The Guardians app shows efficacy for reducing perinatal depression


Preliminary findings suggest The Guardians mobile app, blending gaming and behavioral activation techniques, could be a solution for alleviating perinatal depression among pregnant women.

The Guardians app shows efficacy for reducing perinatal depression | Image Credit: © InsideCreativeHouse - © InsideCreativeHouse -

The Guardians app shows efficacy for reducing perinatal depression | Image Credit: © InsideCreativeHouse - © InsideCreativeHouse -

A behavioral activation (BA) mobile app called The Guardians: Unite The Realms may be effective in reducing depression among pregnant women, according to a recent study published in JMIR Formative Research.


  1. The study suggests that The Guardians: Unite The Realms, a behavioral activation (BA) mobile app, shows promise in reducing depression among pregnant women, providing a potential alternative to traditional interventions.
  2. Perinatal depression affects 10% to 15% of pregnant women in high-income countries and is associated with adverse maternal and infant outcomes, highlighting the importance of effective interventions.
  3. Pregnant women, as per data, may prefer psychotherapeutic approaches like BA over antidepressant medications. The integration of BA into a mobile app aligns with this preference and can increase access to treatment.
  4. The Guardians app, designed as a gaming BA app, incorporates BA techniques into a mobile game context. Preliminary data indicate high user engagement, suggesting that gamification can enhance participation in behavioral activation.
  5. Participants in the study reported high satisfaction levels with The Guardians app. Engagement metrics correlated positively with satisfaction measures. Notably, completing various activities within the app was associated with mood improvements, indicating the potential effectiveness of the intervention.

Perinatal depression (PD) has been estimated in 10% to 15% of pregnant women in high-income countries, and it is associated with multiple adverse maternal and infant outcomes. The US Preventive Services Task Force recommends pregnant or postpartum individuals with increased PD risk receive counseling interventions.

Data has indicated pregnant women may prefer to be treated with psychotherapeutic approaches rather than antidepressant medications. This includes BA, which encourages engagement in activities to reduce depressive symptoms of avoidance and isolation.

Implementing BA into computer-based interventions would significantly increase access to the treatment. Data has indicated efficacy for mobile apps in providing BA.

The Guardians: Unite the Realms is a gaming BA app designed to increase engagement by incorporating BA techniques into the context of a mobile game. Preliminary data has indicated high levels of engagement among users of the app.

Investigators conducted a study to determine the efficacy of The Guardians in managing PD symptoms and receive participant feedback. Eligibility criteria included being aged over 18 years, pregnant, English speaking, having access to a smartphone, and having a Patient Health Questionnaire-9 score of 10 or more.

Patients with a bipolar or psychotic disorder, active mania, psychosis, substance abuse, or immediate risk of self-harm were excluded from the analysis. Postpartum women were also excluded.

Demographic characteristics, psychiatric history, and pregnancy characteristics were obtained during a baseline interview with a trained research assistant. The assistant helped participants download The Guardians app at the end of the interview.

Depressive and anxiety symptoms were evaluated over the following 10 weeks through bi-weekly surveys completed on Research Electronic Data Capture; Vanderbilt University. The final assessment occurred over mobile phone, during which participants completed a qualitative exit interview and received follow-up measures.

In The Guardians, players must collect pets to send on missions with a long-term goal of defeating enemies from 3 different realms. Missions are completed after 10 to 60 seconds in real time, and lead to pets receiving experience and other rewards that can be used to further progression. App analytics are collected through the game’s cloud save and gameplay recovery.

Players are made to select activities from 75 suggestions or by player choice, with categories being low, medium, or high effort. Categories included basics, arts and crafts, social, fitness, and fun. Rewards are not determined by effort or category, and players provide feedback about how they felt about the activity once it is completed.

A major depressive episode (MDE) was reported through the Mini International Neuropsychiatric Interview at baseline. MDE criteria included having a depressed mood most of the day or significantly reduced interest in activities for 2 weeks or longer, as well as presenting with at least 5 MDE symptoms.

App satisfaction was determined using the Mobile Application Rating Scale (MARS) and the Player Experience of Needs Satisfaction scale (PENS). MARS was used to determine engagement, functionality, esthetics, and information quality. PENS was used to determine players’ play experience.

There were 18 women enrolled in the analysis, 10 of whom completed the 10-week study. On average, participants completed 11.07 activities and played for 16.67 days. An average activity completion rate of 68.2% was reported. Of activities, 43.6% were easy, 27.5% medium, and 13.4% hard.

The average MARS rating among participants who completed the 10-week study was 3.49 and the average PENS rating was 4.13. Moderately positive correlations were reported between engagement metrics and satisfaction measures.

Significant differences of depression and anxiety scores between completers and noncompleters was not observed at baseline. Mood improvements of at least “a little better” were reported following 76% of activities.

The mean improvements in mood after completing easy, medium, and hard activities were 3.89, 4.17, and 4.47, respectively. This indicated a significant association between activity effort level and mood improvement.

Participant feedback indicated they felt encouraged to complete activities outside of the game and appreciated the variety of provided activities. However, difficulty in completing certain activities was reported by some participants, with activities they were already doing in their daily lives easier to complete.

These results indicated viability from The Guardians in managing depression among pregnant women. Investigators concluded further studies be conducted to confirm these findings.


Vanderkruik RC, Ferguson C, Kobylski LA, et al. Testing a behavioral activation gaming app for depression during pregnancy: Multimethod pilot study. JMIR Form Res. 2024;8:e44029. doi:10.2196/44029

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