So hi, I'm Nina Vossen. I'm a psychiatrist and professor at Stanford. And I run a lab called Brainstorm, which is Stanford's lab for mental health innovation. And you're gonna hear about our phenomenal lab members and how we all came together in just a minute. But I actually wanted to share a little bit about how we're even here today. So first of all, this work, Live Now, and even, so I'm Nina Vossen. This is Varun Thavar, David Dupie, and Christopher Flinton couldn't actually be here. He is someone who, so fun fact, Varun was presenting on Live Now last year in the poster session, met Dr. Flinton, who is in active duty military, and where is he right now? Germany, he's in Germany right now. So thank you for him for serving our country. And so the two of them actually have been collaborating since APA annual meeting last year. So little shout out there for the value of the benefits of meeting people and collaborating within the APA. So it all started there. To give you a little bit of a background, so I mentioned at lab, it's called Brainstorm on mental health innovation. And very specifically, what the kind of thesis behind a lot of this has been is that a lot of the tech and social media platforms out there, such as Facebook, Instagram, for example, were not created with mental health in mind, right? And only now, 20 years later or 10 years later, are we seeing tremendous mental health effects and realizing that they were caused by these platforms. So background on our lab is that we've worked with primarily tech and social media companies, including Pinterest and TikTok. And when we think about things like community psychiatry and how do we really meet people where they are, our take on meet people where they are has been, where is everyone? They're all online. So like we work with Pinterest, for example, which had about 400 million users. TikTok now has over a billion users. And specifically, by being able to take our experience and understanding of psychiatry, psychology, pathology, and really just the daily lives of what happens when everyone from adults and children are using these platforms, it's helped us then really apply a lot of what we know in research and clinical work to these platforms to make these platforms, first of all, safer. We say, one, do no harm, right? That's not only our oath as physicians, but we say that that's exactly what these platforms need to do as well, as well as then how to do good and leverage these platforms to actually improve upon mental health. And so that's actually what you're gonna see today through Lift Now. And I'm not gonna, I'll turn it over to these guys. I'm the opening act, basically, and these guys are the main event. So they'll be sharing even more about that. So I wanna give a little background there. So a little bit about myself. As I said, I'm a professor at Stanford. Also, fun APA fact, I started the Psychiatry Innovation Lab, which is this afternoon in the Innovation Zone, which is right when you enter and go down the escalators to the left is this whole Innovation Zone, which has grown now over the past several years of the annual meetings. So that's my fun fact there. I'm gonna share a little bit about these two. So David Dupie, we've actually had, David has been working with our lab since he was an MD, MBA student at Yale. He's now a resident at Stanford. But some fun facts about David. One is that when he was in medical school, he actually got a multi-million dollar grant from Yale to focus on physician well-being, and burnout, excuse me, burnout, even before, can we get some water? Even before we realized here at APA the importance. David was doing fantastic work at Yale. A second fun fact is that he was also the winner of the, I think it's the Yale Business School Baking Challenge. Is that true? So our lab meetings are awesome, basically, because of that. And even when I am doing keto, David is thoughtful enough on how to have some keto-friendly desserts as well. Varun, so fun fact about Varun is one, 15? So 16, I'm sorry, he is 16 years old. I am 99.999% sure the youngest person to submit a presentation at APA that to get accepted. So huge, huge props to Varun. Some other fun facts, he actually just a few weeks ago played cello at Carnegie Hall in New York. So very, very impressive young man, and so you'll hear from both of them in just a little bit. So I wanna tell you a little bit about ourselves. Would love to learn about you. So I think first of all, just a little bit of a background in terms of people's backgrounds. So how many psychiatrists, first of all, do we have? Mostly psychiatrists. Of that, how many are veterans administration, military? Coming from that perspective, okay, okay. Maybe, okay, so about five or six. Private practice? Okay, that may be about a third or so. Academia? Another fourth or so. And who did I miss? Could you shout out, tell us your background, or where you're from? That's okay too, it's morning. My next question is, and then this is the last question before I'll turn it over, is what is your favorite video game? So I will start with myself. I am a child of the 80s and 90s, and so Super Mario Brothers is very much my favorite video game. So either yours or actually your, for those of you who have kids, your children's favorite video games. Maybe we can call out some common ones. That's great, yes, yes. I'll turn that over to you, David. I think Barnes are expert. Yes, yes, yes. So what are the most popular video games that folks might be playing? Somebody played Minecraft, or does anybody know? Yes, fabulous. What's in Fortnite, any Fortnite in the room? Call of Duty? And Breath of the Wild just came out, and Breath of the Wild. Okay. It's Use of the Kingdom, exactly. Yes, Halo? That was when I was in college. I don't know if that's still around anymore. Okay, and Roblox? Kids, how many folks' kids are playing Roblox? Exactly, yes. So basically, everyone, who has not either played, who has never played a video game? One, okay. Do your children or grandchildren play video games? I think so. There's a 97% chance that they do. That's why we're so supportive. Yes, so thank you all for coming, and what you'll hear throughout the next hour and a half is really the phenomenally incredible role that video games can and now are playing in changing mental health care delivery. Really, what we're seeing is everything from diagnosis, folks who are able to use aspects of video games to diagnose disease and treat disease, and when you hear exactly that 97% figure, 97% of kids play video games. So we just realized what a tremendous opportunity it is here to really make an impact. We know we have this huge supply and demand mismatch, and so many patients who are on these, hi, welcome, come in, come in, patients who are on these long wait lists, and so this is a really unique way to make an impact. So we're gonna tell you a lot more about it, so I'm gonna turn it over. Thank you so much for coming. Thank you so much, Dr. Vasson, for those introductions. Now, I'd like to introduce to you our presentation. Disclosures. And the objectives for this presentation is to first, to understand the prevalence and the popularity of video games for social engagement and for enjoyment in our modern era among children, among adults, among even the older generations. And then next will be to identify the impact of video games specifically on mental health and their significance as even a treatment option for mental health conditions. And then we're going to introduce the concept of specialized video games for mental health, creating video games specifically for mental health instead of using existing video games for treatment. And then we will show you the LiftNow platform that we've created and how it can be implemented as a video game treatment option for CBTI and for insomnia. Our agenda, first, Dr. Dupuy is gonna share with you video games in the modern world and their impact. And then Dr. Vasson's gonna share with you video games' mental health benefits and their consequences, et cetera. After that, I will share with you strategies for creating and developing video games for mental health, and then I'll show you a sample video game which is mental health-focused, which is LiftNow. And then I'll give you a demonstration, and then we'll close off with Dr. Dupuy, and then we'll have the Q&A. And before I give it off to Dr. Dupuy, I am going to share with you the catalyst for this, for