Evaluation of a therapy-supportive app in youth mental healthcare.

An important development in (youth) mental healthcare is the application of
online interventions as an addition to and improvement of care. These
interventions can be designed to be used fully online and *stand-alone* or
designed in such a way that they should be combined with face-to-face contacts
with therapists (*blended care*). Mental healthcare prefers some type of
support by therapists, and thus prefers blended care. To improve the frequency
of use of an app in mental healthcare, and lower possible resistance of
therapists and youngsters, designers often apply different design strategies. A
promising strategy is called *gamification*, that aims to enhance the
involvement of a client with the online therapy by applying game-elements.
Gamification is applied in different ways in (youth)mental healthcare, but not
systematically studied. This makes it almost impossible to know when and how is
strategy works within this context.

The overall aim of this study is to generate a first impression about the
usability of the therapy-supportive Luca app with youngsters in youth mental
healthcare. For this purpose, we will ask the following research questions:
1. How do therapists and youngsters accept the Luca app, regarding frequency of
use and experiences with the app?
2. Is a higher frequency of use of the Luca app related to a better therapy
progression (i.e. course of complains, therapy retention, motivation for
therapy and substance use)?
3. Is the Luca app with a gamified therapy-goals module more frequently used
compared to the Luca app with a non-gamified therapy-goals module?
4. Do youngsters that received the Luca app with a gamified therapy-goals
module have a better course of complains, therapy retention, motivation for
therapy and less substance use compared to youngsters that received the Luca
app with a non-gamified therapy-goals module?

This study is a non-controlled (and thus non-randomized) prospective study,
with 60 youngsters of the youth mental healthcare institutions Brijder Jeugd
and Lucertis, that receive the therapy-supportive Luca app in the context of
out-patient cognitive behavioural therapy (CBT, their regular therapy).
Pre-tests will take place at the start of their therapy and post-tests after
eight weeks. The first 30 youngsters who, according to their registration at
the therapy centre, participate in the study receive - besides CBT - the Luca
app with a non-gamified therapy goals module and the following 30 youngsters
receive the Luca app with a gamified therapy goals module.

In this study we will evaluate a therapy-supportive app that has been developed
by Brijder Jeugd, De Jutters and Lucertis Kinder- en Jeugdpsychiatrie and is
currently being implemented in these three companies of Parnassia Groep as part
of regular therapy. The Luca app supports patients to also work on their
therapy at home. To use Luca, patient and therapist both download the Luca app.
The therapist can, with permission of a client, see what the client has
described in the Luca app.

The Luca app consists of different therapy-supportive modules:
* Diary: In this module a client can register his/her mood, the situations
he/she encounters and how he/she is doing.
* Medication alarm: In this module a client can set when (what days of the week
and time of the day) he/she has to take specific medication.
* Activity list: In this module the client can make a list of the things he/she
wants to do.
* Emergency plan: In this module a therapist and client set an emergency plan
that can help a client if he/she is not doing well.
* Chat: A client and therapist keep contact with each other by using the chat
function.
* Auxiliaries: In this module a client registers *auxiliaries* that a client
can call if he/she is not doing well or experiences difficulties (like family
members or friends).
* Therapy-goals: In this module a therapist and client first set long-term
goals that focus on that what the client wants to achieve during therapy. These
are transformed into achievable short-term goals for behavioural change in the
daily life of the client.

To study the added value of gamification on the therapy progression (course of
complaints, therapy retention, motivation for therapy and substance use), we
have designed two different versions of one module, i.e. the therapy-goals
module. One version of the therapy-goals module is gamified and the other
version is not-gamified. With both versions, youngsters and their therapists
can set therapy related goals, but the gamified version also exist of some
game-elements that suit the target group. For example, youngsters can estimate
the difficulty of the goals they set and estimate their expectation that they
will achieve these goals and rewards. By achieving goals they work towards
rewards they have set with their therapist. Their progression in setting and
achieving goals is also visualized by using a using mountain as a metaphor.

The Luca app also consists of three other non-therapy supportive modules, on
which we will not focus during the study. These are: a personal
non-therapy-related goals module (where youngsters can set their own goals -
without any contact with their therapist - that do not have a direct link with
their therapy), an information module (for more information about Luca), and a
profile module (where the client can change his or her profile).

Youngsters who participate in this study receive access to a therapy-supportive
app that could enhance their therapy progression. The results of this study
will also provide insights in the evaluation, frequency of use and relation
with therapy progression (i.e., course of complains, therapy adherence,
motivation for therapy and substance use) and the (possible) added value of
gamification. The burden and risks that are related to participation in this
evaluation study are minimal. Because the app is used voluntarily, participants
will only (in addition to their regular therapy) have to fill in questionnaires
at the beginning and end of the study. The extra tasks that therapists will be
asked to do, are signing-up adolescents after the first therapy session, note
down the treatment retention of the participants and fill in some
questionnaires.

Playing specific games can be addictive for some type of youngsters. Therefore,
applying game-elements when treating youngsters that are sensitive to addiction
or youngsters with psychiatric problems should be done in a careful way.
Youngsters with problematic game or gambling behaviour will therefore be
excluded from participation of this study. Besides, participating therapists
will be instructed to be alert and to exclude youngsters if they show this type
of behaviour. Concluding, typical games that can be addictive are Massive
Multiplayer Online Role-playing Games (MMORPGs). MMORPGs have a strong social
aspect, fantasy world and can be played online. These *addictive* entertainment
games are definitely more sensitive to addiction compared to our
therapy-supportive *serious game*. The most important reason for this is that
our game has a *serious content* (i.e. the therapy) and consists of less
immersive game-elements. The game has also been designed with experts from
addiction care to exclude possible unexpected addiction effects as much as
possible. Therefore, we expect that a possible risk on addiction or problematic
behaviour are limited.