Gamification as an approach to improve resilience and reduce attrition in mobile mental health interventions: A randomized controlled trial

Silja Litvin, Rob Saunders, Markus A Maier, Stefan Lüttke, Silja Litvin, Rob Saunders, Markus A Maier, Stefan Lüttke

Abstract

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.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: I, Silja Litvin, am the majority shareholder of the company PsycApps Limited, which developed eQuoo, the game used in the test group for this trial. The corresponding authors have no other conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. CONSORT flow diagram for a…
Fig 1. CONSORT flow diagram for a 3-arm study.
Fig 2. ARM results at each time…
Fig 2. ARM results at each time period.
Fig 3. RPRS scores at each time…
Fig 3. RPRS scores at each time point.
Fig 4. PGIS scores at each time…
Fig 4. PGIS scores at each time point.
Fig 5. Anxiety scores at each time…
Fig 5. Anxiety scores at each time point.
Fig 6. Percentage of participants who submitted…
Fig 6. Percentage of participants who submitted questionnaire responses at each time point.

References

    1. Institute for Health Metrics and Evaluation. Findings from the global burden of disease study 2017. Seattle (WA); 2018.
    1. World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017.
    1. McDaid D, Park AL, Wahlbeck K. The economic case for the prevention of mental illness. Ann Rev Pub Health. 2019;40:373–89.
    1. Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017. J Abnorm Psychol. 2019;128(3):185–99. 10.1037/abn0000410
    1. Davies SC. Annual report of the Chief Medical Officer 2013. Public mental health priorities: investing in the evidence. London: Department of Health; 2014.
    1. Kazdin AE. Addressing the treatment gap: a key challenge for extending evidence-based psychosocial interventions. Behav Res Ther. 2017;88:7–18. 10.1016/j.brat.2016.06.004
    1. National Academies of Sciences, Engineering, and Medicine. Fostering healthy mental, emotional, and behavioral development in children and youth: a national agenda. Washington, DC: The National Academies Press; 2019.
    1. Ormel J, Cuijpers P, Jorm AF, Schoevers R. Prevention of depression will only succeed when it is structurally embedded and targets big determinants. World Psychiatry. 2019;18(1):111 10.1002/wps.20580
    1. Cuijpers P, van Straten A, Smit F, Mihalopoulos C, Beekman A. Preventing the onset of depressive disorders: a meta-analytic review of psychological interventions. Am J Psychiatry. 2008;165(10):1272–80. 10.1176/appi.ajp.2008.07091422
    1. Livingston NA, Shingleton R, Heilman ME, Brief D. Self-help smartphone applications for alcohol use, PTSD, anxiety, and depression: addressing the new research-practice Gap. J Tech Behav Sci. 2019: 4(2);139–51.
    1. Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PS, et al. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med. 2011;41(8):1751–61. 10.1017/S0033291710002291
    1. Ebert DD, Mortier P, Kaehlke F, Bruffaerts R, Baumeister H, Auerbach RP, et al. Barriers of mental health treatment utilization among first‐year college students: first cross‐national results from the WHO World Mental Health International College Student Initiative. Int J Meth Psych Res. 2019;28(2):e1782.
    1. Sickel AE, Seacat JD, Nabors NA. Mental health stigma: impact on mental health treatment attitudes and physical health. J Health Psychol. 2019;24(5):586–99. 10.1177/1359105316681430
    1. [Internet]. Number of smartphone users worldwide from 2016 to 2021; c2019 [cited 2019 Nov 11]. Available from:
    1. Aitken M, Clancy B, Nass D. The growing value of digital health: evidence and impact on human health and the healthcare system. IQVIA Institute for Human Data Science; 2017. [cited 2019 Nov 23]. Available from:
    1. Bry Laura Jane, Chou Tommy, Miguel Elizabeth, and Comer Jonathan S. "Consumer smartphone apps marketed for child and adolescent anxiety: A systematic review and content analysis." Behavior therapy 49, no. 2 (2018): 249–261.
