Virtual reality relaxation for people with mental health conditions: a systematic review

Virtual reality for preoperative patient education: Impact on satisfaction, usability, and burnout from the perspective of new nurses

BACKGROUND

Traditional paper-based preoperative patient education is a struggle for new nurses and requires extensive training. In this situation, virtual reality technology can help the new nurses. Despite its potential benefits, there are studies on patient satisfaction but there is limited information on the usability of virtual reality (VR) technology for new nurses in giving preoperative education to patients.

AIM

To investigate the impact on satisfaction, usability, and burnout of a system using VR technology in preoperative patient education.

METHODS

The study involved 20 nurses from the plastic surgery ward and 80 patients admitted between April and May 2019. Each nurse taught four patients: Two using traditional verbal education and two using virtual reality. The System Usability Scale, After-Scenario Questionnaire, and Maslach Burnout Inventory (MBI) were employed to evaluate the impact of these education methods.

RESULTS

The VR education groups showed a statistically higher satisfaction than the traditional verbal education groups. Among the three subscales of the MBI, emotional exhaustion and personal accomplishment improved statistically significantly. VR was also better in terms of usability.

CONCLUSION

This study suggests VR enhances usability and reduces burnout in nurses, but further research is needed to assess its impact on depersonalization and objective measures like stress and heart rate.

Effect of Relaxation-Based Virtual Reality on Psychological and Physiological Stress of Substance Abusers Under Detoxification: A Randomized Controlled Trial

INTRODUCTION

Substance abuse is a widespread problem, with high rates of treatment dropout. Stress plays a crucial role in this problem, so innovative interventions with stressed patients can assist them in completing treatment.

METHODS

This study is a randomized controlled trial with 60 participants who have substance abuse disorder undergoing detoxification at a residency facility in Tehran, Iran. Participants were randomly assigned to one of three groups: watching a 360° video of nature, a 360° video of a city environment, or no virtual experience. The intervention was performed only for one session. Psychological stress was measured using the Positive and Negative Affect Schedule and Perceived Stress Scale before and after the intervention. Physiological stress was assessed through respiratory rate, skin conductance, and heart rate recordings during the virtual reality (VR) experience. Data analysis was performed using R software (version 4.2).

RESULTS

Paired t-test results indicated significant psychological differences before and after virtual nature experiences, but not in the control and city groups. The repeated measure ANOVA showed a significant reduction in skin conductance (p < 0.01) and respiratory rate (p < 0.01) scores in the nature group.

CONCLUSION

The findings suggest that VR relaxation could be a potentially beneficial intervention for reducing stress in patients during detoxification.

The Impact on Anxiety Symptoms of an Immersive Virtual Reality Remediation Program in Bipolar Disorders: A Randomized Clinical Trial

Background: The objective of this work is to investigate the effectiveness of a cognitive remediation intervention on anxiety symptoms in people with bipolar disorder and the therapeutic effect on people whose anxiety symptoms were above the threshold for a screener and whose comorbidity could be identified as an anxiety disorder. Methods: The experimental intervention included 24 sessions (around 45 min each), two for each week over three months. The entire program was inspired by user-centered rehabilitation principles in a recovery-oriented perspective and an approach to bipolar disorder in an evolutionary and non-discriminating vision. The primary outcomes measure the score of the Zung Self-Rating Anxiety Scale (SAS), hypothesizing a higher decrease in the experimental group than in the control group. The survey has been conducted per the CONSORT guidelines for feasibility studies. Results: We evaluate a decrease in the overall SAS score from T0 to T1 to be higher in the experimental group compared to the control group, indicating an improvement in anxiety symptoms (p < 0.0001). Conclusions: The study suggests that virtual reality could have a role in treating anxiety symptoms and disorders in young adults with bipolar disorders or anxiety symptoms in people with hyperactivity and novelty-seeking behaviorsunder stress and high risk for bipolar disorder.

A virtual reality environment for supporting mental wellbeing of students on remote clinical placement: A multi-methods evaluation

BACKGROUND

Nursing and Allied Health Profession (NAHP) students undertake clinical placements as part of their pre-registration training. The remote nature of some placement sites, shiftwork and the emotionally challenging nature of the workload has led to mental wellbeing issues in many students.

