A Randomized, Controlled Trial of Virtual Reality-Graded Exposure Therapy for Post-Traumatic Stress Disorder in Active Duty Service Members with Combat-Related Post-Traumatic Stress Disorder

Ethical Challenges of Virtual Reality Technology Interventions for the Vulnerabilities of Patients With Chronic Pain: Exploration of Technician Responsibility

Chronic pain, a common disease, is a crucial global public health concern. Approximately 20% of the worldwide population is affected by chronic pain, which accounts for 15% to 20% of hospital visits. In Canada, approximately 7.6 million people-or 1 in 5 people-experience chronic pain. Among this population, 60% has either lost their employment or experienced a reduction in income as a result of their pain. The proportion of older people (aged ≥65 years) with chronic pain is high, comprising one-third of the total older population. In addition, the causes of chronic pain and its cures are unknown, and treatment is limited by these unknowns and the dangers of opioids. These essential factors make patients with chronic pain one of the most vulnerable populations. The use of emerging virtual reality (VR) technology as an intervention for chronic pain has consistently demonstrated early effectiveness and has been termed as a "nonpharmacological analgesic." Nevertheless, we must remain vigilant about the potential ethical risks of VR interventions, as inappropriate VR interventions may exacerbate the vulnerabilities of patients. Currently, a central challenge for VR developers is the ambiguity of patient vulnerability and the unpredictability of ethical dilemmas. Therefore, our paper focused on the vulnerability and ethical dilemmas faced by patients with chronic pain in VR interventions. Through an experience-based, prospective ethical examination, we have identified both existing and potential new vulnerabilities and specific manifestations that patients with chronic pain may encounter in VR interventions. Our aim was to highlight the ethical risks that may be present in VR interventions. On one hand, this can help raise awareness among technology developers regarding the vulnerabilities of patients with chronic pain and mitigate technological ethical risks. In addition, it can assist technology developers in determining the priorities for VR technology interventions. These efforts collectively lay a solid foundation for the comprehensive realization of responsible VR technology interventions.

Virtual reality interventions for the treatment of anxiety disorders: A scoping review

BACKGROUND

& Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults.

METHODS

This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses.

RESULTS

The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans.

LIMITATIONS

Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded.

CONCLUSION

VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.

Review of Psychophysiological and Psychotherapeutic Studies of Stress Using Virtual Reality Technologies

This review addresses the use of virtual reality technologies in the psychophysiology and psychotherapy of stress. Studies using virtual reality both to introduce subjects into a state of stress and to help reduce stress reactions are reviewed. Methods developed for treating patients suffering from stress-related disorders (in particular, PTSD and phobias) are described. In many cases, reductions in stress reactions with the help of virtual reality systems are achieved not only at the self-report (experiential) level, but also at the level of central and peripheral nervous system measures. This allows virtual reality to be regarded as a modern, inexpensive, and effective method, firstly, for introducing subjects into a state of stress with the aim of testing various hypotheses in psychophysiology and, secondly, to reduce stress reactions.

Sensory sensitivity after acquired brain injury: A systematic review

Patients with acquired brain injury frequently report experiencing sensory stimuli as abnormally under- (sensory hyposensitivity) or overwhelming (sensory hypersensitivity). Although they can negatively impact daily functioning, these symptoms are poorly understood. To provide an overview of the current evidence on atypical sensory sensitivity after acquired brain injury, we conducted a systematic literature review. The primary aim of the review was to investigate the behavioural and neural mechanisms that are associated with self-reported sensory sensitivity. Studies were included when they studied sensory sensitivity in acquired brain injury populations, and excluded when they were not written in English, consisted of non-empirical research, did not study human subjects, studied pain, related sensory sensitivity to peripheral injury or studied patients with a neurodegenerative disorder, meningitis, encephalitis or a brain tumour. The Web of Science, PubMed and Scopus databases were searched for appropriate studies. A qualitative synthesis of the results of the 81 studies that were included suggests that abnormal sensory thresholds and a reduced information processing speed are candidate behavioural mechanisms of atypical subjective sensory sensitivity after acquired brain injury. Furthermore, there was evidence for an association between subjective sensory sensitivity and structural grey or white matter abnormalities, and to functional abnormalities in sensory cortices. However, further research is needed to explore the causation of atypical sensory sensitivity. In addition, there is a need for the development of adequate diagnostic tools. This can significantly advance the quantity and quality of research on the prevalence, aetiology, prognosis and treatment of these symptoms.

Extinction-Based Exposure Therapies Using Virtual Reality

The focus of this chapter is an overview of integrating virtual reality (VR) technology within the context of exposure therapy for anxiety disorders, a gold standard treatment, with a focus on how VR can help facilitate extinction learning processes integral to these interventions. The chapter will include an overview of advantages of incorporating VR within exposure therapy, and benefits specifically within an inhibitory learning approach for extinction training. A review of the empirical literature on the effectiveness of VR exposure therapy for specific phobia and PTSD will be provided, as well as practical overview of how to effectively incorporate VR within exposure therapy.

A data-centric artificial intelligent and extended reality technology in smart healthcare systems

Extended reality (XR) solutions are quietly maturing, and their novel use cases are already being investigated, particularly in the healthcare industry. By 2022, the extended reality market is anticipated to be worth $209 billion. Certain diseases, such as Alzheimer's, Schizophrenia, Stroke rehabilitation stimulating specific areas of the patient's brain, healing brain injuries, surgeon training, realistic 3D visualization, touch-free interfaces, and teaching social skills to children with autism, have shown promising results with XR-assisted treatments. Similar effects have been used in video game therapies like Akili Interactive's EndeavorRx, which has previously been approved by the Food and Drug Administration (FDA) as a treatment regimen for children with attention deficit hyperactivity disorder (ADHD). However, while these improvements have received positive feedback, the field of XR-assisted patient treatment is in its infancy. The growth of XR in the healthcare sphere has the potential to transform the delivery of medical services. Imagine an elderly patient in a remote setting having a consultation with a world-renowned expert without ever having to leave their house. Rather than operating on cadavers in a medical facility, a surgical resident does surgery in a virtual setting at home. On the first try, a nurse uses a vein finder to implant an IV. Through cognitive treatment in a virtual world, a war veteran recovers from post-traumatic stress disorder (PTSD). The paper discusses the potential impact of XR in transforming the healthcare industry, as well as its use cases, challenges, XR tools and techniques for intelligent health care, recent developments of XR in intelligent healthcare services, and the potential benefits and future aspects of XR techniques in the medical domain.