    1. Donker T, Petrie K, Proudfoot J, Clarke J, Birch MR, Christensen H. Smartphones for smarter delivery of mental health programs: a systematic review. J Med Internet Res. 2013;15(11):e247 10.2196/jmir.2791
    1. Rathbone AL, Prescott J. The use of mobile apps and SMS messaging as physical and mental health interventions: systematic review. J Med Internet Res. 2017;19(8):e295 10.2196/jmir.7740
    1. Torous J, Chan SR, Tan SY, Behrens J, Mathew I, Conrad EJ, et al. Patient smartphone ownership and interest in mobile apps to monitor symptoms of mental health conditions: a survey in four geographically distinct psychiatric clinics. JMIR Mental Health. 2014;1(1):e5 10.2196/mental.4004
    1. Beard C, Silverman AL, Forgeard M, Wilmer MT, Torous J, Björgvinsson T. Smartphone, social media, and mental health app use in an acute transdiagnostic psychiatric sample. MIR mHealth uHealth. 2019;7(6):e13364.
    1. Torous J, Wisniewski H, Liu G, Keshavan M. Mental health mobile phone app usage, concerns, and benefits among psychiatric outpatients: comparative survey study. JMIR Ment Health. 2018;5(4):e11715 10.2196/11715
    1. Baumel A, Muench F, Edan S, Kane JM. Objective user engagement with mental health apps: systematic search and panel-based usage analysis. J Med Internet Res. 2019;21(9):e14567 10.2196/14567
    1. Torous J, Nicholas J, Larsen ME, Firth J, Christensen H. Clinical review of user engagement with mental health smartphone apps: evidence, theory and improvements. Evid Based Ment Health. 2018;21(3):116–9. 10.1136/eb-2018-102891
    1. Eysenbach G. The law of attrition. J Med Internet Res. 2005;7(1):e11 10.2196/jmir.7.1.e11
    1. Torous J, Lipschitz J, Ng M, Firth J. Dropout rates in clinical trials of smartphone apps for depressive symptoms: a systematic review and meta-analysis. J Affect Disord. 2020;263:413–19. 10.1016/j.jad.2019.11.167
    1. Farvolden P, Denisoff E, Selby P, Bagby RM, Rudy L. Usage and longitudinal effectiveness of a Web-based self-help cognitive behavioral therapy program for panic disorder. J Med Internet Res. 2005;7(1):e7 10.2196/jmir.7.1.e7
    1. Salvatori Penny. "Implementing a problem‐based learning curriculum in occupational therapy: A conceptual model." Australian Occupational Therapy Journal 47, no. 3 (2000): 119–133.
    1. Sardi L, Idri A, Fernández-Alemán JL. A systematic review of gamification in e-Health. J Biomed Inform. 2017;71:31–48. 10.1016/j.jbi.2017.05.011
    1. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: Defining gamification. Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments; 2011 Sep 28–30; Tampere, Finland: New York: ACM; 2011. 10.1145/2181037.2181040
    1. Cheng VW, Davenport T, Johnson D, Vella K, Hickie IB. Gamification in apps and technologies for improving mental health and well-being: systematic review. JMIR Ment Health. 2019;6(6):e13717 10.2196/13717
    1. Johnson D, Deterding S, Kuhn KA, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: A systematic review of the literature. Internet Interv. 2016;6:89–106. 10.1016/j.invent.2016.10.002
    1. Ryan RM, Rigby CS, Przybylski A. The motivational pull of video games: A self-determination theory approach. Motiv Emot. 2006;30(4):344–60.
    1. Höchsmann C, Infanger D, Klenk C, Königstein K, Walz SP, Schmidt-Trucksäss A. Effectiveness of a behavior change technique–based smartphone game to improve intrinsic motivation and physical activity adherence in patients with type 2 diabetes: randomized controlled trial. JMIR Serious Games. 2019;7(1):e11444 10.2196/11444
    1. Brown M, O'Neill N, van Woerden H, Eslambolchilar P, Jones M, John A. Gamification and adherence to web-based mental health interventions: a systematic review. JMIR Ment Health. 2016;3(3):e39 10.2196/mental.5710
    1. Russoniello CV, Fish MT, O'Brien K. The efficacy of playing videogames compared with antidepressants in reducing treatment-resistant symptoms of depression. Games Health J. 2019; 8(5):332–8. 10.1089/g4h.2019.0032
    1. Kelders SM, Sommers-Spijkerman M, Goldberg J. Investigating the direct impact of a gamified versus nongamified well-being intervention: an exploratory experiment. J Med Internet Res. 2018;20(7):e247 10.2196/jmir.9923
    1. Ryan R.M., & Deci E.L. (2001). On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Ann Rev Psychol. 2001;52:141–66.