AIM

This project aimed to evaluate a novel 3D immersive virtual reality environment that supports mental wellbeing for NAHP students on clinical placement. It comprises a calming 3D tropical beach environment where students and tutors can meet for reflection and mutual support.

DESIGN

A multi-methods design gathered quantitative impact data with validated measurement tools and qualitative output related to the lived experience of students.

SETTINGS AND PARTICIPANTS

All 600 pre-registration NAHP students within the institution undertaking clinical placements were invited to participate, irrespective of mental wellbeing status. Students were randomly assigned to either a VR or Conventional cohort; all participants received the control support mechanism in a subsequent placement.

METHODS

All participants completed an initial demographic and Readiness for Therapy survey followed by weekly Beck Anxiety and Depression Inventories during placement. All participants were invited to a semi-structured interview.

RESULTS

Overall, 32 participants engaged with the application; although the VR cohort demonstrated improved scores on both Beck inventories, these were not statistically significant. This is probably due to the low response rate for the control cohort. A total of 15 interviews were conducted and several themes emerged from the data in relation. to both experiential outcomes (escapism, anonymity and sense of community) and instrumental outcomes (calming, mindfulness and combatting loneliness).

CONCLUSIONS

User feedback indicates that a VR environment can provide a calming escape from the pressures and anxiety arising from clinical placement for healthcare students. The relaxing beach environment facilitated mindfulness meditation and the additional opportunities for pseudo-anonymous interactions with peers and tutors were wellreceived by students.

SAFEvR MentalVeRse.app: Development of a Free Immersive Virtual Reality Exposure Therapy for Acrophobia and Claustrophobia

Background: Specific phobias impact over 400 million people worldwide. Digitalizing mental health could alleviate the burden. Still, although the corporate-driven Metaverse is expanding rapidly, there needs to be more momentum in harnessing virtual reality exposure therapy uptake. Objective: This study aims to conceptualize, develop, and deploy a free Virtual Reality Exposure Therapy (VRET) application specifically designed for treating acrophobia and claustrophobia. This pilot study, which holds the promise of a future where mental health is more accessible and effective, explores the feasibility of leveraging transdisciplinary collaboration among specialists to create a safe, accessible, and effective VRET solution. Methods: We conducted a Delphi heuristic approach involving bioethicists, neuroscientists, and tech developers. Second, we reviewed the existing psychological theories and therapeutic strategies for addressing phobias in VR. Third, we conceptualized a thematic analysis-derived framework for a safe, adaptive-gamified free exposure to virtual reality acrophobia and claustrophobia (SAFEvR ACT). Finally, we provide an overview of the iterative improvements made during 12 workshops and 76 weekly briefings on developmental implementations. Results: We developed the SAFEvR ACT into a proof-of-concept application freely deployed on the MentalVerse app platform. Our safety-focused approach can benefit from prevalidation perspectives within future randomized control trials. Conclusions: The resulting application derived from the SAFEvR ACT framework represents a blueprint to counter the current lack of iVR mental health uptake by offering a free VRET alternative. Future research should aim towards developing similar free platforms to lessen mental health burdens and gather quantitative data. We conclude with a call to action to researchers to fine-tune our current approach and take a stand for free digital mental health within MentalVeRse.app.

Immersive Technologies for Depression Care: Scoping Review

BACKGROUND

Depression significantly impacts quality of life, affecting approximately 280 million people worldwide. However, only 16.5% of those affected receive treatment, indicating a substantial treatment gap. Immersive technologies (IMTs) such as virtual reality (VR) and augmented reality offer new avenues for treating depression by creating immersive environments for therapeutic interventions. Despite their potential, significant gaps exist in the current evidence regarding the design, implementation, and use of IMTs for depression care.

OBJECTIVE

We aim to map the available evidence on IMT interventions targeting depression treatment.

METHODS

This scoping review followed a methodological framework, and we systematically searched databases for studies on IMTs and depression. The focus was on randomized clinical trials involving adults and using IMTs. The selection and charting process involved multiple reviewers to minimize bias.

