The document discusses plans for a research study called the Get Happy Club that will use online games to collect behavioral data from depressed patients to help identify markers that can predict success in depression treatment. Players will be recruited from depressed patients and their gameplay will be closely tracked over 6 months to correlate changes in behaviors with treatment outcomes. The games will be instrumented to collect a wide variety of performance metrics beyond just scores to better understand users' cognitive abilities, preferences, motor skills and more. The goal is to generate a large dataset from many participants playing frequently over a long period to help advance research on depression.

1. 1
Welcome.
The Get Happy Club is a game playing club for people here in Minnesota
who are overcoming depression. Join us here and we will help each other -
and help science - as we learn to get better.
Your health-worker recommended you to this site, and you have a full
membership. The Get Happy Club is an exclusive club - it’s open only to
people while they suffer from clinical depression. We are glad you’re here
- but we can’t wait until we have to kick you out.
On our site, you will find favorite single-player games : Solitaire, Sudoku,
Match Three, Find It. Lots more, including two you’ve never seen.
Think of us as a gym. These games are exercise equipment for your brain.
Don’t miss a single workout. Your personal trainer will help you remember.
In a gym, you run into other people who are care about self-improvement -
The more you play, the more chance you have to meet these interesting
people. You can chat - or leave messages. You can even play games with
your new friends.
Shy? Don’t worry. In the Get Happy Club you can be whoever you want.
Come as you are. Or come as you wish you were. Nobody will bother you.
You can show off your scores, or not. You can compete against other
players to win prizes. You compete against players at your own level.
Can playing games help defeat depression? Science does not really know.
Not yet. You can help find the answer.

2. 2
Behind the Scenes at the Get Happy Club
The Get Happy Club is not exactly what it seems, although it is exactly what it says it is.
Players are invited to join the Get Happy Club when they enroll as patients. They are informed
that the club is an experiment to discover correlations between playing games and improving
depression. Although there is no outright deception, there is a little benign misdirection.
Patients are likely to consider game score the principal metric of the study. They are informed
that this is only one of many measures. But the researchers can still allow patients to focus on
game scores and leader boards even though these are of only minor interest.
The other measures will be more accurate when players are unaware that these data will be
closely studied. There is an array of nice prizes, which go to high scorers, frequent players, and
a good number of randomly selected active club members.
There are enough leader boards that everyone is meaningfully ranked somewhere and can
compete against peers. This affords a degree of stickiness.
But, more importantly, there is a social element that combines the virtues of anonymity and
exclusivity ­ ie: the shared experience of depression and the common goal of remission.

3. 3
Rewards
Players will be encouraged to play the games with social rewards. For example, dedicated game
play ­evidenced by high score or unbroken streak­ may earn a player extra posting privileges. In
particular these posting privileges are transferable, so they become more valuable, socially .
This is a familiar mechanism to players of Zynga games, Puzzle Pirates, etc.
Players give informed consent for research use of all their playing data (after it is anonymized
and aggregated). Although these data are enumerated briefly for the players, most players will
still assume that the scientists’ principal interest is traditional game measurements like score,
frequency of play and duration of game sessions.
However these typical measurements are a minor part of the data stream. The actual data of
interest are much more precise and direct measures that reveal psychological and neuro­motor
condition.
For example: We don’t care how many games of Solitaire you win or lose. We care how quickly
you respond when you turn over an Ace. We care about the speed with which you slide the
cards. We care whether you watch the “win” animation or not.
We measure several dozen independent behavioral indicators, and track changes in your
behavior over time. These data are available online in realtime to researchers.
Researchers will correlate the changes in behavior with outcomes. In particular, they will look
for markers that are predictive of success in remission of depression after six months of
treatment.
Future neuroscientists may use these results to create game­based diagnostic tools. These
tools may provide an early warning signal for patients that risk failing to achieve remission and
may sound the alarm for hospitals that underserve their depressed patients.
The Get Happy Club will incorporate explicit gamification mechanisms to reward frequent and
extended play, and player publish their high scores on a broad leaderboardsit as well as
improved scores.
No claims are made that the Get Happy Club can help its members get happy.

4. 4
Why Depression?
Prevalence
In Minnesota, depression is nearly as big a healthcare issue as vascular disease, judging by the
AF4Q study data.
Optimal Vascular Care population: 66910
Depression Remission population: 51329
Success
Unlike the vascular care patients ­ among whom 40% receive optimal care ­ only 5% of the
depression patients achieve the desired outcome.
Optimal Vascular Care percentage: 40%
Depression Remission percentage: 5%
It might be argued that the criterion of success for depression care (remission after six months)
is harder to achieve than merely delivering to vascular patients the mandated elements that
define “optimal care”. After all, remission rates measure outcomes, which are more difficult to
control than procedures.

5. 5
Discrepancies
The differences between the criteria for different care categories (depression remission vs
vascular optimal care) are factored out when the best hospitals in a given category are
measured against the worst.
Consider the 1000 luckiest Minnesota vascular patients in 2011. They went to the most
successful hospitals and 648 of them received optimal care. Meanwhile, among the least lucky
1000, only 120 got such treatment.
1000 Luckiest Vascular patients: 648
1000 Least Lucky Vascular patients: 120
The worst hospitals can certainly improve, if they learn from the best hospitals.
The depressives have a different story to tell. Among the lucky 1000 who went to the Mayo Clinic
Northeast or Mayo Clinic Northwest or three other top clinics, 233 were freed of depression. But
the least lucky 1000 went to sixteen other clinics (of which five belong to the Mayo Health
system). How many of this unhappy thousand were cured? Not a single one.
In fact, among the 2000 unluckiest depressives, there is only one lone remission.
1000 Luckiest Depression patients: 233
1000 Least Lucky Depression patients: 0
Perhaps the worst psychology clinics can learn from the best. Or maybe not.
Right now they seem to be on another planet.