    1. Keyes CL. Mental illness and/or mental health? Investigating axioms of the complete state model of health. J Consult Clin Psychol. 2005;73(3):539 10.1037/0022-006X.73.3.539
    1. Naragon-Gainey K. Affective models of depression and anxiety: Extension to within-person processes in daily life. J Affect Disord. 2019;243:241–8. 10.1016/j.jad.2018.09.061
    1. Hirschfeld R, Montgomery SA, Keller MB, Kasper S, Schatzberg AF, Möller HJ, et al. Social functioning in depression: a review. J Clin Psychiatry. 2000;61(4):268–75. 10.4088/jcp.v61n0405
    1. Bora E, Berk M. Theory of mind in major depressive disorder: a meta-analysis. J Affect Disord. 2016;191:49–55. 10.1016/j.jad.2015.11.023
    1. Teo AR, Choi H, Valenstein M. Social relationships and depression: ten-year follow-up from a nationally representative study. PloS One. 2013;8(4):e62396 10.1371/journal.pone.0062396
    1. Santini ZI, Koyanagi A, Tyrovolas S, Mason C, Haro JM. The association between social relationships and depression: a systematic review. J Affect Disord. 2015;175:53–65. 10.1016/j.jad.2014.12.049
    1. Shrivastava A, Desousa A. Resilience: A psychobiological construct for psychiatric disorders. Indian J Psychiatry. 2016;58(1):38 10.4103/0019-5545.174365
    1. Akeman E, Kirlic N, Clausen AN, Cosgrove KT, McDermott TJ, Cromer LD, et al. A pragmatic clinical trial examining the impact of a resilience program on college student mental health. Depress Anxiety. 2019. 10.1002/da.22969
    1. Kermott CA, Johnson RE, Sood R, Jenkins SM, Sood A. Is higher resilience predictive of lower stress and better mental health among corporate executives? PloS one. 2019;14(6):e0218092 10.1371/journal.pone.0218092
    1. Reppucci N. D., & Saunders J. T. (1974). Social psychology of behavior modification: Problems of implementation in natural settings. Am Psychol, 1974;29(9):649–60. 10.1037//0003-066x.29.9.649
    1. Tondello GF, Mora A, Nacke LE. Elements of gameful design emerging from user preferences. Proceedings of the Annual Symposium on Computer-Human Interaction in Play; 2017 Oct 15; Amsterdam, The Netherlands. New York: ACM; 2017. p. 129–42. ACM.
    1. Vandelanotte C, Spathonis KM, Eakin EG, Owen N. Website-delivered physical activity interventions: a review of the literature. Am J Prev Med. 2007;33(1):54–64. 10.1016/j.amepre.2007.02.041
    1. Liebenberg L, Moore JC. A social ecological measure of resilience for adults: The RRC-ARM. Soc Indic Res. 2018;136(1):1–9.
    1. Hartley MT. Investigating the relationship of resilience to academic persistence in college students with mental health issues. Rehabil Couns Bull. 2013;56(4):240–50.
    1. Liebenberg L, Moore JC. A social ecological measure of resilience for adults: The RRC-ARM. Soc Indic Res. 20181;136(1):1–9.
    1. Kafka GJ, Kozma A. The construct validity of Ryff's scales of psychological well-being (SPWB) and their relationship to measures of subjective well-being. Soc Indic Res. 2002;57(2):171–90.
    1. Braithwaite SR, Delevi R, Fincham FD. Romantic relationships and the physical and mental health of college students. Pers Relatsh. 2010;17(1):1–2.