Effects of Virtual Reality-Based Graded Exposure Therapy on PTSD Symptoms: A Systematic Review and Meta-Analysis

Previous studies reported that virtual reality (VR)-based exposure therapy (VRET) was a clinically beneficial intervention for specific phobias. However, among VRET, VR-based graded exposure therapy (VR-GET) is little known about its efficacy on posttraumatic stress disorder (PTSD) symptoms. Therefore, this meta-analysis investigated the effects of VR-GET for PTSD symptoms. A literature search yielded seven randomized controlled trials. The differences between conditions regarding the primary outcome of PTSD symptoms in the effect size of the individual study were calculated using Hedges' g. The findings showed VR-GET showed a significantly larger effect size for PTSD symptoms (g = 1.100, p = 0.001), compared to controls. However, no significant difference between conventional VRET and controls was found for PTSD symptoms (g = -0.279, p = 0.970). These findings indicated the superiority of VR-GET for PTSD symptoms compared to controls, supporting the importance of immersive PTSD treatments. Nevertheless, the results need to be interpreted with caution due to the substantial number of military service personnel studies. Future trials, considering individually tailored scenarios in virtual environments to cover a wider range of trauma types, are required to investigate its evidence on treating PTSD.

Virtual Reality in Treatment for Psychological Problems in First-Line Health Care Professionals Fighting COVID-19 Pandemic: A Case Series

ABSTRACT

Virtual reality therapy (VRT) is a new psychotherapeutic approach integrating virtual reality technology and psychotherapy. This case series aimed to study effectiveness of VRT in treating psychological problems. We described four cases of first-line health care professionals with emerging clinically significant early psychological problems during the COVID-19 outbreak, and specifically received the VRT treatment. We compared the Patient Health Questionnaire 9 items (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), PHQ-15, and Athens Insomnia Scale to evaluate psychological symptoms and sleep quality before and after sessions. All four cases showed a reduction in scale comparison. General scores of the PHQ-9 reduced 65%, GAD-7 reduced 52.17%, PHQ-15 decreased 38.17%, and scores of the Athens Insomnia Scale reduced 67.44%. Meanwhile, a reduction in depression, anxiety, psychosomatic, and sleeping symptoms was also found, which decreased 76.92% in general. These results are highly significant statistically. This case series demonstrated the effectiveness of VRT on psychological problems as a promising approach to apply on various psychological distress and disorders.

Exposure therapy for PTSD in military populations: A systematic review and meta-analysis of randomized clinical trials

Military populations are disproportionally affected by posttraumatic stress disorder (PTSD) and may experience less benefit from first line psychotherapies for PTSD relative to civilians. We examined the efficacy of exposure therapy among Veterans and active duty military personnel across various control conditions and tested potential treatment-related, demographic, and clinical moderators. Randomized controlled trials of exposure-based therapies for PTSD in military populations were identified from a recent meta-analysis and through PsycINFO and Medline. Nineteen studies met inclusion criteria and were included in the meta-analysis (total N = 2905). Exposure therapy had medium to large effects compared to waitlist and treatment as usual, a small effect compared to non-trauma-focused therapy, and no effect relative to other trauma-focused therapy. The overall effect was similar at post-treatment and follow up. The effect size for exposure was larger in studies with younger participants, more women, fewer participants with comorbid major depression, and fewer participants taking psychiatric medication. Effect sizes were not impacted by treatment length or type, participant race or ethnicity, comorbid substance use, Veteran versus active duty status, or study risk of bias. Findings document the variable efficacy of exposure therapy in military populations across comparator types and point to several potentially important moderators of outcome that should be examined in future research.

Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology

Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.

Protocol for individual participant data meta-analysis of interventions for post-traumatic stress

INTRODUCTION

Several evidence-based treatments are effective for post-traumatic stress disorder (PTSD), yet a substantial proportion of patients do not respond or dropout of treatment. We describe the protocol for a systematic review and individual participant data meta-analysis (IPD-MA) aimed at assessing the effectiveness and adverse effects of psychotherapy and pharmacotherapy interventions for treating PTSD. Additionally, we seek to examine moderators and predictors of treatment outcomes.

METHOD AND ANALYSIS

This IPD-MA includes randomised controlled trials comparing psychotherapy and pharmacotherapy interventions for PTSD. PubMed, Embase, PsycINFO, PTSDpubs and CENTRAL will be screened up till the 11th of January 2021. The target population is adults with above-threshold baseline PTSD symptoms on any standardised self-report measure. Trials will only be eligible if at least 70% of the study sample have been diagnosed with PTSD by means of a structured clinical interview. The primary outcomes of this IPD-MA are PTSD symptom severity, and response rate. Secondary outcomes include treatment dropout and adverse effects. Two independent reviewers will screen major bibliographic databases and past reviews. Authors will be contacted to contribute their participant-level datasets. Datasets will be merged into a master dataset. A one-stage IPD-MA will be conducted focusing on the effects of psychological and pharmacological interventions on PTSD symptom severity, response rate, treatment dropout and adverse effects. Subsequent analyses will focus on examining the effect of moderators and predictors of treatment outcomes. These will include sociodemographic, treatment-related, symptom-related, resilience, intervention, trauma and combat-related characteristics. By determining the individual factors that influence the effectiveness of specific PTSD treatments, we will gain insight into personalised treatment options for PTSD.

