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Riches S, Nicholson SL, Fialho C, Little J, Ahmed L, McIntosh H, Kaleva I, Sandford T, Cockburn R, Odoi C, Azevedo L, Vasile R, Payne-Gill J, Fisher HL, van Driel C, Veling W, Valmaggia L, Rumball F. Integrating a virtual reality relaxation clinic within acute psychiatric services: A pilot study. Psychiatry Res 2023; 329:115477. [PMID: 37802013 DOI: 10.1016/j.psychres.2023.115477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 10/08/2023]
Abstract
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.
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Affiliation(s)
- Simon Riches
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; King's College London, Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom.
| | - Sarah L Nicholson
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Carolina Fialho
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom; King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom
| | - Jordan Little
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Lava Ahmed
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Harley McIntosh
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom; King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom
| | - Ina Kaleva
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom; King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom
| | - Tom Sandford
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Rebecca Cockburn
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Clarissa Odoi
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Lisa Azevedo
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Ruxandra Vasile
- The Oxford Institute of Clinical Psychology Training and Research, Oxford Health NHS Foundation Trust and University of Oxford, Isis Education Centre, Warneford Hospital, Oxford OX3 7JX, United Kingdom
| | - James Payne-Gill
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom
| | - Helen L Fisher
- King's College London, Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; ESRC Centre for Society and Mental Health, King's College London, London WC2B 6NR, United Kingdom
| | - Catheleine van Driel
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Groningen, the Netherlands
| | - Wim Veling
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Groningen, the Netherlands
| | - Lucia Valmaggia
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, United Kingdom; KU Leuven, Department of Clinical Psychiatry, Leuven, Belgium
| | - Freya Rumball
- King's College London, Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, London SE5 8AF, United Kingdom; Oxleas Adult Autism Service, Oxleas NHS Foundation Trust, Kent DA2 7WG, United Kingdom
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Freeman D, Lister R, Waite F, Galal U, Yu LM, Lambe S, Beckley A, Bold E, Jenner L, Diamond R, Kirkham M, Twivy E, Causier C, Carr L, Saidel S, Day R, Beacco A, Rovira A, Ivins A, Nah R, Slater M, Clark DM, Rosebrock L. 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. Lancet Psychiatry 2023; 10:836-847. [PMID: 37742702 DOI: 10.1016/s2215-0366(23)00257-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023]
Abstract
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.
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Affiliation(s)
- Daniel Freeman
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK.
| | - Rachel Lister
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Black Country Healthcare NHS Foundation Trust, Dudley, UK
| | - Felicity Waite
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Ushma Galal
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sinéad Lambe
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Ariane Beckley
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Emily Bold
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Lucy Jenner
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Rowan Diamond
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Miriam Kirkham
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Eve Twivy
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Chiara Causier
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Lydia Carr
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Simone Saidel
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Rebecca Day
- Northamptonshire Healthcare NHS Foundation Trust, Kettering, UK
| | - Alejandro Beacco
- Event Lab, Faculty of Psychology Spain, University of Barcelona, Barcelona, Spain; Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Aitor Rovira
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Annabel Ivins
- Northamptonshire Healthcare NHS Foundation Trust, Kettering, UK
| | - Ryan Nah
- Northamptonshire Healthcare NHS Foundation Trust, Kettering, UK; Central and North West London NHS Foundation Trust, London, UK
| | - Mel Slater
- Event Lab, Faculty of Psychology Spain, University of Barcelona, Barcelona, Spain; Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Laina Rosebrock
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
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Application of Immersive Virtual Reality for Assessment and Intervention in Psychosis: A Systematic Review. Brain Sci 2023; 13:brainsci13030471. [PMID: 36979281 PMCID: PMC10046161 DOI: 10.3390/brainsci13030471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
Virtual reality (VR) has emerged as a safe and non-invasive technology for the assessment of psychotic symptoms, social and cognitive impairments, and psychosocial intervention in improving outcomes in psychosis. This study systematically reviewed the current state of evidence in applying semi- and fully immersive VR for assessing and treating patients with psychosis. A systematic review was conducted adhering to the PRISMA statement and was conducted in Embase, PsycINFO, and PubMed databases for articles published between January 2013 and April 2022, which identified 28 eligible studies, including 12 for assessment and 16 for intervention. In the assessment studies, not all VR tasks could distinguish the differences between patients and healthy controls regarding their physiological responses, paranoid ideation, and certain aspects of cognitive functioning such as memory bias on the object tasks. Comparatively, VR-based interventions are more promising, especially for improving cognitive impairments, social skills, agoraphobic avoidance, negative and positive affective states, auditory verbal hallucination, paranoid ideation and persecutory delusions, and other psychiatric symptoms in patients. We conclude that more rigorous studies are needed to confirm treatment effectiveness and to understand the underlying mechanism of VR-based intervention for psychotic disorders. Future studies should also improve the reliability and validity of VR-based assessments for psychotic disorders.
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Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, Blumenthal N, Li M, Asché L, Jonas S, Bey K, Schulze M, Steffens M, Pensel MC, Guth M, Rohlfsen F, Ekhlas M, Lügering H, Fileccia H, Pakos J, Lux S, Philipsen A, Braun N. Virtual reality in the diagnostic and therapy for mental disorders: A systematic review. Clin Psychol Rev 2022; 98:102213. [PMID: 36356351 DOI: 10.1016/j.cpr.2022.102213] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 08/21/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. OBJECTIVE To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. DATA SOURCE Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. ELIGIBILITY CRITERIA To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. STUDY EVALUATION For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. RESULTS Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. CONCLUSION While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. REVIEW REGISTRATION PROSPERO register CRD42020188436. FUNDING The review was funded by budgets from the University of Bonn. No third party funding was involved.
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Affiliation(s)
- Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Ann-Kathrin Thöne
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pramme
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Nike Blumenthal
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mengtong Li
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Laura Asché
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Katharina Bey
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Maria Steffens
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Max Christian Pensel
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Matthias Guth
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Felicia Rohlfsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mogda Ekhlas
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Lügering
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Fileccia
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julian Pakos
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
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