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Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial
Open accessAbstract
Forty percent of all general-practitioner appointments are related to mental illness, although less than 35% of individuals have access to therapy and psychological care, indicating a pressing need for accessible and affordable therapy tools. The ubiquity of smartphones offers a delivery platform for such tools. Previous research suggests that gamification-turning intervention content into a game format-could increase engagement with prevention and early-stage mobile interventions. This study aimed to explore the effects of a gamified mobile mental health intervention on improvements in resilience, in comparison with active and inactive control conditions. Differences between conditions on changes in personal growth, anxiety and psychological wellbeing, as well as differences in attrition rates, were also assessed. The eQuoo app was developed and published on all leading mobile platforms. The app educates users about psychological concepts including emotional bids, generalization, and reciprocity through psychoeducation, storytelling, and gamification. In total, 358 participants completed in a 5-week, 3-armed (eQuoo, "treatment as usual" cognitive behavioral therapy journal app, no-intervention waitlist) randomized controlled trial. Relevant scales were administered to all participants on days 1, 17, and 35. Repeated-measures ANOVA revealed statistically significant increases in resilience in the test group compared with both control groups over 5 weeks. The app also significantly increased personal growth, positive relations with others, and anxiety. With 90% adherence, eQuoo retained 21% more participants than the control or waitlist groups. Intervention delivered via eQuoo significantly raised mental well-being and decreased self-reported anxiety while enhancing adherence in comparison with the control conditions. Mobile apps using gamification can be a valuable and effective platform for well-being and mental health interventions and may enhance motivation and reduce attrition. Future research should measure eQuoo's effect on anxiety with a more sensitive tool and examine the impact of eQuoo on a clinical population.
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“In much of the literature, gamification and the integration of social components strengthened mHealth app use and engagement, resulting in more positive outcomes and an increased sense of peer support for the MMs and PSP populations [14,36,46]”
From Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation (2022) · cites this paper as [46]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“In particular, mechanics like daily challenges or streak counters are effective in triggering consistent behaviour and fostering psychological ownership of the service (Litvin et al., 2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al., 2020
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“This finding extends Edney et al. ' s (2019) work on attrition reduction by demonstrating that streak mechanics specifically interrupt the honeymoondecline pattern characteristic of subscription services, converting initial interest into habitual behaviour as theorised by Litvin et al. (2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al. (2020)
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“This finding extends Edney et al. ' s (2019) work on attrition reduction by demonstrating that streak mechanics specifically interrupt the honeymoondecline pattern characteristic of subscription services, converting initial interest into habitual behaviour as theorised by Litvin et al. (2020).”
From An Experimental Analysis of Gamification’s Impact on Customer Engagement and Retention in Subscription-Based Business Models (2026) · cites this paper as Litvin et al. (2020)
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“family- and community-level factors were seldom addressed in our identified apps, despite being indicated as an important component of resilience [44,46].”
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“there was an observed lack of social connectedness components within the apps reviewed [14,23,36,46].”
From Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation (2022) · cites this paper as [46]
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“Owing to its ease of use and high validity, the WHO-5 has been extensively used in mental health– and physical health–related mobile apps [19-23].”
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“Gamification serves as the tool that facilitates the interconnectedness of all elements, while addressing the core challenges faced by teenagers (Álvarez-Bermejo et al., 2016; Fleming et al., 2023; Litvin, 2020).”
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“‘Framework’ and ‘Trial’ categories contribute 9% [34, 35, 49, 66, 70] and 8% [59, 60, 74, 83], respectively, underlining the importance of conceptual frameworks and empirical studies in advancing gamification strategies for persons with disabilities.”
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“The results have important implications for clinical practice, where gratitude interventions-whether it is gratitude journaling or expressing appreciation in relationships-could be part of the therapeutic approach to promote psychological health and social cohesion (Litvin et al., 2020).”
The dark side of gamification: an experimental study on digital fitness apps
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Doorley, J. D., Lentz, T. A., Yeh, G. Y., Wayne, P. M., Archer, K. R., & Vranceanu, A.-M. (2022) · Physical Therapy · doi:10.1093/ptj/pzac141 · Cited by 8
Chawla, S., & Saha, S. (2024) · BMC Public Health · doi:10.1186/s12889-024-19565-9 · Cited by 8
“Most research studies exist outside of the Indian context and are based on geriatric, clinical, and young adult population [23].”
