ADHD, long Covid, and the future of prescription video games

On the frosty planet of Frigidus, a virtual world full of icy caverns and treacherous waterfalls, your mission is to race down a track and target the animals that come flying your way. This isn’t exactly easy: Bumping into walls — you navigate via your phone or tablet — can slow down your avatar, and there are other characters meant to distract you from your objective. Still, the idea is that through all these challenges, Frigidus’s frosty terrain can give you something other video games don’t: medical treatment.

Frigidius is just one part of the EndeavorRx universe, a video game that’s designed to treat ADHD in children between the ages of 8 and 12. The game, which was cleared by the Food and Drug Administration in 2020, is designed to prompt the parts of the brain that we use to focus our attention. Now the company that created it, Akili Interactive, is hoping to expand its games for all sorts of other conditions, including depression and Covid brain fog. The goal is to create a new type of medicine, using technology to deliver a treatment that doesn’t require any in-person supervision or risk causing any severe side effects.

The idea of a prescription video game sounds far-fetched, and possibly counterintuitive if you read the headlines warning about the rise of video game addiction. Still, games like EndeavorRx are appealing because they raise the possibility that an extremely fun activity could double as a potential therapy. This approach promises to make it much more affordable to deliver treatment and suggests that we can transform the phones, tablets, and computers we already own into medical devices, simply by downloading an app. The challenge is that the impact of these games — which are still relatively new — is up for debate, even as companies like Akili go public and try to tackle more conditions. This means that, at present, these platforms run the risk of overpromising and under-delivering.

EndeavorRx does have some scientific backing. After analyzing the results of five clinical trials with more than 600 children, the FDA found that the game could facilitate “general improvement in attention” and seemed to mitigate other ADHD symptoms, too. Though EndeavorRx isn’t designed to replace a pharmaceutical, it’s only available to people who have a prescription. Patients with a prescription are sent an access code they can use to download the game. The list price of the game is $450 a month for those covered by insurance, but people who don’t have insurance pay a discounted, though still pricey, $99 a month. These are just some of the reasons Akili executives say that EndeavorRx isn’t just a spin on Mario Kart or a souped-up version of the brain-training app Luminosity.

For all the “I’m not like other video games” energy, playing EndeavorRx does feel familiar. You navigate the virtual galaxy as a cartoonish avatar, which you can dress in various outfits, including an equestrian getup and a Frozen-esque ice queen dress. Within the broader EndeavorRx game, you can visit different worlds, where you can select different tasks that challenge you to focus. Completing these tasks earns you prized mystic creatures that you’re supposed to collect, and the game gets harder or easier depending on how well you’re doing. The hope is that between swatting down targets and sliding through power zones, the technology can essentially train patients to stay focused.

“Under the hood are these really complex and beautiful sets of algorithms that are creating stimuli and closed feedback loops to activate a very specific part of the brain,” Matt Omernick, Akili’s co-founder and chief creative officer, told Recode. “This engine underneath is what’s really making lasting effects in the brain, and the nice skin, or the wrapper or the vessel, is the style and the look and the feel of the video game.”

While Akili’s product was the first of its kind to get clearance from the FDA, it’s far from the first example of video games being used in medicine. Veterans have used video games to alleviate the symptoms of post-traumatic stress disorder, and therapists have increasingly turned to online gaming to work with people with depression, schizophrenia, and anxiety, especially during the pandemic. Some experts believe that these games could do even more as virtual reality takes off.

But proponents may be getting ahead of themselves. When the FDA approved EndeavorRx in 2020, the agency cleared it through a process for marketing lower-risk medical devices. EndeavorRx isn’t that popular yet, either: Less than 1,000 prescriptions were written for the game in the second quarter of this year, and just 3 percent were reimbursed by insurance companies. Some critics have also voiced concern that the game only teaches kids how to get better at games, which is a gain that doesn’t really translate into everyday life. Attrition could also make these kinds of games less effective, as an August study that analyzed people using Akili, as well as other platforms, pointed out.

“Let’s say you want to scale it out to 1 million ADHD kids,” explains P. Murali Doraiswamy, who co-authored the study and serves as director of the neurocognitive disorders program at Duke Medical School. “They have to be self-motivated to do it.”

These drawbacks haven’t held back Akili’s aspirations. The company is already working on a game for adults with depression, and recent research indicated that its platform could help people with lupus. Of course, the company is hoping that developing games for all those conditions could become a big business. Akili raised more than $160 million after going public through a SPAC, or special purpose acquisition company, earlier this year. The company recently partnered with the children’s gaming platform Roblox, too — a sign that it’s happy to blur the line between medical and traditional video gaming.

“I’ve always found that the more engaging, the more fun the activity is, the more likely someone is to come along. Just like a medicine, the better it tastes, the more likely someone is to take it,” explains Josué Cardona, who leads a video game-focused nonprofit, Geek Therapy.

This is all part of a broader effort to reimagine what video games are and what they can do. It’s already clear that our virtual worlds will get more sophisticated as technologies like 5G and the metaverse take off. Now, there’s a race to make them as useful as possible for our everyday lives, whether that’s using them to treat mental health conditions, practicing job interviews, or learning a language.

EndeavorRx’s progress thus far suggests this race is continuing, but we’re still in the early days. For now, it’s not yet clear how big an impact this new approach to health care might have. Still, it does seem fair to say that at least some of the help that kids get from the company’s game is real, even if the planet of Frigidus isn’t.

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