RESULTS

The search identified 16 peer-reviewed articles, predominantly from Europe (n=10, 63%), with a notable emphasis on Poland (n=9, 56%), which contributed to more than half of the articles. Most of the studies (9/16, 56%) were conducted between 2020 and 2021. Regarding participant demographics, of the 16 articles, 5 (31%) exclusively involved female participants, and 7 (44%) featured participants whose mean or median age was >60 years. Regarding technical aspects, all studies focused on VR, with most using stand-alone VR headsets (14/16, 88%), and interventions typically ranging from 2 to 8 weeks, predominantly in hospital settings (11/16, 69%). Only 2 (13%) of the 16 studies mentioned using a specific VR design framework in planning their interventions. The most frequently used therapeutic approach was Ericksonian psychotherapy, used in 56% (9/16) of the studies. Notably, none of the articles reported using an implementation framework or identified barriers and enablers to implementation.

CONCLUSIONS

This scoping review highlights the growing interest in using IMTs, particularly VR, for depression treatment but emphasizes the need for more inclusive and comprehensive research. Future studies should explore varied therapeutic approaches and cost-effectiveness as well as the inclusion of augmented reality to fully realize the potential of IMTs in mental health care.

Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review

BACKGROUND

Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD.

OBJECTIVE

The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD.

METHODS

The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items.

RESULTS

The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria.

CONCLUSIONS

The findings showed that VR exposure therapy-based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues.

TRIAL REGISTRATION

PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891.

Digitally Assisted Mindfulness in Training Self-Regulation Skills for Sustainable Mental Health: A Systematic Review

The onset of the COVID-19 pandemic has led to an increased demand for mental health interventions, with a special focus on digitally assisted ones. Self-regulation describes a set of meta-skills that enable one to take control over his/her mental health and it is recognized as a vital indicator of well-being. Mindfulness training is a promising training strategy for promoting self-regulation, behavioral change, and mental well-being. A growing body of research outlines that smart technologies are ready to revolutionize the way mental health training programs take place. Artificial intelligence (AI); extended reality (XR) including virtual reality (VR), augmented reality (AR), and mixed reality (MR); as well as the advancements in brain computer interfaces (BCIs) are ready to transform these mental health training programs. Mindfulness-based interventions assisted by smart technologies for mental, emotional, and behavioral regulation seem to be a crucial yet under-investigated issue. The current systematic review paper aims to explore whether and how smart technologies can assist mindfulness training for the development of self-regulation skills among people at risk of mental health issues as well as populations with various clinical characteristics. The PRISMA 2020 methodology was utilized to respond to the objectives and research questions using a total of sixty-six experimental studies that met the inclusion criteria. The results showed that digitally assisted mindfulness interventions supported by smart technologies, including AI-based applications, chatbots, virtual coaches, immersive technologies, and brain-sensing headbands, can effectively assist trainees in developing a wide range of cognitive, emotional, and behavioral self-regulation skills, leading to a greater satisfaction of their psychological needs, and thus mental wellness. These results may provide positive feedback for developing smarter and more inclusive training environments, with a special focus on people with special training needs or disabilities.

Integrating a virtual reality relaxation clinic within acute psychiatric services: A pilot study

People with acute psychiatric conditions experience heightened stress, which is associated with worsened symptoms and increased violence on psychiatric wards. Traditional stress management techniques can be challenging for patients. Virtual reality (VR) relaxation appears promising to reduce stress; however, research on VR for psychiatric wards is limited. This mixed-methods study investigated feasibility and acceptability of integrating a VR relaxation clinic within acute psychiatric services. The study evaluated a VR relaxation session for inpatients and outpatients with acute psychiatric conditions (N = 42) and therapists' (N = 6) experience facilitating VR sessions for patients. Self-report assessments of psychological wellbeing were completed by patients pre- and post-VR. Patients and therapists provided qualitative feedback. The number of violent incidents and restrictive practices on the wards in the 12 weeks before VR implementation was compared to the first 12 weeks of VR. Post-VR, there were statistically significant increases in patients' relaxation, happiness, and connectedness to nature, and decreases in stress, anxiety, and sadness. Qualitative findings indicate patients found sessions enjoyable, relaxing, and helpful. Therapists provided positive feedback but highlighted practical challenges. Violent incidents and restrictive practices halved during VR implementation. VR relaxation appears feasible and acceptable in acute services. Larger studies should evaluate potential impact on psychiatric wards.