BackgroundOtani, V. H. O., Novaes, R. A. C. B., Pedron, J., Nabhan, P. C., Rodrigues, T. M., Chiba, R., Guedes, J. V. C., Marques, L. M., & Vissoci, J. R. N. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1297332 · Cited by 9
de Miquel, C., Haro, J. M., Feltz-Cornelis, C. M. V. D., Ortiz-Tallo, A., Chen, T., Sinokki, M., Naumanen, P., Olaya, B., & Lima, R. A. (2024) · Scandinavian Journal of Work Environment & Health · doi:10.5271/sjweh.4173 · Cited by 8
“It may also increase motivation and decrease attrition (71).”
Chen, B., Yang, T., Lin, T., Song, Y., Liu, Y., Wang, Y., Xiao, L., Xu, C., & Chen, H. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-058686 · Cited by 9
“36 Improving mindfulness, well-being and resilience will help nurses efficiently handle mental health problems, such as stress, anxiety, and depression.”
BackgroundHabib, S., Noureldin, A. A., Aboueldahab, M., AbouSheashaa, A., Abaker, M., & Fakhfakh, A. (2025) · Journal of Lifestyle and SDGs Review · doi:10.47172/2965-730x.sdgsreview.v5.n03.pe05565 · Cited by 11
“Research suggests that gamification fosters resilience by incorporating goal-setting, feedback mechanisms, and problem-solving activities, which strengthen employees' ability to cope with workplace demands (Trunk Širca et al ., 2024; Litvin et al ., 2020).”
Amer, N. A., Shohieb, S. M., Eladrosy, W., Liu, S., Nam, Y., & Abdelrazek, S. M. (2024) · Digital Health · doi:10.1177/20552076241263317 · Cited by 8
Cojocaru, A., Braha, A., Anastasescu, C. M., Folescu, R., Bugi, M.-A., Puiu, M., Zamfir, C. L., Hogea, L., Levai, C. M., Bratosin, F., et al. (2024) · Behavioral Sciences · doi:10.3390/bs14100898 · Cited by 9
Rubio, V. J., & Zafra, A. O. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182412997 · Cited by 7
“Gamification has also shown to be a promising approach to increase user engagement with e-Health apps [3].”
BackgroundMethodA Behavioral Strategy to Nudge Young Adults to Adopt In-Person Counseling: Gamification
Piao, S., & Joo, J. (2022) · Behavioral Sciences · doi:10.3390/bs12020040 · Cited by 7
“who developed a game called eQuoo and tested its impact on psychological resilience, well-being, and anxiety attrition rates [23].”
BackgroundUsta, E., & İnözü, M. (2023) · Current Psychology · doi:10.1007/s12144-023-05318-1 · Cited by 6
Järvelä, S., Wei, L., Hassan, L., & Hamari, J. (2022) · International Conference on Entertainment and Media in the Ubiquitous Era · doi:10.1145/3569219.3569343 · Cited by 5
Beer, O. W. J., McInroy, L. B., Hefner, J. L., & Beer, S. (2024) · Journal of Public Child Welfare · doi:10.1080/15548732.2024.2312838 · Cited by 5
“Previous online-based studies indicate that attrition could be reduced using “gamification” (Krause, Mogalle, Pohl, & Williams, 2015; Litvin, Saunders, Maier, Lüttke, & Matsuoka, 2020).”
AVALIAÇÃO DE UM JOGO DE TABULEIRO PARA CONTROLE DE ANSIEDADE EM ADOLESCENTES ESCOLARES
da Silva, A. G. C., de Andrade, J. S., da Silva, F. J. C. P., & de Oliveira, L. L. (2023) · Revista Enfermagem Atual In Derme · doi:10.31011/reaid-2023-v.97-n.2-art.1864 · Cited by 5
James, L., Maessen, M., Genga, L., Montagne, B., Hagenaars, M. A., & Gorp, P. M. E. V. (2024) · Lecture notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering · doi:10.1007/978-3-031-59717-6_13 · Cited by 5
“…Theory (SDT), in the context of an mHealth tool, a tool that satisfies the need for autonomy (i.e., the desire to have control over tasks), competence (i.e., the need to acquire new skills), and relatedness (i.e., the desire to feel connected to others) can enhance intrinsic motivation [15] [20].”