what happened. So my mom had a lung infection a few years ago from a superbug. It was non-contagious, but it was resistant to lots of antibiotics, and treatment required intravenous medication and even lung resection with lots of side effects. And this is extremely rare. And as she was going through this, I found myself in a way to kind of keep my mind off of it, or as a way to cope with what was happening, I turned to video games. I played lots of video games. This was my main interaction with friends, with keeping myself busy, with just keeping my mind off of things. And afterwards, thankfully, she got better. And afterwards, I looked into video games to see if my experience was shared with other people, was something that other people also used. And that was the catalyst for this research. So now I'm going to give it off to Dr. Dupuy to share with us video games and introduction to them. Thank you so much. And before he does that, I just, on a note of disclosures, I just want to reiterate, we do not get money from Nintendo or any of the companies. This is all, you know, stuff that we've been doing at Stanford. And we actually published a piece a couple of weeks ago in Fortune Magazine on video games. And so you could, and specifically video games. And do we talk about this? It's part of my voiceover. Okay, then I'll, okay, you'll hear more about that. Well, a little teaser there, more to come in just a little bit. There we go. But we've been asked by a lot of people, how low are you funded by the video game companies? And zero, zero dollars from video game companies. So go ahead. So just a brief intro to the video games here. Definition, what is a video game? I don't think that these are unfamiliar to anyone in the audience here, but the broad and overreaching definition that we fell upon was interactive electronic games, which, in which players control images on a video screen. They are enormously prevalent, especially amongst younger users with 97% of youth and adolescents playing for at least an hour a day. So all of these folks spending about 4% of their day on video games. And as a business entity, enormous impact, $5.6 billion, actually nearly double that of Hollywood's. Granted some confounding in 2022 with the pandemic still going on and folks not going to movie theaters quite as much. Classifying video games broadly is obviously a huge challenge given the variety of games that are available today. But for our purposes, we thought it helpful to break them up along these two different axes, ranging from simple to complex and non-social to social. So we have some broad examples of video games here with Halo being a very typical, largely non-social for the single player campaign. Very complex, Minecraft, which we'll talk to you about today. Massively multiplayer online game. Very complex and very social. So something that's really makes it conducive to CBTI in the way that we're conceptualizing of it. Nina's favorite, Mario Bros. Non-social and simple. It says nothing about Nina that that's her favorite one. Simple and social being Guitar Hero, which was really popular when I was in middle school. I think it's still around today. Rockstar is still doing it up. Wanna talk to you a little bit about prevalence here too because when we think about video games and video gamers, a pretty stereotypical image comes to mind and one that continues to be championed by the media, largely in a false narrative to discredit mental health as a means of contributing to the conversation about gun control and gun violence that continues to plague our country. When we think about video gamers, stereotypically you might think of a white teen male. You might think cystic acne because of the media. You might think that it's someone who isn't too well socially adjusted, doesn't like to spend time with friends, bit of an oddball, bit of a loner. Lone wolf, I think, is a favorite term that the media likes to use. And this, by and large, is not true. If we look at some of these simple stats here, 48% of gamers are women. 29% of gamers are people of color or otherwise minorities. And the average gamer age now is actually 35. So it's not just white teens without friends. That's a false narrative. That's not the truth here. This graph here is not projecting super well, but what it shows is the breakdown between male and female gamers with men being the lighter blue and women being the darker blue there. So we see actually approaching pretty close to even breakdown between the two as time has gone on from 2006 on the far left to 2022 on the far right. So why are we here talking about video games today? It's because of their enormous social and cultural impact where through video games, the internet generation has connected, has formed relationships online. They've bonded and shared experiences and commonalities, which is a great way for folks to make new connections, to get exposed to new ideas. It's unfortunately an equally good way for folks to be exposed to fringe ideologies and behavioral and thought echo chambers as well. So unfortunately, a sword that cuts both ways. It has increased relationships and connections through being able to access folks across the world. And again, a medium that cuts both ways. A little bit about the politicization of video games. We can see here quotes from a speaker of the House McCarthy and former President Trump. I won't read them out to you, but I will say that we see a lot of scapegoating of video games and video gamers. A lot of questions about whether or not the sale of violent video games is actually what's behind the fact that we've had, on average, more than one mass shooting every single day this year, an acceleration that has occurred continuously since the 80s. If you want more of a discourse on this, please feel free to look us up in Fortune. We wrote about the lack of causal relationship between video game consumption. There's actually some really interesting studies showing that after a large first person shooter title is released, you see a decrease in the amount of violent crime. Not a huge amount, but a significant amount. We also see, conversely, when a new gun store opens up, gun violence and crime in the surrounding area also increases. We won't necessarily claim that this is a smoking gun, no pun intended there, but we will wink and look meaningfully in your way. So yeah, please feel free to check out that piece. We only got a few death threats from NRA members when we published it, and we think it's worthwhile. And with that, I'll hand it over to Dr. Vossen to speak a bit more about video games and mental health. Thank you. Now, so I think just thinking first big picture, as I said, there are enormous mental health benefits, and we're gonna talk about both the pros and cons because there are certainly many concerning things about video games when it comes to mental health. So just to start off, there are really fantastic cognitive, emotional, and social benefits that one gets from gaming. And when I think of the cognitive benefits, I actually think about, I think it was the TV show Alias, where you see that in order to recruit people into the CIA, they look to see, again, this is all fictionalized, right? But they look to see how they're playing certain video games, and in particular, because, as you see here, some of the cognitive benefits, faster and better attention allocation, right? If you're in the CIA, very, very important thing. Higher spatial resolution, enhanced mental rotation, and I think really that one of the biggest things is developing problem-solving skills, both in terms of one-on-one as well as group problem-solving skills, and we'll get to the social component in just a minute. On the emotional side, this is actually, I think, even more surprising. the cognitive benefits make sense, right? You can get a sense of, okay, this is a game, of course, that this is helping people. But it's very, very interesting, actually, that there have been emotional benefits as well, in particular, dealing with challenges and adversity, right? Like that place in the game where you find yourself always dying, you know, like how do you then go back and build up that resilience to keep playing and eventually beat that hurdle that was the big hurdle? And what we see, actually, then, is positive emotions, a real sense of pride after beating a particular adversary, as well as less symptoms related to both depression and