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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.
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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)
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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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“In mobile contexts, gamification is often used to sustain engagement: a 5-week 3-arm RCT [24] of the eQuoo gam-ified mental health app improved resilience and reduced anxiety, with high adherence, and a user study [9] found that a gamified version was preferred over a non-gamified counterpart.”
Effects of a gamified intervention on gratitude in a Colombian population
Pinzón-Salazar, S., Salazar-Ramírez, C., Gaviria, S. Q., Ural, M. A. P., Arenas, J., Gil, C., & Quiroz-González, E. (2026) · Frontiers in Education · doi:10.3389/feduc.2026.1939198
Rehabit:Swim: Designing A Motion-Sensing Exergame For Bed-Rest Rehabilitation
Kim, B., Lee, C., 김유진, Kim, D., Park, J., Lee, G. Y., Kim, Y. J., Kim, J. H., Ryu, J., Lee, C., et al. (2026) · Annual Symposium on Computer-Human Interaction in Play · doi:10.1145/3800965.3834473
Chung, D., Zhang, Z., & Wang, J. (2026) · Behavioral Sciences · doi:10.3390/bs16111983
Khattak, M. W., Ross, V., Dirix, H., Gruden, C., Brijs, T., Adnan, M., & Brijs, K. (2026) · Accident Analysis & Prevention · doi:10.1016/j.aap.2026.108841
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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