    1. Ryff CD. Psychological well-being revisited: Advances in the science and practice of eudaimonia. Psychother Psychosom. 2014;83(1):10–28. 10.1159/000353263
    1. Robitschek C, Ashton MW, Spering CC, Geiger N, Byers D, Schotts GC, Thoen MA. Development and psychometric evaluation of the Personal Growth Initiative Scale–II. J Couns Psychol. 2012;59(2):274 10.1037/a0027310
    1. Compton WC, Smith ML, Cornish KA, Qualls DL. Factor structure of mental health measures. J Pers Soc Psychol. 1996;71(2):406 10.1037//0022-3514.71.2.406
    1. Davey HM, Barratt AL, Butow PN, Deeks JJ. A one-item question with a Likert or Visual Analog Scale adequately measured current anxiety. J Clin Epidemiol. 2007;60(4):356–60. 10.1016/j.jclinepi.2006.07.015
    1. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Scale. Palo Alto, CA: Consulting Psychologists Press; 1983.
    1. Marteau TM, Bekker H. The development of a six‐item short‐form of the state scale of the Spielberger State—Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(3):301–6. 10.1111/j.2044-8260.1992.tb00997.x
    1. Linardon J, Fuller-Tyszkiewicz M. Attrition and adherence in smartphone-delivered interventions for mental health problems: A systematic and meta-analytic review. J Consult Clin Psychol. 2019.
    1. Barrick MR, Mount MK. The big five personality dimensions and job performance: a meta‐analysis. Pers Psychol. 1991;44(1):1–26.
    1. Rajaei A, Daneshpour M, Robertson J. The effectiveness of couples therapy based on the Gottman method among Iranian couples with conflicts: a quasi-experimental study. J Couple Relatsh Ther. 2019;18(3):223–240.
    1. Laufer O, Israeli D, Paz R. Behavioral and neural mechanisms of overgeneralization in anxiety. Curr Biol. 2016;26(6):713–22. 10.1016/j.cub.2016.01.023
    1. Patt A, Zeckhauser R. Action bias and environmental decisions. J Risk Uncertain. 2000;21(1):45–72.
    1. Sullivan MJ, D'Eon JL. Relation between catastrophizing and depression in chronic pain patients. J Abnorm Psychol. 1990;99(3):260 10.1037//0021-843x.99.3.260
    1. Fox S, Bizman A, Herrmann E. The halo effect: Is it a unitary concept? J Occup Psychol. 1983;56(4):289–96.
    1. Maiter S, Simich L, Jacobson N, Wise J. Reciprocity: an ethic for community-based participatory action research. Action Res. 2008;6(3):305–25.
    1. Hart AJ. Naturally occurring expectation effects. J Pers Soc Psychol. 1995;68(1):109.
    1. Leon FR, Lundgren R, Huapaya A, Sinai I, Jennings V. Challenging the courtesy bias interpretation of favorable clients’ perceptions of family planning delivery. Evaluation Review. 2007. February;31(1):24–42. 10.1177/0193841X06289044
    1. Blaine B, Crocker J. Self-esteem and self-serving biases in reactions to positive and negative events: An integrative review InSelf-esteem 1993. (pp. 55–85). Springer, Boston, MA.
    1. Vázquez C, Hervás G, Rahona JJ, Gómez D. Psychological well-being and health. Contributions of positive psychology. Annuary of Clinical and Health Psychology. 2009;5(2009):15–27.
    1. Padesky CA, Mooney KA. Strengths‐based cognitive–behavioural therapy: a four‐step model to build resilience. Clin Psychol Psychotherapy. 2012;19(4):283–90.