anxiety. And then on the social side, I think this is really, really interesting, that in particular, because now video games are so multiplayer in nature, you know, people can literally be playing with people all over the globe, and this is exactly what we saw during COVID, was a very real sense of social connection that people were able to get through video games. And, you know, I said, and for those who know, you know, Super Mario Brothers from back in the day, that was, you know, what I remember playing when I was a kid. That was very much like, you know, you play with yourself, one or two other people may be around, maybe a small little group of kids would be playing, but there wasn't like social interaction in terms of that improving. And that, I think, is what's so different about the games today, is that there's a tremendous, tremendous amount of social interaction. And what we'll see as a result of that is, you know, people not only developing problem solving skills, like we said, there are even studies that have shown an increase in real world, right, so this translating out of the gaming world into IRL, if you will, social and civic engagement, also really for kids and teens helping with improving social skills and group bonding experiences. And I'll share that, you know, what we've even heard, which I think has been really fascinating is teenagers talking about how, you know, over the, you know, cafeteria table in school, we might talk, you know, the depth of our conversation is here, right? We talk about sort of superficial things around, you know, what homework assignment is next and pop quizzes and stuff like that. When we're on these video games, we can go in depth, and we can talk about things that we don't actually even talk about in person, and so it's a huge, tremendous opportunity that we're seeing that especially teenagers, and you see even, you know, who are able to talk on a much, much deeper level facilitated by these games. This is one of my favorite things about this, is in addition to these benefits, we really have psychoeducation, and I'm going to give an example here, which is this video game called Hellblade, and it was developed actually as a collaborative effort between clinicians and video game developers, and the storyline here is that the main character here actually, they portray psychosis as the main character goes through the different challenges and trials, and in this article, research article, you know, they interviewed folks who had played the game, and there's a very, very powerful testimonial I think that I'll actually read aloud here. I had a psychotic break several years ago. My brother never understood. I overheard him say that he was ashamed of me. After this game, he turned to me and said he was sorry. You got the message across that I never could, and so when we think about stigma, and you know, when people ever ask about what are the biggest problems in mental health, I find myself saying that stigma is problems one, two, and three, right? We know what a tremendous problem it is, and so when games like this are able to actually put people in the mindset of, you know, what is it like to experience these incredibly, incredibly difficult symptoms, and then have a sense of empathy after playing, I think it's just really, really tremendous. So you know, just to kind of put it all together, lots of positive benefits that we're seeing out of these very, very popular big video games decreasing loneliness. Two weeks ago, our Surgeon General came out with an advisory about loneliness and how pretty much all of America is struggling with loneliness, and we're seeing here that video games can actually help decrease loneliness, increasing cognition, improving goal-setting behavior, you know, some of the things we've talked about, but also really importantly, like lowering depressive symptoms, helping with emotional regulation, preventing anxiety, inhibiting mood repair. So you know, there's even more, but really just across the spectrum, if we're thinking both from wellness to illness, as well as the different types of mental illnesses, depression, anxiety, you know, that we're really seeing improvements all along the board there. In particular, I think what we've seen is a huge focus specifically on post-traumatic stress disorder, where video games have been really shown to help cope with PTSD symptoms, and also the social engagement, the act of gaming itself has actually really helped. Interestingly, Tetris, and it's funny, I was actually just traveling with a group of people, and we were loading the back, we were loading up the car with everyone's luggage, and the person loading saying, my Tetris skills are the ones helping me figure out how to put each piece of luggage here in a way that's going to optimize our trunk, small amount of trunk space, and you know, so for those who didn't play Tetris, different, a few different shapes that all kind of, you know, you bring them together in order to complete these horizontal lines, and once the horizontal line is completed, you get to, you know, it gets deleted, and you go on, and that that actually, very interestingly, has been shown to impede flashbacks from occurring by temporarily interfering with memory consolidation after a traumatic event, so really interesting things there. And then the next big thing, and I'm sure there are presentations here at APA, is virtual reality has been helping with not only PTSD, but with all sorts of things. We're seeing it for the whole autism spectrum, many aspects of phobias, and just things like that where virtual reality is able to help. And then specifically for older adults, there's been very interesting research that, one, video games can help with loneliness and social isolation. Because the oldest generations didn't grow up playing video games in the way that, you know, we see for, like, obviously Gen Z, millennials, but also Gen X, but Gen X is kind of the, you know, where we really started seeing video games as a part of childhood, but so for the older, for beyond that, that help having some technical support and training is helpful, but that older adults have actually responded to this with very, very high rates of adherence, which is fascinating. And even in, like, retirement communities, you'll see Nintendo Wii getting played, and you'll see, you know, folks kind of playing with each other for this. So really fantastic benefits. At the same time, there are very real negative consequences, which Dr. Dupuy will share with us. So all good things have their opposite side, too, and that's also the case here with video games. There have been a number of studies that have been showed that, you know, video games can lead to increases in aggression. I want to have a disclaimer here, though, too, because the way that aggression has been defined is extremely broad, extremely weak, and often not predicated on real world actions. So when we were completing this article for Forbes and looking at a causal relationship or not, there are instances where the literature indicates an increase in aggression, but the defined aggression as thoughts of wanting to shout or push someone, which I would argue is pretty fundamentally different from buying a semi-automatic weapon and killing multiple people. But, yes, there are correlations and causal relationships between aggression and video game playing. Sleep deficiency, lowered overall mental health, these are also correlations and causal relationships as well. Video games can provide access to misinformation. This is through the game itself as well as through the communities that can grow and evolve around the games and gaming, too. Internet gaming disorder is also something that we should pay attention to briefly as well. It has been recognized as a legitimate diagnosis. It's characterized as an obsession with playing video games to the point of harming relationships and the other things that you would be doing in your life. So it has previously been referred to as video game addiction. I think the phrasing there has been changed to reduce stigma, but the kind of principles around addiction and the manifestations of it largely apply here as well. So you can see symptoms of withdrawal. You can see lack of interest in hobbies or other activities and just a really pervasive focus on continuing to play games. This can also be potentially monetarily dangerous, too, especially with the growth of