ETHICS AND DISSEMINATION

Specific ethics approval for an IPD-MA is not required as this study entails secondary analysis of existing anonymised data. The results of this study will be published in peer-reviewed scientific journals and presentations.

The Effectiveness of Virtual Reality Exposure-Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis

BACKGROUND

In recent years, virtual reality exposure-based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders.

OBJECTIVE

The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared.

METHODS

Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions.

RESULTS

A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (n_co=10) was medium and significant, favoring VRE-CBT (Hedges g=-0.490, 95% CI -0.82 to -0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (n_co=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95% CI -0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (n_co=10) showed no significant difference (odds ratio 0.79, 95% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias.

CONCLUSIONS

The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Virtual Reality Exposure Therapy for Armed Forces Veterans with Post-Traumatic Stress Disorder: A Systematic Review and Focus Group

Virtual reality exposure therapy (VRET) is an emerging treatment for people diagnosed with Post-Traumatic Stress Disorder (PTSD) due to the limited accessibility of psychotherapies. This research aims to determine the guidelines for developing a Virtual Reality–War Scenario program for Armed Forces veterans with PTSD and encompasses two studies: Study 1, a systematic electronic database review; Study 2, a focus group of twenty-two Portuguese Armed Forces veterans. Results showed a positive impact of VRET on PTSD; however, there were no group differences in most of the studies. Further, according to veterans, new VRET programs should be combined with the traditional therapy and must consider as requirements the sense of presence, dynamic scenarios, realistic feeling, and multisensorial experience. Regardless, these findings suggest VRET as a co-creation process, which requires more controlled, personalized, and in-depth research on its clinical applicability.

Are Australian Mental Health Services Ready for Therapeutic Virtual Reality? An Investigation of Knowledge, Attitudes, Implementation Barriers and Enablers

Therapeutic virtual reality (VR) has the potential to address the challenges of equitable delivery of evidence-based psychological treatment. However, little is known about therapeutic VR regarding the perspectives and needs of real-world service providers. This exploratory study aimed to assess the acceptability, appropriateness, and feasibility of therapeutic VR among clinicians, managers, and service staff working in mental healthcare and explore potential implementation barriers and enablers. Eighty-one staff from a network of private psychiatric hospitals in Victoria, Australia (aged M + SD: 41.88 + 12.01 years, 71.6% female; 64% clinical staff) completed an online survey, which included the Acceptability of Intervention Measure (AIM), Appropriateness of Intervention Measure (IAM), and Feasibility of Intervention Measure (FIM). While 91% of participants had heard about VR technology, only 40% of participants had heard of therapeutic VR being used in mental healthcare, and none had used therapeutic VR in a clinical setting. Most participants perceived VR to be acceptable (84%), appropriate (69%), and feasible (59%) to implement within their role or service and envisioned a range of possible applications. However, participants expressed concerns regarding safety, efficacy, and logistical challenges across clinical settings. Findings suggest a strong interest for therapeutic VR among Australian mental health providers working in the private system. However, dissemination efforts should focus on addressing identified barriers to ensure mental health providers are adequately informed and empowered to make implementation decisions.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

Combat-Related Post-traumatic Stress Disorder: A Case Report of Virtual Reality Graded Exposure Therapy With Physiological Monitoring in a U.S. Navy Officer and a U.S. Army Officer

The U.S. Department of Defense (DoD) and the Department of Veterans Affairs (DVA) seek to enhance the efficacy of treatments for warriors with post-traumatic stress disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy (VR-GET) with arousal control has shown particular promise in reducing the symptom severity of PTSD in combat veterans. In this report, we describe the outcome of VR-GET for the treatment of combat-related PTSD in two combat veterans, neither of whom had received treatment for PTSD in the initial years after their return from combat duty.

Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy

BACKGROUND

Virtual reality exposure therapy (VRET) and augmented reality exposure therapy (ARET) are digitally assisted psychotherapies that potentially enhance posttraumatic stress disorder (PTSD) treatment by increasing a patient's sense of presence during exposure therapy. This study aimed to systematically review current evidence regarding the efficacy of VRET and ARET as PTSD treatment.

METHODS

A systematic electronic database search, a systematic quality assessment and two meta-analyses were conducted in accordance with PRISMA guidelines.

RESULTS

Eleven studies on the efficacy of VRET for PTSD (n = 438) were found, but no studies on the efficacy of ARET. The majority of VRET studies were of a low quality and had heterogeneous results. Meta-analyses showed VRET outperformed waitlist control (standardized mean difference -0.64 (95% CI -1.05 to -0.22)) while no significant difference was found between VRET and active treatment conditions (standardized mean difference -0.25 (95% CI -0.77 to 0.27)).

CONCLUSION

VRET was superior to waitlist control groups and as effective as other psychotherapies. However, the results showed considerable heterogeneity due to the low number of studies and variety of VRET methods. VRET may be an effective alternative to current treatments and shows promise for the treatment of PTSD patients that have not responded to previous treatment. Future research should focus on high quality RCTs, including information on side effects and adverse events, with sufficient numbers of participants. This study recognizes a research gap regarding the efficacy of ARET, while it may have potential for PTSD treatment.

Virtual Reality for the Treatment of Anxiety Disorders: A Scoping Review

IMPORTANCE

Virtual reality in head-mounted displays (HMD-VR) may be a valuable tool in occupational therapy to address anxiety. Findings from the virtual reality exposure therapy (VRET) literature may facilitate translation of HMD-VR to occupational therapy psychosocial practice.

OBJECTIVE

To explore how HMD-VR has been used to treat anxiety through VRET and could be translated to occupational therapy.

DATA SOURCES

We searched seven electronic databases for articles published between 2000 and 2020: CINAHL, Cochrane Library, Embase, ERIC, Ovid MEDLINE, PsycINFO, and Web of Science. Search terms included HMD-VR constructs, products, and therapy concepts. Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report studies implementing VRET to treat anxiety. At least two reviewers assessed each citation, and a third resolved disagreements. Articles were included if they were in English, reported experimental data, and used HMD-VR. Letters, commentaries, book chapters, technical descriptions, theoretical papers, conference proceedings (≤4 pages), and reviews were excluded.

