Irene Jimenez Padilla used to suffer persistent traumatic flashbacks from her time as a nurse during the Covid-19 pandemic. Then a cult computer puzzle game changed everything.
Padilla was plagued by memories centred on patients who had died painful deaths in front of her at Guy’s and St Thomas’ hospitals in London. The images kept on returning like an “annoying fly that continuously comes, again and again, buzzing, buzzing, buzzing”, she recalls.
She found the disturbing recollections impossible to control until she signed up for a pioneering therapy based on Tetris. After a few weeks playing the game, which involves rotating variously shaped coloured blocks so they fit together, the change was dramatic. She still remembered the Covid-era events, but no longer constantly relived them in a way that caused her acute distress.
“It was so effective,” she says of the digital balm the Tetris delivered. “All those faces, all those noises — they are gone.”
The Tetris method is part of an emerging frontier of mental health treatments using new technologies that are offering promising early results and possibilities.
Motivated in part by the limitations of existing treatments — mostly involving drugs or talk therapy with a psychologist — many researchers are looking to develop digital tools to treat mental health.
Solving the global crisis in mental health
This is the second in a series examining how employers and governments are tackling the rise in depression and other illnesses — and the new therapies being developed
Part 1: Financial services among hardest-hit in the crisis
Part 2: The new generation of treatments
Part 3: Mental health support on the cheap
Part 4: Which nations are getting it right?
Miranda Wolpert, director of mental health at Wellcome, the charitable foundation, says the new generation of techniques promises to be more targeted, more scalable and potentially transformative for patients.
“We’re now at a tipping point,” Wolpert says. “The sort of mental health intervention you see in five years may look nothing like — or very different from — the ones that you see now.”
Like other cutting-edge solutions to tricky health problems, these technologies are now at varying stages of earning acceptance from regulators, clinicians and — most crucially — patients. In many cases, much larger studies will be needed to prove their effectiveness and value for money.
But supporters of these novel treatments believe there is a huge gap waiting to be filled because growing global mental health needs are outstripping the resources of traditional therapeutic approaches. Some illnesses, such as schizophrenia, remain stubbornly hard to treat.
The impact of psychotherapy, while often evident, can be hard to measure objectively and is often not tracked long term. It is also expensive and time-consuming for many patients.
Meanwhile, there has been only slow progress in discovering new drugs for mental health conditions. When US regulators approved schizophrenia drug KarXT in September, it was seen as the first truly novel treatment for the disease for more than 70 years.
Even the much-hyped efforts to establish psychedelic drugs as mental health treatments have floundered. Earlier this year, US authorities rejected the use of MDMA — the party pill ecstasy’s crucial ingredient — to treat post-traumatic stress disorder (PTSD).
Technology has “opened a new frontier in mental healthcare and data collection”, according to the US National Institute of Mental Health, a government body. It has awarded more than 400 grants for tech-enhanced interventions.
David Crepaz-Keay of the Mental Health Foundation, a UK charity, says one reason researchers are looking at new technologies is because big data and artificial intelligence could play an important role in identifying at-risk populations and enabling earlier interventions.
“Advances in technology and innovative thinking are transforming mental healthcare,” says Crepaz-Keay, the foundation’s head of research and applied learning. “Combined with apps, wearables and other digital tools, these innovations are expanding access and personalising care, in support of maintaining and protecting good mental health.”
One of the most striking potential uses of digital tools is in helping people who hear distressing voices internally, a main symptom of psychosis.
Sufferers report enduring monologues that are often highly critical and may even suggest they don’t deserve to live. Existing drug and psychological treatments are not always effective.
An emerging potential alternative is Avatar therapy. In this, the sufferer creates a digital embodiment of how they think the voice that they hear looks and sounds. The person then has conversations with the avatar, with a therapist providing material for the dialogue.
A crucial insight of Avatar therapy is the element of control it offers the individual by bringing what was internal into the open, says Tom Ward, a clinical psychologist at King’s College London who has been involved in Avatar therapy experiments.