microtransactions within games. This is now a multibillion-dollar industry. And during my MBA, we did a case study on gaming, and one of the most fascinating things was that 80% of the revenue came from 3 to 5% of players. So you have this small population of super users who are just playing or spending rather a ridiculous amount of money on the games that they love and that they play on a daily basis. That being said, the Goldilocks hypothesis on the correlation between screen usage and wellness has now come to prominence. It ironically replaces the old replacement theory, which posited that if you spend time on video games or on screens, you are replacing other social and other healthy activities, and so you're taking away a fundamentally good thing and replacing it with a fundamentally neutral or bad thing. More recent scholarship has shown that this is not quite the case. I know that even if your vision is above 20-20, you probably can't read what's on the graphs here. My vision is also poor, but I do know these graphs, so I will walk you through them. Basically, we have mental wellness on the y-axis, and we have total amount of engagement per day on the x-axis. In the top right, we have video games. On the top left, we have the engagement and wellness curves for TV. Bottom left, computers. Bottom right, smartphones. What's interesting is that for all of them except for video games, which again is the top right, you see that after one hour of usage, there's some increase in mental wellness, but then you see a steady decline for subsequent hours of engagement. This decline ultimately goes below baseline. However, with video games, you see that increases continue through hours two and three of engagement with some differentiation between weekends and weekdays. That's what those two different curves are here, but only after that do you see decline in wellness. Even with that decline, you only go back to baseline wellness. You actually don't see, on average, broadly worsening outcomes with increasing engagement. This suggests that between two and three hours of play is not necessarily a bad thing. We are not telling the parents in the room to definitely go and make your kids play video games for two to three hours. That's probably also too much of a good thing, but something to think about for sure. I'll now pass things off to Varun to talk to us more about how to design serious video games for the benefit of mental health. Thank you so much. Now that we've looked at video games and their benefits in mental health, now we have to think about, well, if these are the benefits of commercial video games, what are the benefits of video games that are specifically built for mental health? These are called serious games, or games built for serious purposes. They've been shown to improve engagement and interest during the treatment process relative to other existing treatment modalities. This is really interesting, because by using video games, you're able to increase engagement and how people perceive the treatment itself. These have been shown to improve social skills and address symptoms of ASD, PTSD, et cetera. Of course, it's video games. It uses a familiar medium for patients, especially of the Gen Z or Gen Alpha community, and it leads to less obstructive and more enjoyable treatment, as there's, of course, less stigma because it's just a video game, and it's less intrusive, and it's more familiar to them. So here are a few examples of serious games that have already been built. One is Achilles Endeavor Rx, which is, very interestingly, a video game-based FDA-approved prescription treatment, the first one for video games for children with ADHD. This is where players chase mystic creatures, race through different worlds, and problem-solve while building their own universe. This is for children with ADHD, and of course, I'd like to reiterate this, it's FDA-approved, and it's a prescription treatment. Another one is Flowey, and this is designed to help people combat panic attacks, and this is where players control a flower that they must navigate through a series of obstacles by breathing and relaxing. This is for panic attacks by already existing research into meditation and breathing, and this utilizes that in a video game format. And finally, another example of a serious game is Depression Quest, where players both understand and cope with depression, and this leads to psychoeducation in serious games. So players take on a role of a character who is trying to overcome depression, and if you're someone who has depression, this helps you understand your condition more, it helps you go through that better, and if you're someone who doesn't, this helps you understand depression by taking on the role of a character who has it, and so you understand the challenges, the difficulties, the treatment that goes along with that. And just for a summary, these are the two paths taken by existing research into video games and mental health. So first one is to create a serious game, to create a purpose-built video game for a specific mental health condition, and while, yes, you get to design the video game for a specific condition, you have to implement the game in software, you have to maintain it and update it throughout software as more software updates on operating systems, et cetera, and the game has to be individually distributed. You don't get to take on an already existing video game who has its own players already. And the other one is to find mental health value in an existing video game with the act of playing an existing video game, and while you're able to, you know, there's no software creation or maintenance because that's already being done for you, and you get to leverage existing distribution, for each condition, you have to try a lot of video games, lots of combinations, and of course these video games are not built for mental health, so they're not tailored for specific conditions, so the impact that can have might be lessened because of this. I know it's early in the morning, but I think it would be great if, given the information we've presented, if you want to get into breakout rooms based on, I guess, the row you have there, and just talk about a few of these guiding questions, so, you know, ethical considerations in video games, and then where can we get video games to be used widely in mental health, potential ideas for serious games, you can use your imagination for that, potential benefits of video games in education, and of course, considerations in designing culturally sensitive serious games for mental health that are inclusive and relevant to diverse populations. So if you could just, like, maybe for just around ten minutes, like, get in, kind of talk together, I know it's early in the morning, but just discuss these, and then we'll share afterwards. So that's ten minutes now, if you would all... Okay. All right, folks, let's bring it back. Let's bring it back for about five minutes of discussion, and then we're really excited to show you more about Lyft Now. All right, Varun, take it away. So yeah, I'd like to, you know, get your thoughts on these questions, so if we can, if you want to go down each question. So for the first one, what are some ethical considerations in using video games for mental health interventions, for issues on privacy, informed consent, and equity? If anybody had any thoughts on that. Yeah? Yeah? So I think the most ethical issues, it's probably wiser to take a balanced approach, right? Ethical considerations is a lot of this technology has developed in isolation of primarily thinking about it as powerful as it has become in the effect of human lives. And so I don't think they started out with a framework of how do you include ethical... So, that needs to be a field of interest as well. I thought you made your mind up. And how do we provide guidance for what may later on affect things that we value? That is beautiful. First of all, for those who just come in, please come in. Have a seat. You're coming in perfect timing. We had a little discussion. We're sharing out what we discussed. First of all, I would love to see pictures of that 200-year-old home. That sounds very amazing. But thank you. I think everything you addressed here was just great. Just quickly and directly, we're trying to record this session, and we can't hear the people asking you questions. So if they ask a question, repeat it, or please use these