FINDINGS

Twenty-eight studies used HMD-VR to treat posttraumatic stress disorder (n = 3), specific phobias (n = 19), and performance-based social anxiety (n = 6); protocols and levels of evidence varied (randomized controlled trials, n = 11; controlled trials without randomization, n = 6; case-control or cohort studies, n = 11). Qualitative examination indicates HMD-VR is an effective treatment tool.

CONCLUSIONS AND RELEVANCE

HMD-VR can be a valuable tool for occupational therapy to simulate environments where clients with anxiety disorders participate. Eliciting presence through multisensory features and body representation may enhance outcomes. What This Article Adds: Drawing from the VRET literature, this scoping review suggests that HMD-VR can be used by occupational therapy practitioners to simulate ecologically valid environments, evaluate client responses to fearful stimuli, and remediate anxiety though immersion in virtual tasks when participation in natural contexts is unfeasible. Having ecologically valid environments is particularly important for people with anxiety disorders because they need support to cope when they encounter triggers in everyday life environments.

Integrating virtual realities and psychotherapy: SWOT analysis on VR and MR based treatments of anxiety and stress-related disorders

The use of virtual reality (VR) and mixed reality (MR) technology in clinical psychology is growing. Efficacious VR-based treatments for a variety of disorders have been developed. However, the field of technology-assisted psychotherapy is constantly changing with the advancement in technology. Factors such as interdisciplinary collaboration, consumer familiarity and adoption of VR products, and progress in clinical science all need to be taken into consideration when integrating virtual technologies into psychotherapies. We aim to present an overview of current expert opinions on the use of virtual technologies in the treatment of anxiety and stress-related disorders. An anonymous survey was distributed to a select group of researchers and clinicians, using an analytic framework known as Strengths, Weaknesses, Opportunities, and Threats (SWOT). Overall, the respondents had an optimistic outlook regarding the current use as well as future development and implementation of technology-assisted interventions. VR and MR psychotherapies offer distinct advantages that can overcome shortcomings associated with traditional therapy. The respondents acknowledged and discussed current limitations of VR and MR psychotherapies. They recommended consolidation of existing knowledge and encouraged standardisation in both theory and practice. Continued research is needed to leverage the strengths of VR and MR to develop better treatments.Abbreviations: AR: Augmented Reality; MR: Mixed Reality; RCT: Randomised Controlled Trial; SWOT: Strengths, Weaknesses, Opportunities, and Threats; VR: Virtual Reality; VR-EBT: Virtual Reality Exposure-Based Therapy.

Clinical predictors of cybersickness in virtual reality (VR) among highly stressed people

The use of virtual reality (VR) in the treatment of psychiatric disorders is increasing, and cybersickness has emerged as an important obstacle to overcome. However, the clinical factors affecting cybersickness are still not well understood. In this study, we investigated clinical predictors and adaptation effect of cybersickness during VR application in highly stressed people. Eighty-three healthy adult participants with high stress level were recruited. At baseline, we conducted psychiatric, ophthalmologic, and otologic evaluations and extracted physiological parameters. We divided the participants into two groups according to the order of exposure to VR videos with different degrees of shaking and repetitively administered the Simulator Sickness Questionnaire (SSQ) and the Fast Motion sickness Scale (FMS). There was no significant difference in changes in the SSQ or the FMS between groups. The 40–59 years age group showed a greater increase in FMS compared to the 19–39 years age group. Smoking was negatively associated with cybersickness, and a high Positive Affect and Negative Affect Schedule score was positively associated with cybersickness. In conclusion, changing the intensity of shaking in VR did not affect cybersickness. While smoking was a protective factor, more expression of affect was a risk factor for cybersickness.

The use of virtual reality in assessment and treatment of anxiety and related disorders

In recent years the development of new virtual environments has been qualitatively high and fast at the same time, but the dissemination of virtual reality (VR) in clinical practice is still scarce. The aim of this review is to give an insight into the state of the art of the use of VR as an assessment tool and treatment intervention in anxiety and related disorders as posttraumatic stress disorder and obsessive-compulsive disorders. Besides an overview into the efficacy of VR, a summary will be given on assumed working mechanisms in virtual reality exposure therapy and how this aligns with current theoretical models. Further, it will be discussed how VR is accepted by patients and research into the reluctance of therapist to use this technology during treatment with focus on the therapeutic alliance and how it may be influenced by the use of VR. Finally, we discuss clinical and future issues as, for example, dissemination into clinical practice and what VR has to offer therapists in future. This not only in adult population but as well in younger patients, as young adolescents VR has a great potential as it connects easily with its playful elements to this population and might be a low threshold step to offer treatment or preventive interventions.

Effect of Virtual Reality on Stress Reduction and Change of Physiological Parameters Including Heart Rate Variability in People With High Stress: An Open Randomized Crossover Trial

Introduction: Although, attempts to apply virtual reality (VR) in mental healthcare are rapidly increasing, it is still unclear whether VR relaxation can reduce stress more than conventional biofeedback. Methods: Participants consisted of 83 healthy adult volunteers with high stress, which was defined as a score of 20 or more on the Perceived Stress Scale-10 (PSS-10). This study used an open, randomized, crossover design with baseline, stress, and relaxation phases. During the stress phase, participants experienced an intentionally generated shaking VR and serial-7 subtraction. For the relaxation phase, participants underwent a randomly assigned relaxation session on day 1 among VR relaxation and biofeedack, and the other type of relaxation session was applied on day 2. We compared the State-Trait Anxiety Inventory-X1 (STAI-X1), STAI-X2, the Numeric Rating Scale (NRS), and physiological parameters including heart rate variability (HRV) indexes in the stress and relaxation phases. Results: A total of 74 participants were included in the analyses. The median age of participants was 39 years, STAI-X1 was 47.27 (SD = 9.92), and NRS was 55.51 (SD = 24.48) at baseline. VR and biofeedback significantly decreased STAI-X1 and NRS from the stress phase to the relaxation phase, while the difference of effect between VR and biofeedback was not significant. However, there was a significant difference in electromyography, LF/HF ratio, LF total, and NN50 between VR relaxation and biofeedback. Conclusion: VR relaxation was effective in reducing subjectively reported stress in individuals with high stress.

