0Phobia - towards a virtual cure for acrophobia: study protocol for a randomized controlled trial

Extended Reality for Mental Health Evaluation: Scoping Review

BACKGROUND

Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, "extended reality" (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care.

OBJECTIVE

We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus.

METHODS

In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review.

RESULTS

We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47%) and Germany (n=12, 14.12%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82%) rather than by using analytical and modeling approaches (n=8, 9.41%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches.

CONCLUSIONS

In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures.

Promoting positive emotions and instilling concern for the needs of others during the COVID-19 pandemic

The purpose of this research is to study the efficacy of the home-based Hero program in promoting positive emotions and prosocial behavior during the COVID-19 pandemic. The sample included 237 12- to 15-year-old adolescents from Argentina. The level of positive emotions and prosocial behavior toward strangers, friends and family in the adolescent intervention group increased through the three evaluation periods. The Hero program was focused on recognizing one's own emotions and provided an opportunity to reflect on different positive aspects of life, thus allowing a change in perspective related to immediate negative events. Moreover, the program provided an opportunity to change adolescents' perspective from personal worries to concerns about others, including friends, family members, and even strangers in need.

The Impact of Mobile Technology-Delivered Interventions on Youth Well-being: Systematic Review and 3-Level Meta-analysis

BACKGROUND

Rates of mental health problems among youth are high and rising, whereas treatment seeking in this population remains low. Technology-delivered interventions (TDIs) appear to be promising avenues for broadening the reach of evidence-based interventions for youth well-being. However, to date, meta-analytic reviews on youth samples have primarily been limited to computer and internet interventions, whereas meta-analytic evidence on mobile TDIs (mTDIs), largely comprising mobile apps for smartphones and tablets, have primarily focused on adult samples.

OBJECTIVE

This study aimed to evaluate the effectiveness of mTDIs for a broad range of well-being outcomes in unselected, at-risk, and clinical samples of youth.

METHODS

The systematic review used 5 major search strategies to identify 80 studies evaluating 83 wellness- and mental health-focused mTDIs for 19,748 youth (mean age 2.93-26.25 years). We conducted a 3-level meta-analysis on the full sample and a subsample of the 38 highest-quality studies.

RESULTS

Analyses demonstrated significant benefits of mTDIs for youth both at posttest (g=0.27) and follow-up (range 1.21-43.14 weeks; g=0.26) for a variety of psychosocial outcomes, including general well-being and distress, symptoms of diverse psychological disorders, psychosocial strategies and skills, and health-related symptoms and behaviors. Effects were significantly moderated by the type of comparison group (strongest for no intervention, followed by inert placebo or information-only, and only marginal for clinical comparison) but only among the higher-quality studies. With respect to youth characteristics, neither gender nor pre-existing mental health risk level (not selected for risk, at-risk, or clinical) moderated effect sizes; however, effects increased with the age of youth in the higher-quality studies. In terms of intervention features, mTDIs in these research studies were effective regardless of whether they included various technological features (eg, tailoring, social elements, or gamification) or support features (eg, orientation, reminders, or coaching), although the use of mTDIs in a research context likely differs in important ways from their use when taken up through self-motivation, parent direction, peer suggestion, or clinician referral. Only mTDIs with a clear prescription for frequent use (ie, at least once per week) showed significant effects, although this effect was evident only in the higher-quality subsample. Moderation analyses did not detect statistically significant differences in effect sizes based on the prescribed duration of mTDI use (weeks or sessions), and reporting issues in primary studies limited the analysis of completed duration, thereby calling for improved methodology, assessment, and reporting to clarify true effects.

CONCLUSIONS

Overall, this study's findings demonstrate that youth can experience broad and durable benefits of mTDIs, delivered in a variety of ways, and suggest directions for future research and development of mTDIs for youth, particularly in more naturalistic and ecologically valid settings.

Phobia Exposure Therapy Using Virtual and Augmented Reality: A Systematic Review

A specific phobia is a common anxiety-related disorder that can be treated efficiently using different therapies including exposure therapy or cognitive therapy. One of the most famous methods to treat a specific phobia is exposure therapy. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. One promising track of research lies in VR exposure therapy (VRET) and/or AR exposure therapy (ARET), where gradual exposure to a negative stimulus is used to reduce anxiety. In order to review existing works in this field, a systematic search was completed using the following databases: PubMed, ProQuest, Scopus, Web of Science, and Google Scholar. All studies that present VRET and/or ARET solutions were selected. By reviewing the article, each author then applied the inclusion and exclusion criteria, and 18 articles were selected. This systematic review aims to investigate the previous studies that used either VR and/or AR to treat any type of specific phobia in the last five years. The results demonstrated a positive outcome of virtual reality exposure treatment in the treatment of most phobias. In contrast, some of these treatments did not work for a few specific phobias in which the standard procedures were more effective. Besides, the study will also discuss the best of both technologies to treat a specific phobia. Furthermore, this review will present the limitations and future enhancements in this field.