mics, OK? Sure. We should also use the mics, too, so they can hear us. Can we take them off, or is it OK? Just don't pull too much. All right, I've got to keep it wired. OK. It's good. Just use it. Oh, no, I just. We're good at video games, not microphones. What I was trying to see is if we could take it off and just pass it around as folks are doing that. So we have some microphones here in the aisles that people can use, or we'll repeat your question if it's inconvenient for you to get to it. I just wanted to say, I really appreciate the points that you just made. A lot of them are actually the founding principles of this lab. We know that whether because of capitalism or hedonism or just simple joy for video games or social media, people are going to keep building it. And we view it as our responsibility as clinicians, as psychiatrists, to kind of act as one of those stone walls in your house and try and put in those clinical guardrails, put in those ethical considerations, because it's much easier to build a compelling product with that as the foundation. Now we have too many housing puns, as opposed to trying to go and retroactively put that in. So it really is a very, very important thing and retroactively put that in. So really appreciate that commentary. Thank you. Then we'll go to question number two. How do you think we can get to a place where video games can be used widely in mental health? And this is a question that's pretty broad. That was by design to get your ideas on multiple issues. So if anybody has any thoughts on that question. Nobody? Oh yeah. I think that forums like this, where you're educating us about the possible use is very helpful. And then, you know, more research so that, you know, if there's education and research, then the clinician population is going to follow suit, you know, because if it works, we're going to use it. Exactly, yeah. And not only about... Oh, another one? And maybe the first part would be to educate everybody, all the populations, not just young people, how to use the video games, how to become more familiar with technology and take it to their advantage. So otherwise, nobody will hear about it or, you know, be able to benefit from it. We completely agree with that. We completely agree with that. And that's exactly why that other piece was published in Fortune and not in a traditional academic publication. We want everyone to know about the potential uses and efficacy of technology, not just as a detractor from mental health and wellbeing, but also as an enabler and a scalable one at that. Thank you so much. Um... I think then we'll move on to question number three. This is a fun one. What are some potential ideas for video games that could be used in a clinical setting? Does anybody have any ideas on that? The psychedelic presentation at this framework of having, you know, therapy alongside of when patients have the psychedelic. The same way, I guess, we could introduce video games and therapy. It's been tracked, monitored with questionnaires and you see the change, but also the time duration that they're using it for would, I think, there would be some potential there about what like CBT is and educating them about CBT and then giving them a series of games which I think the parents would be happy with as well. Definitely, yeah. Thank you so much. No, I'm saying, I mean, that could be a possibility. That actually has started to become done in some video games is that therapists are playing with their patients, not only as a way to just, you know, for younger patients as a way to open up, but also for older patients and of all ages starting to thinking about, think about delivering therapy through video games. Even some have avatars, but some are like, you know, you as you, not just you as a character. I mean, if this is what you're excited about, you're gonna love the rest of the presentation. Yeah, there's such a wide scope, right? There's such a wide scope. You could do it separately with questionnaires and education and then provide it as a separate and then as well. All right, thank you. Hi, thank you for doing this talk. This is like so many different elements of my interests. I proudly identify as a gamer and I'm also in my sleep medicine fellowship right now, so I'm really excited for what comes next. In terms of serious games and the clinical setting, I think we were talking about in our row just, you know, in as people are thinking to develop serious games, I think it's also important that like the wave of gaming has already arrived and a lot of the younger generation is already playing games. And so we see a lot of this generational, I think rift may be a strong word, but like even in therapy and building rapport for people who you may see a younger adult in your office who is really guarded and really withdrawn and really you may be struggling to be building that connection with them. The minute you mention a video game or something that they're really passionate about, all of a sudden this door opens and there's just depth of insight and reflection and you show that graph of how wide and varied video games are and I think that is so interesting because there are so many different types of games that suit different people's reward styles. And so people who really love to hone a skill will definitely resonate with the idea of playing fighting video games where there's this immediate reaction, honing a skill, how well can you be an other person, which is totally different from games like Stardew Valley or Animal Crossing where you're building a community, you're building something that feels good and warm like a melting pot of chocolate. So yeah, I'm really excited about this. Excellent, thank you. This is related to a question I was asking the presenters during that period. I would love to see video games that really help people develop, I work a lot with ADHD kids and we do neurofeedback and such, but games that help kids to improve their sustained attention. But also, you know, ADHD is sometimes called a reward deficiency syndrome and certainly video games have been good at activating reward centers. So to be able to activate those reward centers and reward people for sustaining their attention because, and as you were saying, probably cell phones are much more of a problem than video games as far as impairing, because a lot of parents tell me their kids can only play video games for a very short period of time or their ability to do their homework really goes down because they really have lost their sustained attention. You know, kids with ADD and people spend more time on their cell phones, you know, these days than they do video games probably. And cell phones reward very brief attention. So games that help with sustained attention and games that help with learning disabilities, I think that would be so helpful. Excellent. Thank you. Actually, one of the games that Varun had introduced earlier, NeuroRacer, is designed for exactly that. It's for the ADHD population. It does help with sustained concentration as well. I think you're absolutely right when you say that, you know, there's a reason why mine and generations below mine in time are referred to as the distracted generations, right? There's so much competing for attention. We get thousands of notifications every day on our cell phones. We're constantly cycling between this app and that app. My cardinal three are probably Reddit, Instagram, and my email. And so I'm just as guilty of this as anyone else. We see that these continuous dopamine hits, they really do cheapen sustained concentration and other things. And so there is actually, and broadly, you know, we're seeing this movement towards, you know, de-distractifying, a fun tech term, you got to iffy everything, de-distractifying ourselves, reducing our number of notifications to kind of get back to that place where sustained concentration is more in hand. So completely agree. Thank you. I think we're actually running out of time here, so we might save the remaining last few questions to our general Q&A, because we really want to be able to show you the hard work that Barn has put into Lyft now and into making CBTI more broadly accessible through Minecraft. Thank you so much. Yeah, I completely agree. We'll keep for those guiding questions for the Q&A section. And we saw a lot of awesome engagement, and this group over there, you are very engaged. This group here, very engaged. So