MethodWenger, F., Allenhof, C., Schreynemackers, S., Hegerl, U., & Reich, H. (2024) · JMIR Formative Research · doi:10.2196/53768 · Cited by 6
Experiences of Users with an Online Self-Guided Mental Health Training Program Using Gamification
van der Lubbe, L. M., Gerritsen, C., Klein, M. C. A., Rodgers, R. F., & Hindriks, K. V. (2023) · Journal of Healthcare Informatics Research · doi:10.1007/s41666-022-00124-z · Cited by 5
Moore, M., & O’Sullivan, D. (2023) · International Journal of Mentoring and Coaching in Education · doi:10.1108/ijmce-07-2022-0050 · Cited by 5
Gamification and Retention in Mental Health Apps
Nagvanshi, S., Munshi, A., & Bhatnagar, S. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-8886-0.ch011 · Cited by 4
Griffith, F. J., Ash, G. I., Augustine, M., Latimer, L., Verne, N., Redeker, N. S., O’Malley, S. S., DeMartini, K. S., & Fucito, L. M. (2024) · npj Digital Medicine · doi:10.1038/s41746-024-01321-3 · Cited by 4
Alqahtani, F., & Orji, R. (2025) · Human Behavior and Emerging Technologies · doi:10.1155/hbe2/8111089 · Cited by 14
Jiao, M., Ding, Z., Huang, C., Xu, Y., 钟宝亮, & Chen, H. (2025) · Behavioral Sciences · doi:10.3390/bs16010040 · Cited by 3
“Gamified features are hypothesized to enhance intrinsic motivation, user engagement, and emotional reward, potentially amplifying training effects and mitigating attrition (de Paiva Azevedo et al., 2019; Litvin et al., 2020).”
von Boros, L., Schaubruch, L. M., Arnold, M., Rigotti, T., Helmreich, I., Lieb, K., Wessa, M., Tüscher, O., & Schäfer, S. K. (2026) · Work & Stress · doi:10.1080/02678373.2026.2618071 · Cited by 2
“For example, one study found a significant effect only when comparing a gamified resilience intervention to a waitlist, but not to a CBT diary intervention (Litvin et al., 2020).”
Science‐Based Mobile Apps for Reducing Anxiety: A Systematic Review and Meta‐Analysis
Doğan, T., Koçtürk, N., Akın, E., Kurnaz, M. F., Öztürk, C. D., Şen, A., & Yalçın, M. (2024) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.3058 · Cited by 8
Tang, S. X., Foroughi, M., Brinen, A. P., Birnbaum, M. L., Berretta, S. A., Behbehani, L. M., Kane, J. M., Yoon, E., & Cronin, W. F. (2026) · Early Intervention in Psychiatry · doi:10.1111/eip.70119 · Cited by 4
“…activating reward circuitry and eliciting positive experiences and emotions in people with SSD by leveraging proven design elements like points, rewards and progress tracking (Välimäki et al. 2021; Litvin et al. 2020), thereby creating a neuropsychological state that may be conducive to treatment.”
The Magic of the In-Between: Mental Resilience Through Interactive Narrative
Harmon, S., Gale, H., & Dermendzhiyska, E. (2021) · Lecture notes in computer science · doi:10.1007/978-3-030-92300-6_35 · Cited by 4
Manning, J. B., BLANDFORD, A. E., & Edbrooke-Childs, J. H. (2023) · JMIR Formative Research · doi:10.2196/50460 · Cited by 4
“Reflection is not limited to PI; it can also be facilitated through apps supporting emotional self-awareness [56,57], chatbots offering guided therapy [41,58], or timely reminders [32,41,59].”
