing an appropriate sampling strategy to address the research question [ , ] and one failed to ensure that the sample was representative of the population under study [ ].
RCT was the design of choice for 17 of the included studies. The number of participants ranged from 27 [ ] to [ 85 , ] in RCT studies and from 1 [ ] to 40 [ ] in quasiexperimental studies. No study that recruited adolescents emerged in our final article list Table 3.
Fifteen studies involved healthy participants, in most cases recruited from university staff and students, whereas three studies recruited participants among full-time workers [ 82 ], soldiers [ 86 ], and older adults in federal programs for assistance [ ]. The other studies included soldiers who had posttraumatic stress disorder [ ]; older adults who lived in a nursing home [ ] and with Parkinson disease [ ]; adults with at least minimal symptoms of depression [ ], clinical depression, and comorbid anxiety [ ], systemic lupus erythematosus [ ], obesity [ ], physical disabilities [ ], and hematologic malignancies [ ]; women after emergency cesarean section [ ]; children with molar incisor hypomineralization—affected teeth [ ], chronic wounds on the lower limbs that require active dressing changes [ ], and who sustained second- and third-degree burns to the shoulders, neck, chest, bilateral forearms, and left thigh [ ] Table 3.
All studies used self-reported quantitative measures of psychological constructs. Five studies used the State-Trait Anxiety Inventory [ ], three studies [ , , ] used the Hospital Anxiety and Depression Scale [ ], and two studies [ 85 , ] used the Perceived Stress Scale [ ]. Ten studies included physiological measures, three adopted cognitive tasks [ , , ], and four used other types of performance tasks [ , , , ].
Eight studies reported that COTS games were superior for reducing stress when compared with basic stress management training [ 86 ], guided relaxation or sitting quietly [ ], a traditional exercise program at a moderate intensity [ ], surfing the web [ 36 ], a passive video game distraction [ ], a standard distraction procedure [ ], and not playing games [ 85 , ].
Two studies compared the effects of different video games on reducing stress [ , ], showing that playing an action game elicited higher arousal and stress than playing a CVG [ , ].
Another study compared two versions ie, cooperative vs competitive of the same action-adventure game, showing a decrease in stress levels after both [ ]. One study showed that although an action game increased stress, it also elicited happiness in players [ 80 ]. Finally, two studies investigated the relationship between stress and the use of some COTS games.
In particular, individuals with a low level of stress reported playing this game to enhance their offline lives. By contrast, highly stressed individuals reported that playing this game magnified rather than relieved their suffering [ ]. Twelve studies reported outcomes for decreasing anxiety Table 3. Nine studies reported improvement after playing a COTS game compared to an eye movement desensitization and reprocessing EMDR therapy alone [ ], watching a film [ ], surfing the web [ ], anxiolytic medication [ ], physiotherapy alone [ ], passive video game distraction [ ], and not playing a game [ , , ].
Furthermore, in two studies that did not include a control group, exergames diminished anxiety in only one session [ ] and in a more extended program including a total of 30 sessions [ ].
Another study compared the efficacy of an exergame and a CVG played in virtual reality; anxiety reduction was more significant in the case of the exergame [ ]. Only two studies focused on both stress and anxiety in a combined manner Table 3 [ , ]. In the first study, exergames were efficacious in reducing anxiety in a sample of individuals with physical disabilities; however, no differences emerged in stress or depression [ ].
In the other study, self-reported acute stress symptoms and the frequency of intrusive traumatic memories after traumatic childbirth reduced after engaging in the brief cognitive intervention, including playing Tetris; however, no differences emerged regarding anxiety and depression [ ]. Twenty-four studies used only one video game, whereas the other four studies adopted two video games of different genres [ , , , ].
Twelve studies used exergames, whereas nine studies used CVGs. Four studies adopted an action game [ 80 , , , ], which was a shooter game in three studies [ 80 , , ] and a fighting game in the other [ ]. Three studies used action-adventure games [ 86 , , ], which was a survival horror game in one study [ 86 ]. Games delivered via console were the most popular, with 13 studies using this game platform Table 4. Nine studies used a PC, three studies. In the 26 studies that measured the effect of time playing COTS games on stress and anxiety levels, there was a heterogeneous result.
The mean number of sessions was 6. The actual time spent playing video games differed among studies, ranging from about 2 minutes [ ] to up to 15 hours [ , ].
Only two studies ie, the two cross-sectional studies did not indicate the exact playing time Table 4. This systematic review examined studies performed to investigate the efficacy of COTS video games for diminishing stress and anxiety. After applying the inclusion criteria, 28 papers were included for analysis.