“What inspires the idea is that people who hear voices are having a very compelling experience of communication with another,” Ward says. “But by definition, that experience is not shared with anybody else — with a mental health professional, with a friend or anyone. So it’s sort of a social experience that is also isolating in the sense that it’s unchecked.”
The results of research run by Ward and his colleagues have been striking. Avatar participants reported better moods and lower voice severity and related distress after 16 weeks, compared with those who received traditional therapies. Those who received an extended Avatar treatment, tailored to their life histories, heard voices less often than before.
Efforts are under way to see if Avatar therapy can be rolled out internationally. Trials of a version of the technology are planned in Ethiopia and India. Researchers are exploring whether the avatar could be automated using artificial intelligence, with a therapist present in support. Safeguards would be needed given the sensitive nature of the treatment — and to check the essential ingredients that seem to make it effective are there.
“We hear relatively often from people who create an avatar that ‘This is the first time I’ve really been able to share this experience with a mental health professional’,” Ward says. “So there’s something about the act of creating embodiment that offers that opportunity.”
The new thinking in mental health extends to taking well-known older ideas in surprising new directions.
Researchers are examining therapies springing from electroconvulsive therapy (ECT) that has been used for decades, often effectively, to treat severe depression. In this, electric currents are sent through the brain to cause a temporary seizure. The treatment requires close medical supervision, including general anaesthetic and patients and their relatives have sometimes clashed with medical authorities over whether it is being misused.
Scientists have been investigating whether it’s possible to greatly lower the dose of electricity. In October, researchers reported intriguing results from a treatment known as transcranial direct current stimulation (tDCS). This uses a weak current of 2 milliamperes or less, compared with about 800 for ECT. This results in a much milder but — still potentially therapeutically beneficial — impact on the brain. That has made tDCS an option for unsupervised home use.
Participants suffering from at least moderate depression found a 10-week course of 36 half-hour sessions helpful, according to the study funded by tDCS device maker Flow Neuroscience. About 45 per cent reported remission of their condition, versus fewer than 22 per cent in a control group who used the device but didn’t receive the therapy.
It was not without negative side-effects. A couple of patients described developing “burns”, perhaps through using dried-out sponges, the study says, although it added that these caused no scarring.
The study demonstrated that tDCS was a “potential first line option that could help those in need”, according to Cynthia Fu, the study’s lead author and a professor of affective neuroscience and psychotherapy at King’s College London.
An even more direct use of electricity to treat severe depression is through direct implants of neural devices. Deep brain stimulation, via electrodes implanted through holes in the skull, is an experimental treatment that has shown some encouraging results. It resulted in “rapid and sustained improvement in depression”, according to one study published in 2021.
But doubts remain — including among some scientists — about whether this is a desirable treatment option in the longer term, given how invasive it is. Risks stem from both the surgery itself and potential ongoing side-effects from the treatment such as vision problems, negative moods and speech difficulties.
The connections between mental health and aspects of lifestyle are also a focus of deepening interest. Prominent among these is the science of sleep.
While sleep therapy primarily targets insomnia, which is estimated to affect about one in ten people, growing attention is being paid to broader links between sleep and other conditions. Insomnia is thought to increase the risk of developing psychiatric disorders.
“There is a lot of ongoing research to understand how targeting and improving sleep and body clock disruption may help improve mental health and reduce the risk of developing mental health problems,” says Simon Kyle, a professor at Oxford university’s Sir Jules Thorn Sleep and Circadian Neuroscience Institute.
Kyle’s focus is known as sleep restriction therapy. While this might sound like a counter-intuitive response to insomnia, the idea is to improve quality of sleep by consolidating it and making it more reliable. This is done by determining optimum sleep start-times and end-times for each patient — which they then have to implement. Such personalised rest schedules should sync with biological sleep cycles.
Kyle and colleagues successfully tested the approach in research published last year. About 42 per cent of a group given four brief sessions of nurse-delivered sleep restriction therapy reported a clinically meaningful improvement in their insomnia. The study emphasises the therapy’s potential cost-effectiveness, since it does not require a sleep specialist and involved less than 90 minutes of nurse time per participant.