we'd love to hear at the end what folks were talking about. Let's start talking about Lyft now, which is a platform that I'll share with you, like the process and how we created it. It's a platform we built with Dr. Flinton, who unfortunately isn't here today, for the treatment of insomnia using video games. So first, before I share with you the game, let's talk about the process of creating a serious game. And this is a step process that we found through the research in the survey, through actually creating the video game. This is a five-step point process that works. And so first is to identify the problem. And this is where, I mean, of course the video game is supposed to be tailored to this kind of problem. And you have to recognize that sometimes certain problems or conditions won't be able to be solved through video games. They may require other types of procedures. They may require more invasive types of procedures. Not all of them can be, but a wide variety can. And it's important to where we can use serious games for their benefit, we should, given how effective they are and how effective they're proven to be. Next is to understand the current mental health strategies. And by using the strategies that are already there, that are already proven to be effective and safe, etc., if we can implement them into the video game, which I'll talk about a bit later, we can get the best of both worlds. Existing treatment and using this new treatment modality. Next is to identify the game structure and progression. And this is to ensure the game is fun and engaging and interactive, etc. And one handy tip that I thought about while building Lyft now is, is this game going to be fun for people and interactive for people, even if they don't have the condition? Is it still going to warrant that kind of interactivity and enjoyment from them? And if that question is answered yes, then the people who do have the condition are also gonna feel that way. Next is to implement the current strategies that we've identified in step number two, and to implement them into the game. And some strategies don't have exact video game equivalents, so some kind of creativity is necessary in implementing these strategies. For example, therapy questions, you know, like normal therapy questions can be implemented through the game through interactive questioning. So while players play the game, the game can ask them certain questions that they can input, and those questions can be stored in the game. And finally, of course, it's clinical and developer validation. We need to ensure that the game is effective and safe, and it's backed by evidence. And so clinical validation is extremely important to make sure that these games are effective. So let's start with this process. So let's go with the problem, insomnia in veterans. And insomnia is very common in veterans. Symptoms are present in up to 54% of military personnel and veterans, and it's more common with veterans who already have existing conditions like PTSD, traumatic brain injury, chronic pain, etc., and can be a major obstacle to recovery and reintegration. Insomnia can, of course, have a very negative impact on veterans' physical and mental health. It may lead to fatigue, irritability, difficulty concentration. It can worsen symptoms of already existing conditions like PTSD, depression, and anxiety, and can increase the risks of accidents, injuries, and even suicide, which is a major problem in veterans. So what's a current mental health strategy? CBTI, which is cognitive behavioral therapy for insomnia, and this works by identifying and challenging harmful behaviors and thoughts towards sleep, behaviors and cognition or thoughts. And CBTI is found to be more effective than medicine in many cases, and it's currently the primary treatment for acute or chronic insomnia. Now let's talk about the game structure and progression. So I talked to you a little bit, I asked, you know, who plays Minecraft here. So for those who don't know what Minecraft is, Minecraft is a video game created in 2009. It's owned, it was created by Mojang, and which is now owned by Microsoft. It is the most popular video game of all time. 200 million licenses sold, and 126 million monthly active users. It is incredibly popular among many, many groups, and it's an open-world game where players can explore and build anything they want, and players can cooperate and compete with other players. When my mom had her illness, this was a game I found. It really helped me because I could play with my friends no matter where they were, no matter where I was. This is a game I can, I played then, and I continue to play now. And the most important part of Minecraft is that it is, it is changeable, it is morphable. You can change the game to whatever you want it to be relatively easily. So using Minecraft's existing, like, APIs, you can morph the game into a mental health treatment using CBTI and other mental health strategies. Oh, API is basically like the modules and existing, like, structure in the game that you can kind of change in, in Minecraft itself. So to say it a little bit differently, Minecraft has an enormous amount of plasticity that allows us to kind of redesign it and reform it in a way that is conducive to whatever it is you're trying to do, whether trying to make a new kind of level, change the aesthetics, or have it be an amenable vector for CBTI. So we have, like, the ground truth, we have the basic form of Minecraft, but we've been able to shift it such that it is able to deliver CBTI well. Thank you so much. Let's also talk about voice integration, which is another important part of playing a game. It's talking to other people. And benefits of voice integration, you know, it allows you to communicate with each other in real time, it helps players coordinate strategies and share tips, you can connect with each other and build friendships in the game and even outside the game, and it can, of course, be conducive to social engagement and improvement. You are literally talking to people while playing the game. And through Lyft now, the software we've chosen is called Discord. It's also a very popular voice and text chat app with lots of integration with video games. It has over 350 million users and 150 million monthly active users, and it's, of course, available on most platforms, the most popular platforms that people play on. And by integrating them together, both Minecraft and Discord, which is possible through, you know, the plasticity, as Dr. Dupuy was mentioning, for both Minecraft plasticity and Discord plasticity. Sorry, plasticity is a hard word. You can integrate them to have an environment in which they both work together. And so this is the Lyft now approach. So meeting people where they are is first and paramount. Both softwares have hundreds of millions of active users, and, of course, you can tailor this for a specific mental health condition using plasticity, which is fully customizable and configurable game environments in Minecraft. You're able to adapt to new mental health conditions, and this was an idea that I was making sure that was in Minecraft. So the game is based on libraries of game modules that you can build yourself or we can build in-game as building blocks to put in each part. And I'll talk about what these different modules are to give you a better idea, but it's based on basically reconfigurability and using existing ideas and structures for building out new games. I'll talk a little bit about this a bit later. It's easy to update and maintain. Of course, Minecraft is not maintained by us, it is maintained by Microsoft. So there's a community of developers improving and updating and maintaining the game as we're able to build the game itself. Of course, simplified training adoption because Minecraft and Discord are so popular, and, of course, the game we're building is based on a well-known quest construct where you're trying to go through certain paths and obstacles to find a final idea or a final boss or a final monster, essentially. And so it's very well known, it's been practiced in many video games. And because of a separated server architecture where you have to be able to be... Well, as soon as whitelisting, it's basically we have to say, okay, you're allowed to get on or you're allowed to be on the server so no random person can join. So it's a separated server and architecture with a fully controlled