Ethical Issues with Simulating the Bridge Problem in VR

We aim to generate a dilemma for virtual reality-based research that we motivate through an extended case study of Thomson's (Yale Law J 94(6):1395-1415, 1985) Bridge variant of the trolley problem. Though the problem we generate applies more broadly than the Bridge problem, we believe it makes a good exemplar of the kind of case we believe is problematic. First, we argue that simulations of these thought experiments run into a practicality horn that makes it practically impossible to produce them. These problems revolve around concepts that we call "perspectival fidelity" and "context realism." Moral dilemmas that include features present in the Bridge variant will, as a result, be practically impossible to simulate. We also argue that, should we be wrong about the practical impossibility of creating a VR simulation of Bridge, such a simulation must face an ethical horn which renders these simulations ethically impermissible to develop or use. For these reasons, we argue that it is virtually impossible to simulate the bridge problem (and other thought experiments with similar features) both practically and ethically in VR.

Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review

Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Cognitive behavioural therapy in virtual reality treatments across mental health conditions: a systematic review

Background

Virtual reality (VR) has been effectively used in the treatment of many mental health disorders.However, significant gaps exist in the literature. There is no treatment framework for researchers to use when developing new VR treatments. One recommended treatment across a range of diagnoses, which may be suitable for use in VR treatments, is Cognitive Behavioural Therapy (CBT). The aim of this systematic review is to investigateCBT treatment methods that utilize VR to treat mental health disorders.

Objectives

To investigate how CBT has been used in VR to treat mental health disorders and to report onthe treatment characteristics (number of sessions, duration, and frequency) that are linked to effective and ineffective trials.

Methods

Studies were included if patients had a mental health diagnosis and their treatment included immersiveVR technology and CBT principles. Data were extracted in relation to treatment characteristics and outcomes,and analysed using narrative synthesis.

Results

Ninety-three studies were analysed. Exposure-based VR treatments were mainly used to treat anxiety related disorders. Treatments generally consisted of eight sessions, once a week for approximately one hour. VR treatments were commonly equal to or more effective than traditional face-to-face methods. No specific treatment characteristics were linked to this effectiveness.

Conclusion

The number, frequency and duration of the VR treatment sessions identified in this review, could be used as a treatment framework by researchers and clinicians. This could potentially save researchers time and money when developing new interventions.

Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis

BACKGROUND

Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events.

METHODS AND FINDINGS

We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis.

CONCLUSIONS

In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.

A systematic review of factors associated with outcome of psychological treatments for post-traumatic stress disorder

OBJECTIVE

Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap.

METHOD

We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission.

RESULTS

Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome.

CONCLUSION

Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials.

Message Delivery for the Treatment of Posttraumatic Stress Disorder: Longitudinal Observational Study of Symptom Trajectories

Background

Individuals with posttraumatic stress disorder (PTSD) face symptoms that can hinder access to treatment, such as avoidance and guilt. Telemedicine offers a technological solution to increase access to mental health care and overcome barriers to treatment. Although an increasing body of literature focused on synchronous telehealth (eg, live video), no studies have examined the delivery of PTSD treatment via two-way multimedia messages (ie, texting or messaging).

Objective

The aim of this study was to conduct a longitudinal observation of treatment for PTSD delivered using two-way asynchronous messaging. We also sought to identify individual and treatment characteristics that could predict the observed outcome differences.

Methods

Outpatients diagnosed with PTSD (N=475) received interventions from licensed therapists, which were delivered via messaging once or more than once per day, 5 days a week for 12 weeks. PTSD symptoms were assessed every 3 weeks using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Trajectories of PTSD symptoms were identified using growth mixture modeling (GMM). Using logistic regression, the demographic, treatment, and messaging characteristics of patient groups that improved were compared with the characteristics of patient groups that did not improve.

Results

The GMM identified 4 trajectories of PTSD symptoms: moderate improvement (197/475, 41.4%), high symptoms (197/475, 41.4%), chronic symptoms (61/475, 12.9%), and acute improvement (20/475, 4.3%). Patients with a clinically significant reduction in PTSD symptoms (231/475, 48.6%) were more likely to communicate via video (odds ratio [OR] 1.01, 95% CI 1.01-1.05; P=.03), have a higher working alliance with their therapist (OR 1.03, 95% CI 1.01-1.05; P=.02), and be at their first treatment experience (OR 2.03, 95% CI 1.18-3.54; P=.01). Treatment adherence was associated with greater therapeutic alliance (OR 1.07, 95% CI 1.03-1.10; P<.001), education (OR 2.13, 95% CI 1.13-4.03; P=.02), and more patient-generated messages per week (OR 1.08, 95% CI 1.04-1.13; P<.001).

Conclusions

Multimedia message delivery for PTSD treatment showed symptom-reduction rates similar to traditional forms of treatment delivery, suggesting further study of messaging as a treatment medium. Most patients completed an 8-week course, reflecting the acceptability of messaging interventions. Delivering treatment via two-way messaging offers increased opportunities for widespread access to mental health care.

Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis

Background: Psychological therapies are the recommended first-line treatment for post-traumatic stress disorder (PTSD). Previous systematic reviews have grouped theoretically similar interventions to determine differences between broadly distinct approaches. Consequently, we know little regarding the relative efficacy of the specific manualized therapies commonly applied to the treatment of PTSD. Objective: To determine the effect sizes of manualized therapies for PTSD. Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: 114 randomized-controlled trials (RCTs) of 8171 participants were included. There was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T), as well as Eye Movement Desensitization and Reprocessing (EMDR), had a clinically important effect. The manualized CBT-Ts with the strongest evidence of effect were Cognitive Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus; guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging evidence for a number of other therapies. Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBT-Ts considered by the review CPT, CT and PE should be the treatments of choice. The findings should guide evidence informed shared decision-making between patient and clinician.

Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

Impact of Fire Arms Training in a Virtual Reality Environment on Occupational Performance (Marksmanship) in a Polytrauma Population

INTRODUCTION

Polytrauma, to include major limb amputation, in a military population presents unique rehabilitation challenges with the overarching goal of restoring function leading to the primary question, "Is this Service Member (SM) capable of returning to duty following rehabilitation?" The US military has a vested interest in maximizing injured SMs occupational performance to allow for return to duty. The purpose of this report is to describe marksmanship (shot grouping and weapon qualification) and return to duty outcomes following a course of VRE-based firearm training in a polytrauma patient population.

METHODS

The medical records, stored in the Armed Forces Health Longitudinal Technology Application (AHLTA), of all patients who received rehabilitative care at the Center for the Intrepid (CFI) to include VRE-based firearms training between 01OCT2015 and 01AUG2016 were manually reviewed for inclusion. Subjects included all adult (18 years and older) SMs (active duty at time of admission) with a diagnosis of polytrauma who had been referred to and treated (received additional services such as physical and or occupational therapy) at the CFI. Approval for this research was received from the Brooke Army Medical Center Department of Clinical Investigation Office of the Institutional Review Board.

RESULTS

Medical records of 30 SMs with a polytrauma diagnosis met the inclusion criteria. Mean shot group sizes for the M9 and M4 weapon decreased between initial and post training time points for the M9 zero (p = 0.009) and M4 zero (p = 0.020). There was no significant difference between initial and post training time points at the other shooting distances with either weapon. There was an 89% qualification rate for both the M9 (n = 18) and M4 (n = 19) weapons for those who attempted qualification; 43% of the population (n = 13) did not attempt qualification with either weapon.

CONCLUSION

SMs with polytrauma demonstrated a high rate of weapon qualification (accuracy) following VRE-based firearm training. Shot group size (precision) at short distances with a M9 pistol and M4 rifle also improved with training. While overall marksmanship appeared to improve, high return to duty rates were not directly related to firearm training or marksmanship. Future efforts need to focus on consistent clinical documentation of firearm training procedure and the establishment of psychometric properties for marksmanship outcome measures.

The efficacy of virtual reality exposure therapy for PTSD symptoms: A systematic review and meta-analysis

BACKGROUND

Virtual reality exposure therapy (VRET) for PTSD is an emerging treatment of remarkable promise, but its efficacy and safety are still unclear. Our aim was to investigate the efficacy of VRET for individuals with PTSD, and to identify the potential moderating variables associated with interventions.

METHODS

Literature search was conducted via PubMed, Embase, Web of Science, Cochrane Library, PsycInfo, Science Direct, and EBSCO. We identified 18 studies on PTSD including 13 randomized controlled trials (RCTs; 654 participants) and 5 single-group trials (60 participants).

RESULTS

The main effects analysis showed a moderate effect size (g = 0.327, 95% CI: 0.105-0.550, p<0.01) for VRET compared to control conditions on PTSD symptoms. Subgroup analysis revealed that the effects of VRET were larger when compared to inactive groups (g = 0.567) than active control groups (g = 0.017). This finding was in agreement with depressive symptoms. A dose-response relationship existed with more VRET sessions showing larger effects. There was a long-range effect of VRET on PTSD symptoms indicating a sustained decrease in PTSD symptoms at 3-month follow-up (g = 0.697) and 6-month follow-up (g = 0.848). The single-group trials analysis revealed that the VRET intervention had a significant effect on PTSD.

LIMITATIONS

Many of the combat-related PTSD subjects resulted in uncertainty regarding meta-analytical estimates and subsequent conclusions.

CONCLUSIONS

These findings demonstrated that VRET could produce significant PTSD symptoms reduction and supported its application in treating PTSD.

Virtual Reality Support for Joint Attention Using the Floreo Joint Attention Module: Usability and Feasibility Pilot Study

BACKGROUND

Advances in virtual reality (VR) technology offer new opportunities to design supports for the core behaviors associated with autism spectrum disorder (ASD) that promote progress toward optimal outcomes. Floreo has developed a novel mobile VR platform that pairs a user receiving instruction on target skills with an adult monitor.

OBJECTIVE

The primary objective of this pilot study was to explore the feasibility of using Floreo's Joint Attention Module in school-aged children with autism in a special education setting. A secondary objective was to explore a novel joint attention measure designed for use with school-aged children and to observe whether there was a suggestion of change in joint attention skills from preintervention to postintervention.

METHODS

A total of 12 participants (age range: 9 to 16 years) received training with the Joint Attention Module for 14 sessions over 5 weeks.

RESULTS

No serious side effects were reported, and no participants dropped out of the study because of undesirable side effects. On the basis of monitor data, 95.4% (126/132) of the time participants tolerated the headset, 95.4% (126/132) of the time participants seemed to enjoy using Floreo's platform, and 95.5% (128/134) of the time the VR experience was reported as valuable. In addition, scoring of the joint attention measure suggested a positive change in participant skills related to the total number of interactions, use of eye contact, and initiation of interactions.

CONCLUSIONS

The study results suggest that Floreo's Joint Attention Module is safe and well tolerated by students with ASD, and preliminary data also suggest that its use is related to improvements in fundamental joint attention skills.

Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): a meta-analysis

Contrary to specific phobias, for which Virtual Reality Exposure Therapy (VRET) constitutes an effective treatment, uncertainty still exists regarding the usefulness of VRET for posttraumatic stress disorder (PTSD). Therefore, this meta-analysis investigated the efficacy of VRET for PTSD as compared to waitlist and active comparators. A literature search yielded nine controlled studies encompassing 296 participants (124 VRET, 172 controls). The differences between conditions regarding the primary outcome of PTSD symptom severity and the secondary outcome of depressive and anxiety symptoms post-treatment were calculated using Hedges' g. Compared to waitlist controls, VRET showed a significantly better outcome for PTSD symptoms (g = 0.62, p = .017) and depressive symptoms (g = 0.50, p = .008). There was no significant difference between VRET and active comparators regarding PTSD symptoms (g = 0.25, p = .356) and depressive symptoms (g = 0.24, p = .340) post-treatment. No significant effects emerged for anxiety symptoms. These findings suggest that VRET may be as effective as active comparators for PTSD patients. However, the results must be interpreted with caution due to the limited number of trials and the substantial number of - predominantly male - military service members studied. Additional controlled trials, considering a wider range of trauma types and balanced gender, are required to strengthen the evidence.

Virtual reality applications for chronic conditions management: A review

Background: Virtual Reality (VR) as a computer technology that simulating real environments and situations exploited in numerous healthcare areas such as chronic diseases. The significance of timely treatment and rehabilitation of patients with chronic conditions is high due to the long lasting nature of these conditions. This paper sought to perform a review of published works in the field of VR application in chronic conditions for treatment and rehabilitation purposes.

Methods: We searched the MEDLINE database through PubMed in April 2016 for retrieving published papers from January 2001 to December 2015. From 117 retrieved papers, 52had the inclusion criteria, and their full texts were accessible. Data were extracted from papers based on following items: the name of the first author, year of the study, applied VR methods, type of condition and disease, number of subjects that participated in the study, and finally the status of success and failure of VR application. Data were analyzed using descriptive analysis.

Results: Results of the reviewed investigations have been considered in two main categories including treatment oriented papers (n=38, 73%) while twenty of these papers have been conducted on phobias (53%); also, there are rehabilitation-oriented experiments (n=14, 27%) while thirteen of these papers have been performed on stroke. In 40 papers (77%), the VR technology application reported proper and in 11 papers (21%) the application of VR resulted in relatively proper outcomes and only there is a work (2%) with poor results for VR intervention.

Conclusion: VR technology has been increasingly used in recent years for treatment and rehabilitation purposes among patients affected by chronic conditions in order to motivate them for more successful management.

Evidenced-Based Treatment of Posttraumatic Stress Disorder: An Updated Review of Validated Psychotherapeutic and Pharmacological Approaches

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate psychotherapeutic and pharmacologic approaches to treating patients with posttraumatic stress disorder.

ABSTRACT

A strong evidence base exists for psychological and pharmacological interventions for the treatment of posttraumatic stress disorder (PTSD). The published literature investigating the effectiveness of these treatments in reducing the symptoms and impairments associated with PTSD has expanded substantially in recent years. This review provides a concise overview of the empirical literature examining these treatment approaches. Evidence-based, trauma-focused therapies are recommended as first-line interventions, with the most support for cognitive- and exposure-based approaches. Prolonged exposure and cognitive processing therapy are the two most cited and rigorously investigated. Various other evidence-supported protocols are discussed. Pharmacotherapies can be used when evidence-based psychotherapies are not available or are ineffective, or on the basis of patient preference. Pharmacotherapy with the most support for PTSD includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Evidence supports the implementation of these interventions across genders, populations, and settings. Given that little research directly compares the effectiveness of different PTSD interventions and their mechanisms of action, it remains uncertain how to best select and tailor treatments to optimize individual outcomes. Future directions and novel, ongoing research are discussed.

Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials

Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = -0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (β = -0.007, p <  0.05). These results indicate that VRET is an effective and equal medium for exposure therapy.

Active duty and ex-serving military personnel with post-traumatic stress disorder treated with psychological therapies: systematic review and meta-analysis

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments. Objective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD). Method: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout. Results: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD -1.22, -1.78 to -0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD -0.35, -0.11 to -0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD -0.83, -1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.

Deterioration rates in Virtual Reality Therapy: An individual patient data level meta-analysis

Ample evidence supports the use of Virtual Reality (VR) for anxiety disorders. Nonetheless, currently there is no evidence about moderators or potential negative effects of VR treatment strategies. An Individual Patient Data (IPD) approach was employed with 15 retrieved datasets. The current study sample was composed of 810 patients. Randomized control trials (RCTs) for each primary outcome measure were performed, in addition to moderator analyses of the socio-demographic variables. Deterioration rates were 14 patients (4.0%) in VR, 8 (2.8%) in active control conditions, and 27 (15%) in the WL condition. With regard to receiving treatment, patients in a waiting list control condition had greater odds of deteriorating than in the two active conditions, odds ratios (ORs) 4.87, 95% confidence interval (CI) [0.05, 0.67]. In the case of the socio-demographic variables, none of them were associated with higher or lower odds of deterioration, with the exception of marital status in the WL condition; married people presented a significantly lower probability of deterioration, OR 0.19, 95% CI [0.05, 0.67]. Finally, when comparing pooled effects of VR versus all control conditions, the OR was 0.61 (95% CI 0.31-1.23) in favor of VR, although this result was not statistically significant. This study provides evidence about the deterioration rates of a therapeutic VR approach, showing that the number of deteriorated patients coincides with other therapeutic approaches, and that deterioration is less likely to occur, compared to patients in WL control groups.