    1. Taft CT, Murphy CM, King DW, Musser PH, DeDeyn JM. Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men. J Consult Clin Psychol. 2003;71(4):812 10.1037/0022-006x.71.4.812
    1. Eng W, Coles ME, Heimberg RG, Safren SA. Domains of life satisfaction in social anxiety disorder: relation to symptoms and response to cognitive-behavioral therapy. J Anxiety Disord. 2005;19(2):143–56. 10.1016/j.janxdis.2004.01.007
    1. Ducasse D, Dassa D, Courtet P, Brand‐Arpon V, Walter A, Guillaume S, et al. Gratitude diary for the management of suicidal inpatients: A randomized controlled trial. Depression and anxiety. 2019. May;36(5):400–11. 10.1002/da.22877
    1. Donkin L, Christensen H, Naismith SL, Neal B, Hickie IB, Glozier N. A systematic review of the impact of adherence on the effectiveness of e-therapies. J Med Internet Res. 2011;13(3):e52 10.2196/jmir.1772
    1. Bakker D, Rickard N. Engagement in mobile phone app for self-monitoring of emotional wellbeing predicts changes in mental health: MoodPrism. J Affect Disord. 20181;227:432–42. 10.1016/j.jad.2017.11.016
    1. Forand NR, Feinberg JE, Barnett JG, Strunk DR. Guided internet CBT versus “gold standard” depression treatments: an individual patient analysis. J Clin Psychol. 2019;75(4):581–93. 10.1002/jclp.22733
    1. Fuhr K, Schröder J, Berger T, Moritz S, Meyer B, Lutz W, et al. The association between adherence and outcome in an Internet intervention for depression. J Affect Disord. 2018;229:443–9. 10.1016/j.jad.2017.12.028
    1. Price M, Gros DF, McCauley JL, Gros KS, Ruggiero KJ. Nonuse and dropout attrition for a web-based mental health intervention delivered in a post-disaster context. Psychiatry. 2012;75(3):267–84. 10.1521/psyc.2012.75.3.267
    1. Chiu TM, Eysenbach G. Stages of use: consideration, initiation, utilization, and outcomes of an internet-mediated intervention. BMC Med Inform Decis Mak. 2010;10(1):73.
    1. Lin Y, Tudor-Sfetea C, Siddiqui S, Sherwani Y, Ahmed M, Eisingerich AB. Effective behavioral changes through a digital mHealth app: exploring the impact of hedonic well-being, psychological empowerment and inspiration. JMIR mHealth uHealth.2018;6(6):e10024 10.2196/10024
    1. Li N, Chen W. A mobile game for the social and cognitive well-being of elderly people in China. Stud Health Technol Inform. 2017;242:614–21.
    1. Ahtinen A, Mattila E, Välkkynen P, Kaipainen K, Vanhala T, Ermes M, et al. Mobile mental wellness training for stress management: feasibility and design implications based on a one-month field study. JMIR mHealth uHealth. 2013;1(2): e11 10.2196/mhealth.2596
    1. Dias LPS, Barbosa JLV, Vianna HD. Gamification and serious games in depression care: a systematic mapping study. Telemat. inform. 2018;35(1):213–24. 10.1016/j.tele.2017.11.002
    1. Wahle F, Kowatsch T, Fleisch E, Rufer M, Weidt S. Mobile Sensing and support for people with depression: a pilot trial in the wild. JMIR mHealth uHealth, 2016;4(3):e111 10.2196/mhealth.5960
    1. Boyle SC, Earle AM, LaBrie JW, Smith DJ. PNF 2.0? Initial evidence that gamification can increase the efficacy of brief, web-based personalized normative feedback alcohol interventions. Addict behav. 2017;67:8–17. 10.1016/j.addbeh.2016.11.024
    1. Cheng VWS, Davenport T, Johnson D, Vella K, Hickie IB. Gamification in apps and technologies for improving mental health and well-being: systematic review. JMIR Ment Health. 2019;6(6):e13717 10.2196/13717
    1. Topp CW, Østergaard SD, Søndergaard S, Bech P The WHO-5 Well-Being Index: a systematic review of the literature. Psychother Psychosom. 2015;84(3):167–76. 10.1159/000376585
    1. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol. 1988;47:1063–70.
    1. Kessler RC, Mroczek D. Final versions of our non-specific psychological distress scale [memo dated March 10, 1994]. Institute for Social Research, Survey Research Center, The University of Michigan, 1994.
    1. Fahrenberg J, Myrtek M, Pawlik K, Perrez M. Ambulatory assessment-monitoring behavior in daily life settings. Eur J Psychol Assess. 2007;23(4):206–13.

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