title: Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review.
abstract: BACKGROUND
  Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of "active" technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being.
  
  
  OBJECTIVE
  This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being.
  
  
  METHODS
  A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched.
  
  
  RESULTS
  A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration.
  
  
  CONCLUSIONS
  Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data.
authors: Swansea University, Medical School, Swansea, United Kingdom. menna.brown@swansea.ac.uk.
authors: Menna
authors: http://orcid.org/0000-0003-1427-1648
authors: M
authors: Brown
authors: Noelle
authors: http://orcid.org/0000-0002-7827-2255
authors: N
authors: O'Neill
authors: Hugo
authors: http://orcid.org/0000-0003-3382-1684
authors: H
authors: van Woerden
authors: Parisa
authors: http://orcid.org/0000-0003-4610-1643
authors: P
authors: Eslambolchilar
authors: Matt
authors: http://orcid.org/0000-0001-7657-7373
authors: M
authors: Jones
authors: Ann
authors: http://orcid.org/0000-0002-5657-6995
authors: A
authors: John
keywords: Web-based mental health interventions; adherence; dropout; engagement; gamification; patient compliance; patient nonadherence; well-being