A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations

In this paper, we conduct a literature survey on various virtual reality (VR) treatments in psychiatry. We collected 36 studies that used VR to provide clinical trials or therapies for patients with psychiatric disorders. In order to gain a better understanding of the management of pain and stress, we first investigate VR applications for patients to alleviate pain and stress during immersive activities in a virtual environment. VR exposure therapies are particularly effective for anxiety, provoking realistic reactions to feared stimuli. On top of that, exposure therapies with simulated images are beneficial for patients with psychiatric disorders such as phobia and posttraumatic stress disorder (PTSD). Moreover, VR environments have shown the possibility of changing depression, cognition, even social functions. We review empirical evidence from VR-based treatments on psychiatric illnesses such as dementia, mild cognitive impairment (MCI), schizophrenia and autism. Through cognitive training and social skill training, rehabilitation through VR therapies helps patients to improve their quality of life. Recent advances in VR technology also demonstrate potential abilities to address cognitive and functional impairments in dementia. In terms of the different types of VR systems, we discuss the feasibility of the technology within different stages of dementia as well as the methodological limitations. Although there is room for improvement, its widespread adoption in psychiatry is yet to occur due to technical drawbacks such as motion sickness and dry eyes, as well as user issues such as preoccupation and addiction. However, it is worth mentioning that VR systems relatively easily deliver virtual environments with well-controlled sensory stimuli. In the future, VR systems may become an innovative clinical tool for patients with specific psychiatric symptoms.

Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review

BACKGROUND

Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations.

OBJECTIVE

The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems.

METHODS

A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated.

RESULTS

A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology's limitations.

CONCLUSIONS

Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world.

Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine

Is virtual reality (VR) already a reality in behavioral health? To answer this question, a meta-review was conducted to assess the meta-analyses and systematic and narrative reviews published in this field in the last twenty-two months. Twenty-five different articles demonstrated the clinical potential of this technology in both the diagnosis and the treatment of mental health disorders: VR compares favorably to existing treatments in anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to the real world. But why is VR so effective? Here, the following answer is suggested: VR shares with the brain the same basic mechanism: embodied simulations. According to neuroscience, to regulate and control the body in the world effectively, the brain creates an embodied simulation of the body in the world used to represent and predict actions, concepts, and emotions. VR works in a similar way: the VR experience tries to predict the sensory consequences of an individual's movements, providing to him/her the same scene he/she will see in the real world. To achieve this, the VR system, like the brain, maintains a model (simulation) of the body and the space around it. If the presence in the body is the outcome of different embodied simulations, concepts are embodied simulations, and VR is an embodied technology, this suggests a new clinical approach discussed in this article: the possibility of altering the experience of the body and facilitating cognitive modeling/change by designing targeted virtual environments able to simulate both the external and the internal world/body.

Patients’ perspectives about the design of a mobile application for psychotic disorders

Aim

Based on the design of applications for psychotic disorders illness self-management, this study aimed to understand patients’ patterns of technology usage, as well as their expectations and requirements concerning the design of an app for rehabilitation and illness management purposes. It also aimed to identify guidelines for mobile application development for this population.

Method

After a literature review, a questionnaire was developed, focused on behaviours and opinions about technology usage. It was applied, through a cross-sectional study, to a sample of 102 users of mental health services with psychotic disorders (62% men; with ages between 22 and 66 years old).

Results

Nearly 59% of the participants were willing to download an app for illness self-management, and 51% evaluated as essential the self-management of their mental health condition. However, correlation analysis revealed that the more years with mental illness, the less importance is given to an app for this purpose.

Conclusion

The use of mobile technologies seems to the have potential to empower individuals with mental health problems, especially younger ones and those in early disease stages. Concerns about privacy/security should be considered, as well as simple screening designs and texts. The results also reveal the importance of user participatory design.

Skin Conductance Reactivity to Standardized Virtual Reality Combat Scenes in Veterans with PTSD

Interest in virtual reality (VR) as a clinical tool to augment posttraumatic stress (PTSD) treatment has grown substantially in recent years due to advances in VR technology. Moreover, its potential assisted use in the PTSD diagnostic process has been recognized. In this study we examined physiological responding, skin conductance, to a standardized presentation of non-personalized combat-related VR events (e.g. encountering enemy fire; explosions) as compared to non-combat classroom VR events in 19 Veterans with and 24 Veterans without combat-related PTSD who had been deployed to Iraq and Afghanistan. Veterans watched a total of 12 VR scenarios-six combat-related and six non-combat-related-with each scenario gradually increasing in emotional intensity by adding more VR events in addition to repeating prior VR events. Results show that Veterans with PTSD displayed larger skin conductance reactivity across VR combat events, but not for non-combat VR events, as compared to combat Veterans without PTSD. Nevertheless, Veterans with and without PTSD showed a similar reduction of emotional arousal to repeated presentation of the same VR combat events. Within the PTSD sample, the elevated level of VR combat-related arousal correlated marginally with severity of hyperarousal symptoms. This study confirms that the use of a non-personalized and standardized VR presentation successfully distinguishes Veterans with PTSD from those without on a measure of psychophysiological arousal to combat-related VR stimuli. The assessment of physiological reactivity during the repeated presentation of standardized, trauma-related VR events highlights its use for PTSD assessment as well as treatment.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.

"That Guy, Is He Really Sick at All?" An Analysis of How Veterans with PTSD Experience Nature-Based Therapy

Serving in the military leads to mental diseases, such as post-traumatic stress disorder (PTSD), for a percentage of soldiers globally. The number of veterans with PTSD is increasing and, although medication and psychological treatments are offered, treatment results could be improved. Historically, different forms of nature-based therapy have been used for this target group. However, in spite of anecdotally good results, studies measuring the effect of this form of therapy are still lacking. The aim of this study is to explore how veterans with PTSD manage their everyday lives during and after a ten-week nature-based intervention in a therapy garden.

METHODS

Eight veterans participated in qualitative interviews, which were conducted during a one-year period and were analyzed using interpretative phenomenological analysis (IPA).

RESULTS

Five themes emerged from the IPA analysis: Bodily symptoms; relationships; building new identities; the future; and lessons learned. All the participating veterans gained a greater insight into and mastering of their condition, achieved better control of their lives, and developed tools to handle life situations more appropriately and to build a new identity. This improved their ability to participate in social activities and employment.

CONCLUSION

The results should be considered in the future treatment of veterans with PTSD.