Interest in this field was crucially fueled by publication of the first study on this topic in [ 36 ]. This suggests that much of the research in this area is of high quality; nevertheless, the quality scores varied substantially according to the study design. With respect to the population of focus, the majority of studies involved young adults ie, years. This finding also emerged in a previous systematic review on the use of video games, including COTS and custom-made games, to train cognitive skills [ 20 ].
A possible explanation of this tendency could be that many studies have enlisted college students as participants for recruitment simplicity. Three studies involved middle-aged adults ie, years old [ 82 , , ]. Based on emerging results, the use of COTS games can offer essential support for people of this age group, who, besides representing the most significant percentage of video game players [ 14 ], are particularly susceptible to high stress and anxiety [ , ].
Three studies recruited older adults ie, up to 55 years old. The results of these studies suggest that the use of COTS games can be helpful for the elderly population not only to improve cognition [ – ] or to enhance physical activity [ – ] but also for relaxation [ , , ].
This fact appears relevant since, if older adults generally do have lower stress and anxiety and better emotional regulation than younger adults [ ], given the COVID pandemic, this age group is currently experiencing significant adverse psychological consequences [ , , ]. The COVID pandemic has exacerbated stressors for older adults because of the risk of becoming seriously ill and the need for social isolation to mitigate this risk.
With respect to younger age groups, two studies recruited children ie, under 12 years old [ , ]. Playing COTS games, mainly through consoles ie, Nintendo Wii , helped to diminish anxiety and alleviated pain in even very young children during painful or invasive medical procedures such as burn dressing changes and dental treatment.
This fact appears to be important because there is a need for therapeutic alternatives within this age range with relatively limited medication options [ ]. Finally, no study emerged specifically focusing on adolescents ie, years old. Concerning the health characteristics of the participants included in the studies, interestingly, COTS video games reduced stress and anxiety not only in healthy individuals eg, [ , , ] but also in patients suffering from different mental disorders such as posttraumatic stress disorder [ ]; Parkinson disease [ ]; depression [ , ]; comorbid anxiety [ ]; as well as physical problems such as physical disabilities [ ], systemic lupus erythematosus [ ], hematologic malignancies [ ], or severe burns [ ].
The outcome measures adopted in the studies included in this systematic review predictably primarily constituted self-administered psychological questionnaires, which were used in all studies.
Nonetheless, numerous studies also included physiological measures eg, heart rate variability, blood pressure, concentration of salivary cortisol , cognitive tests, and performance tasks, which seem to be more reliable in assessing change over time. Therefore, openness to different methods of assessment is desirable from the perspective of empirical evidence.
Moreover, since many different tools are used, especially self-report questionnaires, in the future, it will be essential to define a set of standard measures for the evaluation of stress and anxiety that are specific to the different age ranges of participants. With respect to outcomes, 14 studies included in this systematic review primarily focused on investigating COTS games for reducing stress, 12 focused on anxiety, and 2 assessed both of these conditions [ , ].
Empirical evidence emerged concerning the efficacy of COTS video games in reducing both stress and anxiety.
COTS games appear to be superior for reducing stress when compared with both control procedures eg, sitting quietly or surfing the web [ 85 , , , ] and traditional techniques such as stress management training [ 86 ], guided relaxation [ ], or a standard distraction procedure [ ]. An action-adventure game ie, Lego: Marvel Superheroes decreased stress both in the cooperative and competitive versions [ ]. However, other studies reported no decreases in the levels of stress of the players.
A more significant increase in stress levels emerged after playing FIFA and Call of Duty compared with the levels recorded after watching nonviolent television [ ]. Playing an action game, specifically a shooter game ie, Counter-Strike , elicited an arousal stress response but also increased happiness in players [ 80 ].
Concerning anxiety, studies that emerged from this systematic review reported better improvement after playing a COTS game compared with not playing the game [ , , ], surfing the web [ ], watching a film [ ], a passive video game distraction [ ], EMDR therapy [ ], anxiolytic medication [ ], or physiotherapy alone [ ]. Furthermore, two studies found a significant decrease in anxiety after a single exergame session [ ] and after an exercise program with the same video game genre [ ].
Regarding studies examining both stress and anxiety, in the first, anxiety, but not stress or depression, decreased after an intervention using exergames in a sample of individuals with physical disabilities [ ]. In the second, playing a CVG ie, Tetris within a brief cognitive intervention reduced the frequency of intrusive traumatic memories after emergency cesarean section, but did not affect anxiety or depression [ ].