6. 6
Pillars:
These are the design goals of the Get Happy Club
Lots of Data:
This is a Big Data project in which large web­based data sets will be created. Identifiable data
will be absent, and the resulting information will be open to queries using a well defined API.
Access will be open to all researchers
Lots of Metrics
A wide variety of different measurements will be performed ­ mostly measuring unconscious
preferences and behaviors. A broad selection of games offer very differing measures ­ from
reflex action to more profound cognitive effort.
Lots of Plays
We want to deliver a longitudinal stream of data from each player. It is not absolute measures of
player performance that we seek, but rather changes in performance level over time. We expect
that some of these trends are predictive of final outcomes.
The design target is to host six plays a week from each participant for a six month period.
Gamification incentives (including extrinsic rewards) will be enough to get players started. But
not enough to achieve the high level of compliance sought. For this we need to develop highly
addictive games.
Lots of Players
Similarly we want to achieve a high degree of participation. Patients suffering from depression
are difficult to motivate, but we need to persuade a large percentage of them to participate in the
Get Happy Club for a serious amount of time.
Again ­ incentives can be employed to get a patient to sample the site ­ but large scale
participation will depend upon the games. These games must have highly refined game design.
They must appeal to these patients ­ even those who do not consider themselves gamers.
Solution:
We can guarantee additive, appealing games: We render the classic casual games that this
population prefers. Most already play Sudoku, Solitaire or similar games every single day.
In the Get Happy Club, these games have been instrumented to collect performance data.

7. 7
Data Mine
An almost unlimited variety of data can be gleaned from cleverly instrumnented games:
Cognitive Tasks
Depression has been correlated with cognitive impairment. In particular with defects in memory,
attention and psychomotor speed and dysphasia.1
Color Preference
Color has long been associated with affect. After all, outside the clinical setting, depression is
known as the “blues”. Early attempts to measure this association were disappointing, but more
recent, more sensitive studies have successfully quantified color preference biases that predict
depression and anxiety.2 Interestingly, differences in stated color preference were less dramatic
than demonstrated preference.
The Get Happy Club offers researchers a stream of unconscious demonstrations of color
preference, rather than deliberate color decisions. Many games can be engineered to create this
color preference data. For example a Match 3 game in which win opportunities (and shape
assignments) are randomly distributed among the colors can measure the color bias with which
a player pursues matches.
Psychomotor & Reflex
Get Happy Club games will measure the interval between stimulus and response for a very
broad group of stimuli. They will also measure cursor trajectory and dynamics for simple touch
(or mouse) actions in order to detect telltale elements such as lethargy, tremor, hesitation and
sloppiness. These are revealed in the manipulation of game pieces and the handling of user
interface elements. Our studio did very interesting work in this area under an NSF grant in 2004.
Facial Affinities
We want to see which faces the patient chooses. Researchers have shown that depressed
patients seek smiles less often than healthy people. Stranger avatars, in­game GUI elements,
components of Memory, Find It and Whack­a­Mole can all provide opportunities for subtle face
choices. Another, more profound choice is the Player’s single choice of his own avatar.
1
Kauhanen ML; Korpelainen MJ; Myllylä, VV Poststroke Depression Correlates With Cognitive
Impairment and Neurological Deficits Stroke.1999; 30: 1875­1880
2
Helen R Carruthers, HR; Morris, J; Tarrier, N; Whorwell, PJ: jThe Manchester Color Wheel: development
of a novel way of identifying color choice and its validation in healthy, anxious and depressed individuals
BMC Medical Research Methodology 2010, 10:12 doi:10.1186/1471­2288­10­12

8. 8
Dysphasia and Vocabulary
Word­frequency maps of the patients postings and chats will reveal a pattern of word choice that
offer a clue to the progress and perhaps the prognosis of their depression. At a much higher
level, changes in the total measure of social activity in the Get Happy Club have an obvious
insight into the patient’s emotional state.
Confounds
There are many confounds that can distort the results. For example QIPS: Minnesota Dept of
Health’s Quality Improvement Program, which incentivizes hospitals for improving their six­month
remission score, has had an unintended consequence. Evidence shows that hospitals preferentially
enroll patients with lower severity and comorbidity in order to artificially elevate their success rate3
This gaming of the system, will distort all AV4Q research as much as it does the Get Happy Club
data. Hopefully a solution to this problem will be found outside the Get Happy Club and can be
shared.
Where is the Creativity?
Look.
We are really a creative studio. Honest. We have designed, developed and
delivered scores of innovative games. We are rather embarrassed to suggest
that your best bet is to use folk games like Sudoku and Solitaire. But it is.
Let’s be real. You are not going to convince large and representational
samples of patients to play a brand-new game. Not for a long period. And,
Good Lord! not depressed patients!
We could claim that our new game would be as addictive and as well tuned
and as appealing as these games that the patients already love. But that is a
naive and ridiculous claim.
If the goal were to experiment with creative design, we would. But the goal
is to develop a large database for neuroscientists to experiment creatively.
Our job is to support that creative effort.
3
Minnesota Department of Heath: Minnesota Statewide Quality Reporting and Measurement System:
Quality Incentive Payment System Updated May 2012
http://www.health.state.mn.us/healthreform/measurement/QIPSReport051012final.pdf