This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines (20). The review protocol was registered in the Prospective Register of Systematic Review (PROSPERO) with the identification code CRD42024531914.

A search strategy using Medline, PsycINFO, Web of Science, and SCOPUS was conducted. This search strategy combined terms related to population (adolescent OR teenager OR youth OR juvenile OR young OR minor), games (game OR gaming OR gamified OR gamification), interventions (intervention OR program OR treatment OR therapy OR trial), and classrooms (classroom OR school OR education institution). All searches were performed based on titles, abstracts, and keywords. The bibliographic database searches are detailed in Supplementary Table 1 .

The search terms were selected considering the search strategies in previous systematic reviews on game-based interventions (21–23). The following limits and filters were activated in all databases, if possible: (1) publication date (from inception until 2024), (2) document type (only articles), and (3) languages (English and Spanish). In addition, gray literature—such as dissertations, conference abstracts, or reports—was excluded to ensure methodological consistency across included studies. The reference list of included studies was examined through a reverse citation search.

The eligibility criteria were selected using the “Population”, “Intervention”, “Comparison”, “Outcomes”, and “Study” (PICOS) approach (24):

Duplicate articles in the databases were automatically removed by Mendeley. Then, 2 authors (CAL and APA) independently screened all articles in Rayyan QCRI. Abstracts and titles were screened to identify those relevant to the research question. When insufficient information was available to determine eligibility, full articles were reviewed. The selected articles were examined for their reference lists to identify additional relevant studies that might not have appeared in the initial database search. Initial disagreements among the authors were resolved by consensus. No additional reviewer was needed to resolve the initial disagreement.

The quality appraisal (QA) of the studies was evaluated independently by 3 authors (CAL, APA, and JPSM) using the National Heart, Lung, and Blood Institute (NHLBI) tools for quality assessment (25). Considering the characteristics of the studies included in this systematic review, two tools were used: one for controlled intervention studies, and another for single-arm studies.

The total score range was 0–14 for the “Quality Assessment of Controlled Intervention Studies” tool: good QA (11-14), fair QA (6-10), and low QA (≤ 5); and 0–12 for the “Quality Assessment Tool for Before-After Studies with No Control Group” tool: good QA (9-12), fair QA (5-8), and low QA (≤ 4). The answer options were scored with 1 when the criterion was met and with a 0 when the criterion was not met, could not be determined, was not applicable, or was not reported. Discordances in quality rating were resolved through discussion between the authors.

A data extraction form was developed based on the Centre for Reviews and Dissemination templates. Data collected included information on authors, publication date, country of study, study design, sample size, setting, outcomes, and results. In addition, the name, reference(s), objective, format, and games of the interventions included in this systematic review were extracted. A narrative synthesis was carried out to describe the main characteristics of game-based interventions, the quality of evidence, and the relationship of the findings within and between the included studies. A summary of each study and its main features was provided in the tables.

As shown in Figure 1 , the initial database search yielded a total of 1,152 published articles. In addition, 4 articles were included from other resources (i.e., reverse citation search). After removing duplicates, 1,130 titles and abstracts were reviewed, of which 41 were chosen for full-text review. Finally, 17 articles were included in this systematic review.

Among the 17 studies, the cluster randomized controlled trial design was the most common (n = 12), where the whole classrooms were randomly assigned either to the intervention or control condition. Only six studies included a follow-up assessment. The sample sizes ranged from 40 to more than 14,000 adolescents, and participants’ ages ranged from 11 to 18. Gender distribution was balanced in most cases, although one study was conducted on a female-only education center. Regarding the outcomes, most studies (n = 12) included some measure of knowledge acquisition (regarding the aspects that the intervention targeted), attitudes, and intentions, among others. In addition, eight studies reported users’ opinions and/or satisfaction with the intervention. These outcomes were predominantly measured using ad hoc questionnaires—some previously employed in other studies, others specifically developed for the current research—while only 7 studies used some validated instruments. The description of each study can be found in Table 1 .

