68 Chapter 2 by including only studies employing a randomised controlled design, the current review provides the highest quality of evidence for the effectiveness of games for mental health (Akobeng, 2005). Recommendations for Future Research The first recommendation is to reach agreement on clear definitional boundaries of ‘applied game’, ‘gamification’ and ‘serious game’. While conducting the review, we encountered grey areas between the definitions asking ourselves, for instance, when a (gamified) intervention could be called a ‘game’, and whether there would be a distinction between game elements that could be seen as more basic or more complex and sophisticated, being more indicative of gamified or serious game interventions, respectively. Clear definitions would not only aid coding of interventions, but also the interpretation of (possibly mixed) results. Not being able to distinguish between gamified and serious game interventions has limited the conclusions of our review, because one would expect that the quality or level of sophistication of a digital game could matter for its effectiveness (Scholten & Granic, 2019). Gamification, involving the addition of game elements to an intervention, is often done to transform activities perceived to be demotivating into more enjoyable experiences (Turan et al., 2016). While it does not necessarily focus on playfulness and fun (Fleming et al., 2017), it aims to ensure engagement with a task that is less motivating or not entertaining in the first place. Youth today, however, are digital natives (Prensky, 2012), use interactive media and technology daily and have grown accustomed to interacting with highly engaging, sophisticated and immersive contexts (Knowles et al., 2014; The Lancet Child Adolescent Health, 2018). Gamified interventions may not be as attractive, interactive, flexible and responsive to individual needs as youth nowadays would expect and prefer (Liverpool et al., 2020) and, thus, they may prove less effective in improving mental health (Scholten & Granic, 2019). Instead, digital health interventions that stimulate intrinsic motivation to play, offer choice and autonomy over one’s gameplay and that are simply fun (i.e., one would continue playing outside the therapeutic or trial environment), may be more effective in improving mental health (Granic et al., 2014; Scholten & Granic, 2019). Consequently, gamification may be most suitable to test mechanisms of change and basic game mechanics that may be fruitful to iterate on. In contrast, well-designed immersive and entertaining environments that retain youths’ attention and foster replayability might be more suitable to improve mental health for the long term. On a related note, it is important to mention that our findings showed that for all clinical populations except those with externalising problems,
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