JMIR Publications

ABSTRACT

Background:

Gamified digital mental health interventions have been proposed as a scalable and engaging approach to addressing the substantial treatment gap in child and adolescent mental health. However, the evidence remains fragmented, and it is unclear which specific gamification elements contribute to clinical effectiveness and sustained engagement.

Objective:

This review aimed to (1) characterize the gamification elements implemented in digital mental health interventions for children and adolescents, (2) evaluate their effects on internalizing mental health outcomes, (3) assess engagement, adherence, and user experience outcomes, and (4) descriptively explore whether specific gamification elements are associated with differences in clinical or engagement outcomes.

Methods:

A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. Six electronic databases were searched for studies published between January 2018 and March 2026. Eligible studies examined gamified digital interventions targeting internalizing symptoms in children and adolescents aged 4–18 years. Gamification elements were systematically coded across ten categories using a predefined coding framework. A three-level random-effects meta-analysis was conducted for controlled studies reporting validated mental health outcomes.

Results:

Twenty-seven studies (N=28,777; mean age range: 5.05–18.78 years) were included. Feedback, challenges, and progress tracking were the most frequently implemented gamification elements, social interaction and competition were rare. The meta-analysis of five eligible controlled studies yielded a small overall effect in favor of gamified interventions (g=−0.28, 95% CI −0.43 to −0.14, P<.01). Narrative synthesis indicated more consistent effects for depression and anxiety outcomes in clinical or at-risk samples, particularly for CBT-based serious games with some degree of human support. Engagement and adherence limitations were frequently reported across studies.

Conclusions:

Gamified digital interventions show promising improvements for internalizing outcomes in children and adolescents, particularly in clinical contexts with structured therapeutic content and human guidance. However, gamification alone does not appear sufficient to ensure therapeutic effectiveness or sustained engagement. Future research should determine which gamification elements enhance clinical outcomes and engagement, for whom they are most effective, and under which conditions.