Supporting youth mental health and resilience with eQuoo - a novel gamified mobile app

For mental health awareness month, Sarah Price and Philip Jefferies describe challenges related to youth mental health and introduce the eQuoo project, which is registered at the ISRCTN registry.
Supporting youth mental health and resilience with eQuoo - a novel gamified mobile app

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A recent NHS report looking into the mental health of children and young people in England found that 1 in 5 between the ages of 8 and 25 had a probable mental health disorder, peaking at 23.3% in 17-19-year-olds  (NewLove-Delgado et al., 2023). However, there is a larger proportion of individuals that do not meet the criteria for a classification of a probable mental illness, yet still struggle with their mental health. This ‘subclinical’ or ‘subthreshold’ cohort may experience some symptoms of a mental health disorder but not others, or may experience symptoms to a more moderate, yet still impactful, extent. One study that surveyed more than 12,000 adolescents across 11 countries in Europe found that nearly a third had subclinical symptoms of anxiety and depression (Balázs et al., 2013).

A developing body of research is documenting the widespread implications of subclinical mental health issues, including general functional impairment and higher suicidality (Balázs et al., 2013), social impairment (Angold et al., 1999), poorer emotion regulation (Van Beveren & Braet, 2015) and planning ability (Unterrainer et al., 2018), lower educational attainment and likelihood of pursuing further education (Burger, Becker, & Schoon, 2023), and reduced quality of life and wellbeing (Švancer et al., 2020). Furthermore, subclinical anxiety and depression in adolescence have been associated with a greater likelihood of clinical disorder onset in adulthood (Pine et al., 1999; Wolitzky‐Taylor et al., 2014), meaning that it is important to act on these issues early.

However, only one in three adolescents with a probable mental illness currently have access to mental health treatments, with many languishing on wait lists (NHS, 2019). A recent survey also indicated that 67% of young people reported wanting mental health support without accessing their doctor, but only half knew of such support options (YoungMinds, 2020). While waiting or searching for support, many young people experience a decline in their symptoms, with 76% of parents reporting that their children had worsening mental health prior to receiving support (YoungMinds, 2018).

It is clear that there is a need for accessible interventions for adolescents who are experiencing difficulties with their mental health. One meta-analysis found that interventions aimed at subclinical populations were generally found to be effective (Cuijpers, Smit, & Van Straten, 2007). However, interventions must be scalable and available to those who may benefit from them, which are typical shortcomings of many. To address this, NICE (2020) has recommended digital interventions for less severe disorders. Recent reviews are indicating that digital mental health interventions can be efficacious (Firth, Torus, Nicholas, Carney, Rosenbaum & Sarris, 2017). However, attrition and non-completion rates are reported to be high (e.g., Hollis et al., 2017; Linardon, Cuijpers, Calbring, Messer & Fuller-Tyszkiewicz, 2019), with Eysenbach (2005) reporting more than 99% of participants in some studies who dropped out before completing fixed-length interventions. One potential solution is to add gamification to deliver the therapeutic features in a game format, which may aid retention by keeping participants engaged in a way that they enjoy experiencing and coming back to.

One promising solution involving gamification is a mental health and wellbeing app called ‘eQuoo’. PsycApps developed eQuoo to harness the power of storytelling to deliver psychoeducation using clinically proven strategies used in cognitive behavioural therapy and positive psychology. The app takes the form of a game, where users create an avatar and navigate a series of interactive stories where they are presented with scenarios that challenge them to understand and implement a range of psychological skills. eQuoo has been tested in several settings and found to be effective in improving the mental health and resilience of university students (Litvin et al., 2023), young adults (Jefferies et al., 2023), and an older sample of employed individuals (35-44 years old; Litvin et al., 2020). However, despite recent additions to the app to broaden its appeal to a younger audience, it has yet to be tested with adolescents.

The project

The current study aims to examine how using a gamified mental health app (eQuoo) improves mental health and wellbeing in a college-aged sample (16–19-year-olds) over time. Participants will be students aged 16 years or older enrolled in one of the 14 colleges across England that are part of Activate Learning and NCG college groups. Approximately eight thousand students from the colleges will be invited to participate in the research, enabling a strongly representative sample of students at this age in England. The study is a cluster randomised control trial, and students are assigned to either a six-month waitlist control group or immediate intervention group depending on the college they attend.

After completing an online survey about their mental health and wellbeing, students will be asked to download eQuoo on their phones (intervention group participants only). There is a recommended play time of a minimum of 1 hour per week for the six weeks following the initial download, and a maximum of engaging three skills per 24-hours to promote paced usage. Follow up surveys will be conducted at 2, 4, and 6-week intervals for both groups, with further longitudinal effects captured in 3, 6, and 12 month surveys. The participating colleges will also provide grades and attendance data, and usage data from the app will be recorded.

Further details about the study design are available at

The implications of this research

This project will provide critical evidence for the efficacy of a gamified mental health digital intervention for supporting the mental health and wellbeing of college-aged students (16-19 years of age). We anticipate that the project will highlight the effectiveness of cost-effective digital interventions such as eQuoo for treating subclinical mental health problems. We also expect the project to stimulate broader college-level and government policy discussions regarding the prevalence of mental health problems young people face as well as availability and funding for mental health supports such as eQuoo.


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  • ISRCTN registry ISRCTN registry

    A primary clinical trial registry recognised by WHO and ICMJE that accepts studies involving human subjects or populations with outcome measures assessing effects on human health and well-being, including studies in healthcare, social care, education, workplace safety and economic development.