Automated virtual reality cognitive therapy versus virtual reality mental relaxation therapy for the treatment of persistent persecutory delusions in patients with psychosis (THRIVE): a parallel-group, single-blind, randomised controlled trial in England with mediation analyses

BACKGROUND

Persecutory delusions are a major psychiatric problem that often do not respond sufficiently to standard pharmacological or psychological treatments. We developed a new brief automated virtual reality (VR) cognitive treatment that has the potential to be used easily in clinical services. We aimed to compare VR cognitive therapy with an alternative VR therapy (mental relaxation), with an emphasis on understanding potential mechanisms of action.

METHODS

THRIVE was a parallel-group, single-blind, randomised controlled trial across four UK National Health Service trusts in England. Participants were included if they were aged 16 years or older, had a persistent (at least 3 months) persecutory delusion held with at least 50% conviction, reported feeling threatened when outside with other people, and had a primary diagnosis from the referring clinical team of a non-affective psychotic disorder. We randomly assigned (1:1) patients to either THRIVE VR cognitive therapy or VR mental relaxation, using a permuted blocks algorithm with randomly varying block size, stratified by severity of delusion. Usual care continued for all participants. Each VR therapy was provided in four sessions over approximately 4 weeks, supported by an assistant psychologist or clinical psychologist. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 2 (therapy mid-point), 4 (primary endpoint, end of treatment), 8, 16, and 24 weeks. The primary outcome was persecutory delusion conviction, assessed by the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. We assessed the treatment credibility and expectancy of the interventions and the two mechanisms (defence behaviours and safety beliefs) that the cognitive intervention was designed to target. This trial is prospectively registered with the ISRCTN registry, ISRCTN12497310.

FINDINGS

From Sept 21, 2018, to May 13, 2021 (with a pause due to COVID-19 pandemic restrictions from March 16, 2020, to Sept 14, 2020), we recruited 80 participants with persistent persecutory delusions (49 [61%] men, 31 [39%] women, with a mean age of 40 years [SD 13, range 18-73], 64 [80%] White, six [8%] Black, one [1%] Indian, three [4%] Pakistani, and six [8%] other race or ethnicity). We randomly assigned 39 (49%) participants assigned to VR cognitive therapy and 41 (51%) participants to VR mental relaxation. 33 (85%) participants who were assigned to VR cognitive therapy attended all four sessions, and 35 (85%) participants assigned to VR mental relaxation attended all four sessions. We found no significant differences between the two VR interventions in participant ratings of treatment credibility (adjusted mean difference -1·55 [95% CI -3·68 to 0·58]; p=0·15) and outcome expectancy (-0·91 [-3·42 to 1·61]; p=0·47). 77 (96%) participants provided follow-up data at the primary timepoint. Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater improvement in persecutory delusions (adjusted mean difference -2·16 [-12·77 to 8·44]; p=0·69). Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater reduction in use of defence behaviours (adjusted mean difference -0·71 [-4·21 to 2·79]; p=0·69) or a greater increase in belief in safety (-5·89 [-16·83 to 5·05]; p=0·29). There were 17 serious adverse events unrelated to the trial (ten events in seven participants in the VR cognitive therapy group and seven events in five participants in the VR mental relaxation group).

INTERPRETATION

The two VR interventions performed similarly, despite the fact that they had been designed to affect different mechanisms. Both interventions had high uptake rates and were associated with large improvements in persecutory delusions but it cannot be determined that the treatments accounted for the change. Immersive technologies hold promise for the treatment of severe mental health problems. However, their use will likely benefit from experimental research on the application of different therapeutic techniques and the effects on a range of potential mechanisms of action.

FUNDING

Medical Research Council Developmental Pathway Funding Scheme and National Institute for Health and Care Research Oxford Health Biomedical Research Centre.

Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic

Background

The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool.

Objective

The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany.

Methods

The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants' home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers.

Results

In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants' sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05).

Conclusion

A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients.

Clinical trial registration

https://clinicaltrials.gov/, DRKS00027911.