Does gamification enhance adherence?: A randomized controlled trial of a digital self-esteem intervention

Background: Mental health problems and low self-esteem are highly prevalent among college students and are associated with impaired academic functioning and poorer long-term well-being. Digital interventions are a promising and scalable approach to improve student mental health, but adherence is often limited. Gamification may improve engagement, though evidence remains scarce.Objective: This study examines whether adding gamification elements to a guided digital CBT-based self-esteem intervention for students improves adherence, satisfaction, and mental health outcomes.Methods: In a randomized controlled trial, 873 students were allocated to a gamified or non-gamified version of a guided self-esteem intervention. The primary outcome was adherence (number of modules completed), while secondary outcomes included satisfaction, self-esteem, depressive symptoms, anxiety, and quality of life. Assessments were conducted at baseline and at 4-week follow-up.Results: No significant differences were found between conditions on adherence, satisfaction or clinical outcomes in the full sample. Among intervention starters (i.e. completed ≥1 module), the gamified version showed a small increase in adherence (d = .17). Across conditions, participants showed significant improvements in self-esteem, depression, anxiety, and quality of life from pre- to post-test (d = .44–.76).Conclusions: Gamification may modestly increase adherence among intervention starters but does not improve satisfaction or clinical outcomes. Both intervention versions were associated with improvements over time; however, the lack of an untreated control condition limits causal interpretation. Future research should investigate mechanisms behind gamification components.