The studies reviewed tested the effects of 12 interventions that included some kind of game in the classroom to increase knowledge and/or promote healthy attitudes related to mental health: four interventions aimed at promoting responsible drinking; three focused on preventing/reducing tobacco use among adolescents; two programs targeted different types of substance-related and addictive disorders (doping, tobacco, alcohol, cannabis, and screen use); two focused on reducing anxiety; and one was addressed at increasing knowledge about depression and reducing its associated stigma. While some interventions were delivered in a single session (n = 3), most of them (n = 8) included at least four that took place once per week during consecutive weeks. The playful activities delivered in the classroom were diverse: videogames in which the students had to make decisions regarding the behavior of the main character and see the consequences (n = 2), virtual reality games that simulated social situations and bodily sensations (n = 2), interactive games and competitive quizzes to increase knowledge (n = 6), and a collaborative digital escape room to learn about different types of risky behaviors (n = 1). A description of the interventions, detailing the playful activity that each one included, can be found in Table 2 .

The overall quality of the studies included was rated as fair. No studies were rated as good, while 4 presented low quality. The risk of bias was mainly due to a lack of blinding in controlled studies, while single-arm studies did not report information on the sample’s representativeness and sample size calculation. The quality assessment of the included studies is detailed in Supplementary Table 2 .

Eight studies reported users’ opinions about the program, and these were favorable in all cases (see Table 3 ): Escape Addict obtained a 5.68 out of 7, and students provided positive feedback about the contents and dynamics of the intervention. GO: KA, on its part, presented moderate levels of satisfaction (average of 3 out of 5), with one subsample (“good females”) showing more favorable opinions towards it. The Blurred Minds program received positive feedback from the participants in two studies (28, 29). Project EX had an average of around 8 points out of 10 in two studies (36, 39), and the game session was well-rated (7.41/10), although the meditation session was the most liked one. ACTION received better acceptability scores than the control intervention, although they were high for both groups (37). Finally, as reported by Tuijnman et al. (40), 92% of the adolescents who participated in the study indicated they would recommend Moving Stories.

This systematic review highlights the need for further research on the effects of game-based interventions implemented within classroom settings to promote knowledge and healthy attitudes related to mental health in adolescents. So far, most of the studies published in the literature have focused on exploring the benefits of these programs to prevent or intervene in different substance-related disorders (e.g., drinking behaviors, tobacco use, and doping). However, it would be pertinent for future lines of research to explore the efficacy of these interventions in addressing other prevalent mental health problems in adolescents, such as affective or eating disorders, among others (11). Additionally, it is crucial for such studies to explore the long-term effects of interventions targeting adolescents, particularly regarding their impact on knowledge, attitudes, and healthy behaviors.

Identifying potential mediating or moderating factors that may influence the effectiveness of game-based interventions could be key in customizing programs to meet the unique needs of different adolescent groups. Personalization of interventions seems essential to improve the effectiveness of school-based programs (45). Considering factors such as the age, gender, and socioeconomic context of adolescents, among others, could help to design interventions more in line with their needs and interests (46–48). In this regard, exploring diversity emerges as a fundamental aspect of understanding how game-based interventions can be better adapted to meet adolescents’ needs. For instance, Bezençon et al. (26) observed that gender and academic performance played a role in knowledge acquisition. Future research should investigate how diversity-related factors, such as socioeconomic status, race, ethnicity, gender identity, and cultural background, might influence the effectiveness of these programs. Recognizing these elements is essential to developing inclusive and culturally sensitive interventions that can be applied to diverse adolescent populations. Therefore, it is crucial to ensure that these interventions are accessible and relevant to all adolescents, regardless of their background or identity.