With respect to video game characteristics, considering game genre distribution, exergames were the most frequently used, closely followed by CVGs.
This result is partly surprising, as previous literature focused almost exclusively on CVGs to reduce stress and anxiety. This genre of games has proven to be able to diminish state anxiety [ 35 , , ] as well stress of the players [ 36 ], even to a greater extent than medical treatment [ ].
As noted above, many studies included in this review used different genres, especially exergames. Owing to their high level of interactivity and high-quality entertainment [ – ], exergames represent one of the most appealing video game genres for inducing positive emotions and decreasing stress and anxiety.
In addition to exergames and CVGs, this systematic review showed that other genres of COTS video games could also be helpful for the reduction of stress and anxiety, including action games [ 80 , , , ], particularly shooter games [ 80 , , ] and a fighting game [ ]; action-adventure games [ 86 , , ], including survival horror games [ 86 ]; RPGs, in particular MMORPGs [ ]; sports games [ ]; racing games [ ]; and AR games [ 82 ].
Concerning action games, and in particular shooter games, a study performed using Counter-Strike reported a high physiological arousal response, accompanied by the perception of a positive emotional state and decreased negative emotions [ 80 ]. Based on this result, it appears possible that shooter games activate an intense arousal response in the player while improving their emotional state, likely because they require high cognitive resources [ , ].
However, this hypothesis requires further investigation. Two other studies included in this review showed an increase in stress levels and a physiological arousal response after playing a shooter game ie, Call of Duty , which were higher than those measured after watching nonviolent television [ ] or playing a CVG ie, Clusterz [ ].
This systematic review also offers evidence about the efficacy of action-adventure games for reducing stress, not only in young adults but also in children [ 86 , , ].
This fact is interesting because this genre of games includes titles suitable for children, such as those used in the two studies that emerged from the review ie, Ice Age 2: Meltdown and Lego: Marvel Superheroes. A subgenre of action-adventure video games that reduced stress and anxiety in young adults was survival horror. One study performed on young adult male soldiers reported that playing a horror game ie, Left 4 Dead combined with biofeedback techniques reduced stress to a greater extent than training as usual [ 86 ].
Therefore, together with exergames and CVGs, horror games could represent another game type for effectively managing stress and anxiety. This video game genre shares many characteristics with CVGs, such as ease of learning and short duration. For this reason, it would be interesting to further explore the use of racing games for the reduction of stress and anxiety in other age groups such as adolescents and adults who could also obtain a benefit.
Based on the results of this review, another interesting genre to help reduce stress and anxiety is AR games [ 82 ], which combines smart mobile technology with physical exploration in the real world. They may have a possible therapeutic role in helping stressed or anxious people deal with their everyday experiences.
Regarding the platform, 11 of the included studies delivered games via a console, especially Nintendo Wii Fit and Microsoft Xbox with Xbox Kinect. Curiously, one of the most famous and popular consoles ie, Sony PlayStation was used in only one study in the PlayStation 3 version [ ]. No study has used recent versions of this console, namely PlayStation 4 and PlayStation 5, released in and Nine studies included in the review used a PC as the platform and virtual reality systems were used in three studies [ , , ].
Only one study adopted smartphones [ 82 ] or mobile consoles [ ]. Finally, the effect of time of play was heterogeneous, both in terms of the number of sessions and the specific time spent playing video games.
In particular, the number of sessions ranged from a minimum of 1 eg, [ 36 , , ] to a maximum of 30 over 10 weeks [ ], and the total playing time varied from a few minutes [ ] to over 15 hours [ ].
The fact that even single and short sessions ie, 1 or 5 minutes of play were effective in reducing stress and anxiety appears particularly interesting. In addition to offering data in favor of the effectiveness of COTS video games in reducing stress and anxiety, the results of this review also raise some critical reflections on the possible risks of using these games for this aim. First, COTS games appear to be not always useful for relaxation.
Some studies included in this review reported an increase in stress after playing a sports game ie, FIFA [ ], as well as a more intense stress and arousal response after an action game, in particular a fighting game ie, Mortal Kombat: Komplete Edition , than a CVG ie, Tetris Ultimate [ ].
In another study using an MMORPG ie, World of Warcraft , highly stressed individuals reported that playing this game magnified rather than relieved their suffering [ ]. Second, some gaming platforms are not suitable for all ages. In particular, concerning the use of video games played in virtual reality, it is important to emphasize the possible risks for children under 12 years old [ ].
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