BackgroundA Behavioural Strategy to Nudge Young People to Adopt In-Person Counselling: Gamification
Piao, S., & Joo, J. (2022) · [ ] With Design: Reinventing Design Modes · doi:10.1007/978-981-19-4472-7_88 · Cited by 3
Singh, P., Chen, E., Steel, B., Chicoine, N., Yakdan, S. M., Bydon, M., Steinmetz, M. P., Ghogawala, Z., Ray, W. Z., Johnson, B. P., et al. (2025) · Neurosurgery · doi:10.1227/neu.0000000000003717 · Cited by 3
Qiu, Y., Carter, E. A., Benda, N. C., Sirey, J. A., Kim, S., Kim, Y.-H., Yu, Z., Kiosses, D. N., Marino, P., Gunning, F. M., et al. (2025) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2025.09.004 · Cited by 2
Kim, E., Jeon, H., Lee, J., Oh, H., Kim, M., Shin, J., & Kim, E. (2025) · Journal of Medical Internet Research · doi:10.2196/69248 · Cited by 2
“However, these products did not clearly address caregivers’ concerns regarding potential side effects and overdependence on DTx. Nonetheless, gamification is an effective strategy to encourage participation and enhance the effectiveness of digital intervention [33,34].”
Alharthi, M. (2024) · International Journal for Research in Education · doi:10.36771/ijre.48.2.24-pp55-113 · Cited by 2
Towards an effective methodology for the integral gamification of classes
Lepe-Salazar, F., & Álvarez, T. Y. C. (2024) · Multimedia Tools and Applications · doi:10.1007/s11042-024-19846-w · Cited by 2
Manning, J. B., BLANDFORD, A. E., & Edbrooke-Childs, J. H. (2024) · Journal of Medical Internet Research · doi:10.2196/50457 · Cited by 3
“Other approaches include condition-based education [17], self-management through guided therapy [18,19], peer or social support [20,21], and gaming or entertainment [22,23].”
The Design of a Gamified App for Supporting Undergraduates' Resilience
Nicolaidou, I. A., & Aristeidis, L. (2022) · European Conference on Games Based Learning · doi:10.34190/ecgbl.16.1.708 · Cited by 2
“Most resilience apps target adults belonging to specific professional groups (e.g., Litvin et al., 2020) and not the general public, are not gamified (e.g., Wood et al., 2017), and do not have strong theoretical foundations.”
BackgroundA Review of Gamification Related to Mental Health Treatment
Arihta, C., Fujiono, D., Verónica, V., Moniaga, J. V., & Rianto, I. D. (2022) · doi:10.1109/iconeei55709.2022.9972282 · Cited by 2
Uso de jogos no controle de ansiedade em crianças e adolescentes: uma revisão integrativa
da Silva, A. G. C., de Carvalho, Y. F., & de Andrade, J. S. (2022) · Revista Científica Multidisciplinar Núcleo do Conhecimento · doi:10.32749/nucleodoconhecimento.com.br/saude/ansiedade-em-criancas · Cited by 2
“(LITVIN et al., 2020).”
Metadata
- Authors
- Litvin, S., Saunders, R., Maier, M. A., & Lüttke, S.
- Affiliations
- Ludwig-Maximilians-Universität München (DE)
- University College London (GB)
- University of Tübingen (DE)
- Corresponding author
- Litvin, Silja
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2020-09-02
- Volume
- 15
- Issue
- 9
- Pages
- e0237220
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC7467300
- OpenAlex
- W3082570758
- Cited by
- 177
- References
- 88
- Citations by year
- 2026: 33 · 2025: 31 · 2024: 32 · 2023: 34 · 2022: 25 · 2021: 21 · 2020: 1
- FWCI
- 18.28
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UCL Discovery (University College London) (submittedVersion)
- Open access LMU (Ludwid Maxmilian's Universitat Munchen) (submittedVersion, cc-by)
- HRB National Drugs Library (Health Research Board) (submittedVersion, cc-by)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Developmental and Educational Psychology › Educational Games and Gamification
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- gamification, mobile mental health intervention, resilience, attrition, mobile application, psychoeducation, anxiety, psychological well-being, personal growth, intervention adherence, reciprocity, generalization
- MeSH terms
- Adolescent, Adult, Anxiety, Female, Humans, Male, Mental Health, Middle Aged, Surveys and Questionnaires, Treatment Outcome, Outcome Assessment, Health Care, Telemedicine, Video Games, Resilience, Psychological, Young Adult
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