For educators, it is considered essential to create interventions that not only inform but also actively involve adolescents through interactive elements and relevant contexts. It would also be necessary for public policies to support the integration of these programs into the school curriculum, providing the necessary resources for their implementation and continuous evaluation. In addition, training educators in the use of these tools could contribute to maximizing their impact (49, 50). Encouraging the consistent practice of acquired skills over time, as well as adapting game content to be resonant with adolescents’ daily experiences could be elements that contribute to increasing their impact and sustainability (15, 16). This, along with the integration of playful elements that promote collaboration and mutual support, could facilitate the creation of more inclusive and motivating learning environments (51). Finally, assessing how different game elements, such as narrative, interactivity, and rewards, influence mental health outcomes could provide valuable information for designing effective interventions. All these improvements could help maximize the potential of games as intervention tools in promoting mental health among adolescents.

One limitation of our review is the lack of a meta-analysis. While this approach was considered, it was deemed not feasible for several reasons. Primarily, there is a lack of standardized and validated operational definitions for mental health outcomes in game-based interventions. This heterogeneity in both outcome conceptualization and measurement tools significantly reduced comparability across studies, limiting the potential for data synthesis. Furthermore, outcomes such as knowledge, intentions, and attitudes were measured inconsistently across studies. Specifically, only five studies reported the necessary data, and the wide variety of instruments used rendered the data non-comparable. Additionally, the small number of available datasets would result in low statistical power and unreliable pooled estimates.

Another limitation is the generally low or fair quality of the studies included in this systematic review. The characteristics of the programs (i.e., number of sessions, intervention components, and measures) and targets (i.e., addictive behaviors, depression, and anxiety) were heterogeneous. For what concerns to outcomes, most of them were assessed using ad hoc questionnaires which, although sometimes showing acceptable internal consistency, lacked validation—thereby reducing the precision and reliability of the findings. Furthermore, in several cases, the description of the games used was incomplete, limiting the ability to analyze the contribution of specific program components. Only one-third of the studies included follow-up assessments, which hinders understanding of the long-term effects of these interventions. Taken together, these limitations suggest that it is still premature to draw strong conclusions about the effects of classroom-based game interventions to promote mental health among adolescents.

The variability in cohort characteristics across the studies included (e.g., periods of implementation, regional differences, and adolescent population variations) may have influenced the results. Such factors, including social, cultural, and educational changes over time, could limit the generalizability of the findings. Also, studies from the earliest available research were included in the systematic review to offer a comprehensive overview of the evidence on this topic. While this approach enabled the capture of the field’s evolution, it may also present a limitation, as older studies may vary significantly in methodology, context, and outcomes, potentially impacting the overall interpretation of the findings. Moreover, this systematic review included only studies published in English or Spanish, so other relevant evidence could have been excluded.

One last limitation of this review is the limited identification of theoretical frameworks underpinning the interventions. Most studies did not explicitly report the psychological theories guiding their design, which hinders the understanding of the causal mechanisms through which game elements might influence mental health outcomes. This gap limits the ability to draw conclusions about why certain intervention components may be more effective than others. Future research should place greater emphasis on grounding interventions in established theoretical models, which would help clarify the mechanisms of change and inform the development of more effective and targeted game-based strategies.

Game-based interventions represent a promising strategy to address adolescent mental health challenges, particularly in relation to substance-related and addictive disorders. This systematic review found evidence supporting their effectiveness in improving knowledge and attitudes toward alcohol and tobacco use, as well as in reducing the intention to consume these substances. Although further research is needed in areas such as anxiety and depression, the high levels of satisfaction and engagement reported by adolescents highlight the acceptability of these interventions in educational settings. Based on these findings, we recommend that teachers consider integrating evidence-informed game-based activities into health education curricula; that intervention designers align game content with specific psychological targets and employ validated outcome measures; and that policymakers support the implementation and evaluation of these programs by providing resources and training in schools. These recommendations can guide the development of more rigorous, theory-driven interventions and promote mental health literacy among adolescents.