environment by us. So we control everything here. So it's controlled, it has privacy, and it has security. I'm just gonna add one more thing. Yeah. So one more element of the approach here and why we think video games are really conducive. I want to use a bit of an analogy here for the folks who might not play games as frequently. We've all had conflicts or difficult conversations or things that we need to hash out with a therapist, with a fellow provider, with a family, with a loved one. And these conversations can be really difficult and intimidating. I know that when I was younger and we didn't really have social video games, one of the things that I would do would be to go on a car ride with someone. And you're both kind of engaged, you're having a shared experience, and you're not just sitting and directly facing the person that you're trying to hash things out with. And that made the barrier to conversation so much lower. And we find that today a lot of folks will do the same thing through video games, where they have that shared medium. They're both doing something together. It's a shared experience. And somehow that just kind of lowers the threshold to having this conversation. And we believe that this approach is scalable in a way that having all of us go on car rides with our patients simply is not. And so that's another one of the major reasons that this approach is the one that we ultimately decided to pursue. As I mentioned before, in terms of the server foundations, LyftNow is based on a cloud application where you can integrate both Minecraft and Discord that's available on most different mediums, so like tablets, phones, computers. It provides Minecraft and Discord integration to provide a communication channel before, after, and during the video game. You can anonymize players, so players don't know who other people are while they're playing with them, they just can have fun with them. So they, through handles, which are basically their name, their given name, so you'll find commonly that players don't actually put their full name when they're playing video games. They'll put something like XXGamerTagXX, or XXMonsterSlayerXX. This is like common to just, for anonymization. Of course, there's a validation of players to ensure parental and medical authorization. As I was talking before, we have to validate them, and if they don't have that parental and medical authorization, they're not going to be able to be validated. And as you were mentioning, as someone was mentioning before, therapists for playing in the video game. So therapists can play in the video game, but they can also observe the game through a spectator role, and this is, so they are outside of the game, they can ask questions and all that inside the game, but they won't be able to play, they won't be able to be seen. They're just seeing everybody else play the game. And so this is useful for therapists and therapy integration into the game. And there are research tools, like in-game questions and discussion breaks inside the game that are able to be built, and there's built-in quantitative and qualitative data collection through players answering questions. The actual gameplay itself, players will advance through different scenarios and enemies, and they constantly beat these monsters while they're going through the game, and there are five levels, right? So at the end of the five levels, there's this final monster that you have to beat, and then you beat the game, and then you can play it over and over. So it's very repeatable, so you don't get, like, after two or three times playing it, you don't get really bored. There's levels of randomization through it to make sure every experience is new and exciting. And I'll talk about this a little later, but regulating sleep schedules through the game, and this is part of the CBTI element of it. So there's a built-in sleep schedule in the game for players to go through, and players work together to fight monsters and enemies, and this fosters social connections and communications through the game. So now, that was step three. Let's talk about step four, which is implementing mental health strategies in LyftNOW. So the first one we implemented is the ISI questionnaire, the Insomnia Severity Index, which is a standardized index for regulating insomnia symptoms and the condition. So players will take this survey, this questionnaire, before playing each game to track their symptoms and their progress while playing the game over time. And as an incentive for players to play it, they'll gain materials and rewards upon completing the survey. Now is the sleep cycle simulation. So the players go through the sleep cycle in the game. So there's day, there's night. The players will have to sleep in the night. Otherwise, they'll gain adverse side effects, side effects they don't want that hinder their performance in the game. And if they go through a proper sleep cycle, so they only sleep at night, they only, you know, there's research into not eating too late, not drinking too late, not having any drugs or anything. If they do that, then they'll have no side effects they're able to play the game with any of those. And then finally, sleep tips. And this is challenging cognition. The game will give players information about sleeping in general as they play the game. So there'll be tips that come up that say, oh, do this, oh, do that. And the players, the idea is that the player reads these tips and then applies them to their real life. Of course, this game is not fully finished yet. We have done research into the game. We have built it out. The next steps now are clinical validation, which is of course step five. And using, seeing how this works in the real world and how it works with players. So using, you know, validated measures to assess the game's impact on mental health and collecting data to see its benefits. And finally, it's, we need to get iterations from developers, seeing how we can build it more, how we can make it more effective. And we, of course, will continue to collect participant data and share the results with clinical trials to the broader community for peer review and feedback. The goals of LiftNow in general, and of course serious games like it, oops, are to provide an engaging and interactive overall experience. To integrate existing mental health strategies, to provide a tailored mental health experience, and to create a social environment for mutual player growth. So it's engaging, it actually has mental health benefits, and it's social. Just so you know, there are computers set up there for after the, since we are running out of time a little bit. So we, so everyone was so engaged, this is a dream come true. It looks like no one is in here for a while, so we are gonna stay afterwards, and specifically we have, is it this one as well? Yeah, this one too. Three computers set up for folks to be able to actually test out and try and play the game themselves. And so we will stay afterwards until everyone has had the chance to play, whoever's interested. So we'll get through the presentation part now, and then anyone who wants to stay after, certainly afterwards, you are welcome. We are here, we are here, you are here. Thank you. Now I'm gonna give it off to Dr. Dupit. Show the game. Are you gonna show the demo? Oh, show the demo, wow. Give me one moment. And Varun's gonna show you the demo, especially for those who have never played Minecraft before, and then, as I said, you can play. And Varun, when you're showing, if you can both help people know, like, you know. So this is the, what's known as the lobby. This is just for players to come in. And here's the ISI questionnaire I was talking about here. So you can click it. It wouldn't be a great demo if there wasn't any technical difficulties. Unfortunately, the ISI questionnaire is saying no to me right now. So there's the sleep tips, that's good. So you know, you can't, so you know, this is the sleep tips for engaging players to just tell you as you're playing the game. The reason it's not saying no right now is because that you can't take it multiple times before you, like, play a game in order so that you can't just, like, keep playing it and gain that many resources and just beat the game easily. That defeats the purpose of the game. So you can enter this. No cheating, basically. Yeah. You can enter this portal here that'll take you to the first world. And this is the first