Perhaps the most surprising innovation is the potential use of Tetris to improve mental health.
The game was developed four decades ago by Russian scientist Alexey Pajitnov and has become an obsessive pastime for some. A 2011 documentary called Ecstasy of Order: The Tetris Masters recounts the battles to win the world championship.
Tetris’s power to absorb the attention of players is crucial to its nascent role in mental health. Emily Holmes, leader of the group researching it, recalls becoming fascinated by “how we think in images rather than how we think in words”.
Holmes, a psychologist and neuroscientist at Sweden’s Uppsala university, says she found parallels between gaming and “how trauma replays itself in the mind’s eye, again and again”.
Traumatic flashbacks are not a “logical verbal representation of the world”, Holmes argues, but instead constitute a “vivid set of imagery” that are often associated with memories.
“If you’ve had a car crash, for example, with a red car, you might see snippets of that red car,” she says, picking up and brandishing an object from her desk by way of example. “My red pen might trigger a visual intrusive memory of a red car. So you’re not even on top of what you’re remembering.”
Holmes alighted on the “mental rotation” at the heart of Tetris as a possible solution because of what scans suggest about brain activity. The parts of the organ active during flashbacks are the same as those used during visual and spatial activity. “You can’t play Tetris and do other visual things very well — the brain’s got limited capacity,” Holmes says. “You could either focus on the traumatic imagery or the Tetris — but not both at once.”
The theory is that the process of distraction by the game makes the trauma imagery more malleable, allowing it to be rearranged in the mind in a less harmful form. “You’ve faded out this memory enough that when it is reconsolidated back into your long-term memory, it’s in, as it were, a weaker form,” Holmes says. “And if it’s less vivid and hyper perceptual, the next time you get a red trigger you’re less likely to have the intrusive memory of the red car.”
Holmes and colleagues tested the approach in a study published last year. Participants listed their intrusive memories at the start of the work and then were prompted to summon the image associated with one of them before each gaming session. Once they had played Tetris for 20 minutes, they graded how they felt.
The effect became clear in less than a month. During just the fourth week, participants who were given immediate access to the Tetris intervention reported significantly fewer intrusive memories than those who were not. They also had fewer symptoms of PTSD, insomnia and anxiety, and an increase in work functioning and wellbeing.
Sophie, a British doctor, recalls her scepticism when an email dropped offering the chance to try Tetris therapy. A clinician in a hospital intensive care unit, she had been feeling intense episodes of distress about events during the Covid pandemic, involving dying patients and distressed relatives.
“I went into it going, ‘how on earth can playing a game of Tetris help me?’” recalls Sophie, who asked not to use her real name, from the kitchen in her home in north-west England. “I was really negative about it. I was just convinced it was a waste of my time.”
Sophie found the easy availability of the treatment attractive. A great virtue of the Tetris therapy was that — unlike a human interlocutor — it was available 24 hours a day. If she started feeling troubled by flashbacks, she could start playing it during a break in work, at home — even in the early hours if she woke with a nightmare.
Within a few weeks, Sophie recalls noticing “a complete difference in myself”. She has not forgotten these terrible events, but she is able to recall and speak about them now with a calmness she previously found impossible.
Even now, Sophie finds it hard to suspend her incredulity that something apparently so trivial could be so effective. “I have to admit that it did work even though I wasn’t expecting it to,” she says. “That really was a surprise to me.”
The Tetris treatment may be in its infancy and will need to undergo rigorous and much bigger testing. But it illustrates how the next generation of therapies has the potential to be far more accessible and straightforward than before — with implications for the many people seeking help for mental health.
“You don’t need medication for that, you don’t need a psychologist to talk about your life,” says Padilla, who worked as a nurse during the pandemic. “It’s so simple — just sitting in front of a computer and playing Tetris.”
Helplines are available for people who need support with their mental health. Most work only in a single country such as SANEline (0300 304 7000) in the UK and the US’s 988 Lifeline. To find a local helpline, you can visit: findahelpline.com or befrienders.org
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