Background <p>Active video games (AVGs) are increasingly recognized as a viable alternative to traditional physical activities, with growing evidence supporting their benefits for physical and mental health. This systematic review examines whether AVG interventions, compared with traditional exercise and video games, can enhance immediate affective responses (AR) and improve mental health symptoms (MHS).</p> Methods <p>A systematic review of randomized controlled trials (RCTs) was conducted following PRISMA guidelines. We searched multiple electronic databases to identify studies investigating the effects of AVGs on AR and MHS in young adults. Data were extracted using a pre-designed form for synthesis.</p> Results <p>This review included 20 RCTs (<i>n</i> = 1,100). Most studies (14/18) on AR found AVGs superior to control conditions in at least one measure, such as enjoyment, self-efficacy, or situational interest, though results for some outcomes were non-significant. Two studies reported null findings and two reported negative effects for AVGs. In contrast, evidence for improving MHS was limited and inconsistent, with only one out of four studies showing a significant positive effect.</p> Conclusion <p>Preliminary findings support a cautious optimism regarding AVGs’ ability to improve AR in young adults, with enjoyment being a key mechanism. However, evidence is currently insufficient to confirm efficacy for MHS. Strengthening this evidence base necessitates future studies that are more rigorous, target specific populations, and differentiate between AVG types.</p> Registration <p>This systematic review has been registered on PROSPERO, ID: CRD42024572153.</p>