Background There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand. Objective This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok’s millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones. Methods First, this paper follows each development step of solidifying BlueLine’s game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player’s interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions. Results With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions. Conclusions This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine’s game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism.

BACKGROUND The rise of depressive symptoms among Bangkok's millennials is growing yearly. Habitualized by their daily city life routine revolves around their smartphone screens for work and leisure. While accessibility to mental health care is expanding, it cannot keep up with the growth. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mHealth intervention apps and serious games with positive feedback. It presents an opportunity for this approach to be explored in Thailand. OBJECTIVE This study focuses on the development process of selecting CBT and related therapeutic components as the game structure to support gamified mechanisms in a visual narrative serious game, BlueLine. In the game, players will learn and understand how to lessen the impact of depressive symptoms through the gamified interactions on their smartphones. METHODS Firstly, this paper followed the development steps of solidifying BlueLine’s game structure through the integration of the ABCDE model and narrative in games. Secondly, the approach to select CBT and related therapeutic elements for gamification based on suitability to the game structure. This forms the base of player’s interactions throughout the scenarios in BlueLine which can be broken down into four main components: narrative, verbal interactions, physical interactions, and social media interactions. Throughout the process, these scenarios were reviewed by CBT experts in Thailand. RESULTS Each of the gamified CBT mechanisms were implemented into scenarios where players would play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his virtual life and relationships. Through the ups and downs, Blue struggles with his triggered dysfunctional beliefs, and it is up to the player's interactions to guide him in overcoming them. During this process, the player can learn and understand how to lessen the impact of depressive symptoms through the gamified interactions. CONCLUSIONS This paper presents the development process of gamifying CBT and related therapeutic techniques into game scenarios of BlueLine. A scenario can harbor multiple CBT and related therapeutic components such as self-monitor, relaxation/mindful activities, problem-solving, and gratitude journal. In the case of BlueLine’s game structure, this does not limit the fact that a single game mechanism has to be tied with the same combination of CBT elements.