world now. So you can, there's someone who tells you, oh, nobody likes me. Yeah. Yeah. So, I mean, you can, like, access, you know, your, the stuff you need. Let's take a few things. And there should be, there'll be a monster coming up here soon. My apologies, it seems that... Wait, one moment. My apologies there seem to be some technical difficulties with the game right now But let me show you the world really quickly So this is like one of the levels here where you're able to fight monsters. Oh, it's because it's day you're able to fight monsters and Take chat and you know fight monsters and interact with the resources There are actually bed stations here, so it's day right now, but if it were to be night You could sleep in them and so, you know, I'll tell you here It says the bed is occupied. But the point is you cannot sleep at over the day So you can't like in insomnia patients It's important that they sleep at a regulated sleep schedule at like at night instead of during except during the day And then you can enter the next world With More monsters and You have here like more what these called loot or they're basically Resources and as you progress through the game you get better and better resources As you play so you can update your update your weapons and update your what you have here So ironically, we're suffering from a good design right here contrary to what it might seem in that It's really important that the players have good sleep behaviors reinforced So you can't sleep in a bed during the daytime as far and had said We also know that when we administer these questionnaires, they have set intervals, right? Like the major depression inventory We only administer every two weeks. That's when it's efficacious same thing with the ISI here where you can't just take the same Evaluation over and over again. It's not very effective in that way So it is timed to be spaced out So also here are some like monsters here that you can like fight as you're playing the game These are just supposed to be We've in the demo here. We've made them Only not that strong because I don't want to show off the fact that I'm not that I'm not very good at video games but also just for just for ease of use, uh-huh, but they can attack you and You can play against them and this is kind of the the gameplay idea Anyways, let's move on to the next world and also you can eat food and all that in the game to maintain your hunger Because eating food is good That's a base minecraft thing, so let's move on to the next world You know what it is, it's the Wi-Fi Yeah, I think Yeah, we'll let you we'll let you all play a little later and just kind of trying out the game. Let's move on to the last few slides Oops Yeah, so I'll give it off to dr. Dupyta to round it out to round us out All right, well, thank you all for your attention and for your enthusiastic discussion, I'm really looking forward to our bonus Q&A session given that we're three minutes from our Alleged session end but this room is not occupied until 130 Hopefully we don't have that many questions until 130, but we'll be here for at least a little bit to chat with you all about everything video game mental health related There were some key points that we wanted you to take apart or take away from this We couldn't decide which one was the best ones. They're all labeled number one Let's go through them I'd say numerical order, but that's crazy So video games have clearly been proven to possess a large amount of impact on our society that cuts well across traditional lines They're used and enjoyed by so many more than we might have traditionally considered to be typical users We've been able to benefit cognitively from commercial video games those that have not actually been designed for Mental health impact, but do have a demonstrable and often positive impact on users mental health Serious video games a relatively newer genre and one that actually has its first FDA-approved Prescription Are a new entity they've been shown to have benefits and can be a powerful standalone or adjuvant medication medication for mental health issues For mental health issues and we were really excited to show with you and hopefully have some of you demo lift now as an example of a serious video game and before we Transition into folks being able to practice with lift now or ask us additional questions We wanted to leave you all with a call to action It's really important that we as mental health experts come to recognize the valuable contributions that our colleagues in private industry and in in tech in Video game development have to offer and that of course this be a two-way street so that we can together Create products create games that can uplift the mental health of the millions of users who daily use video games It's also critical that we improve and innovate over and above Serious games that are currently available. I know that when we think about Private industry that there are some some stigmas there as well where we like to think that only academia is pure and That private industry is maybe too influenced by outside forces But I'd argue that there's so much more that we can take from one another in clinical medicine We're really good at being risk averse and data-driven to the benefit of our patients But we're traditionally not very good at engagement Whereas in the private sector engagement is almost scarily good deleteriously good and so it's so critical for us to learn from one another so that we can finally combine Effective user engagement with effective treatment Alright, thank you all very much, and we're happy to take your questions You brainstormlab.sanford.edu to contact us with any questions, Q&A, but also for those who, if you want to start coming up here and demoing the game, please do. For those who can't, please email us and we can give you the instructions on how to demo at home if you want to be a early, early tester of Lift Now, created by our barn. Before people leave, I just want a round of applause for our 16-year-old, youngest APA presenter who not only is here giving a presentation, he has AP exams next week, but like built this entire thing, recognizing the impact that that can make on mental health. And just, you know, as psychiatrists, when we see that someone is building such a unique way, you know, a unique treatment for our patients, it's just really, this is the future. And so really impressed with him. I just want to say, right, thank you. Thank you. So Q and A come up, playing the games come up, and do you want to just let folks, I mean, give a couple of instructions for people to come up here and play. So as people play the game, if they normalize their sleep, that is if they, you know, go to bed at a reasonable time, get up at a reasonable time, then they, that's recorded somehow, and then they get extra tools, et cetera, that helps them play the game more effectively the next day, is that the way it works? That's right. So there's clear positive implications for sleeping well and for observing regulated sleep cycle. And there are, of course, also penalties for not doing so. And how is, what time they go to bed Come up, come up, folks. Please start, start playing. How is what time they go to bed and what time they wake up, how is that recorded? So basically we have a log of when is daytime and when is nighttime, and we have a corresponding log of when someone enters or exits a bed as well. So it's possible to track those two things against each other and see if the way they've slept is optimal given the time in the game that they decided to do so. I'm sorry, the first part, how do they record when they go to bed and when they wake up? So time exists differently in the game, right? Like it's not one-to-one fidelity with the real world. So in many games, I don't know, a few hours might correspond to a full day or a few minutes might correspond to a full day. And then based off of the timeframe in the game, right? So, I know it's kind of similar to step three, right? Where- I see, so the bedtime and arising time is simulated within the game. Exactly. But it's teaching that, those principles. Precisely, precisely. Yeah, it'd be very cumbersome if it was one-to-one with real life. Okay, great, thank you very much. So we have-

Dr. Nina Vossen

Stanford

Brainstorm lab

mental health innovation

technology impact

social media

video games

psychoeducation

ethical considerations

LiftNow

Minecraft