Detecting Fear of Heights Response to a Virtual Reality Environment Using Functional Near-Infrared Spectroscopy

To enable virtual reality exposure therapy (VRET) that treats anxiety disorders by gradually exposing the patient to fear using virtual reality (VR), it is important to monitor the patient's fear levels during the exposure. Despite the evidence of a fear circuit in the brain as reflected by functional near-infrared spectroscopy (fNIRS), the measurement of fear response in highly immersive VR using fNIRS is limited, especially in combination with a head-mounted display (HMD). In particular, it is unclear to what extent fNIRS can differentiate users with and without anxiety disorders and detect fear response in a highly ecological setting using an HMD. In this study, we investigated fNIRS signals captured from participants with and without a fear of height response. To examine the extent to which fNIRS signals of both groups differ, we conducted an experiment during which participants with moderate fear of heights and participants without it were exposed to VR scenarios involving heights and no heights. The between-group statistical analysis shows that the fNIRS data of the control group and the experimental group are significantly different only in the channel located close to right frontotemporal lobe, where the grand average oxygenated hemoglobin Δ[HbO] contrast signal of the experimental group exceeds that of the control group. The within-group statistical analysis shows significant differences between the grand average Δ[HbO] contrast values during fear responses and those during no-fear responses, where the Δ[HbO] contrast values of the fear responses were significantly higher than those of the no-fear responses in the channels located towards the frontal part of the prefrontal cortex. Also, the channel located close to frontocentral lobe was found to show significant difference for the grand average deoxygenated hemoglobin contrast signals. Support vector machine-based classifier could detect fear responses at an accuracy up to 70% and 74% in subject-dependent and subject-independent classifications, respectively. The results demonstrate that cortical hemodynamic responses of a control group and an experimental group are different to a considerable extent, exhibiting the feasibility and ecological validity of the combination of VR-HMD and fNIRS to elicit and detect fear responses. This research thus paves a way toward the a brain-computer interface to effectively manipulate and control VRET.

Recommendations for Implementing Gamification for Mental Health and Wellbeing

Gamification is increasingly being proposed as a strategy to increase engagement for mental health and wellbeing technologies. However, its implementation has been criticized as atheoretical, particularly in relation to behavior change theory and game studies theories. Definitions of the term “gamification” vary, sometimes widely, between and within academic fields and the effectiveness of gamification is yet to be empirically established. Despite this, enthusiasm for developing gamified mental health technologies, such as interventions, continues to grow. There is a need to examine how best to implement gamification in mental health and wellbeing technologies in a way that takes quick production cycles into account while still emphasizing empirical investigation and building a rigorous evidence base. With reference to game studies and the medical (eHealth/mHealth) literature, this article interrogates gamification for mental health and wellbeing by examining core properties of the game form. It then explores how gamification can best be conceptualized and implemented for mental health and wellbeing goals from conceptualization through to iterative co-development and evaluation that accommodates software development schedules. Finally, it summarizes its conceptual analysis into recommendations for researchers and designers looking to do so. These recommendations are: (1) assess suitability, (2) implement to support, (3) assess acceptability, (4) evaluate impact, and (5) document comprehensively. These recommendations aim to encourage clear language, unified terminology, the application and evaluation of theory, comprehensive and constant documentation, and transparent evaluation of outcomes.

Analysis of Usage Data from a Self-Guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Controlled Trial

This study examined user engagement with ZeroPhobia, a self-guided app-based virtual reality (VR) Cognitive Behavior Therapy for acrophobia symptoms using cardboard VR viewers. Dutch acrophobic adults (n = 96) completed assessments at baseline and immediately following treatment. Primary outcome measures were the Acrophobia Questionnaire (AQ) and the Igroup Presence Questionnaire (IPQ). Usage data consisted of number of VR sessions practiced, practice time, and fear ratings directly after practicing. Results show that of the 66 participants who played at least one level, the majority continued to finish all levels, spending on average 24.4 min in VR. Self-reported fear consistently decreased between the start and finish of levels. Post-test AQ scores depended quadratically on time spent in VR. Higher pre-test AQ scores were significantly associated with subjective anxiety after the first level and a reduction of post-test AQ scores, but not with number of sessions, suggesting it might be more beneficial to play one level for a longer time period instead of practicing many VR levels. Results also show an optimum exposure level at which increasing practice time does not result in increased benefit. Self-guided VR acrophobia treatment is effective and leads to consistent reductions in self-reported anxiety both between levels and after treatment. Most participants progressed effectively to the highest self-exposure level, despite the absence of a therapist.

Comparison between Full Body Motion Recognition Camera Interaction and Hand Controllers Interaction used in Virtual Reality Exposure Therapy for Acrophobia

Virtual Reality has already been proven as a useful supplementary treatment tool for anxiety disorders. However, no specific technological importance has been given so far on how to apply Virtual Reality with a way that properly stimulates the phobic stimulus and provide the necessary means for lifelike experience. Thanks to technological advancements, there is now a variety of hardware that can help enhance stronger emotions generated by Virtual Reality systems. This study aims to evaluate the feeling of presence during different hardware setups of Virtual Reality Exposure Therapy, and, particularly how the user's interaction with those setups can affects their sense of presence during the virtual simulation. An acrophobic virtual scenario is used as a case study by 20 phobic individuals and the Witmer-Singer presence questionnaire was used for presence evaluation by the users of the system. Statistical analysis on their answers revealed that the proposed full body Motion Recognition Cameras system generates a better feeling of presence compared to the Hand Controllers system. This is thanks to the Motion Recognition Cameras, which track and allow display of the user's entire body within the virtual environment. Thus, the users are enabled to interact and confront the anxiety-provoking stimulus as in real world. Further studies are recommended, in which the proposed system could be used in Virtual Reality Exposure Therapy trials with acrophobic patients and other anxiety disorders as well, since the proposed system can provide natural interaction in various simulated environments.

Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial

IMPORTANCE

Globally, access to evidence-based psychological treatment is limited. Innovative self-help methods using smartphone applications and low-cost virtual reality have the potential to significantly improve the accessibility and scalability of psychological treatments.

OBJECTIVE

To examine the effectiveness of ZeroPhobia, a fully self-guided app-based virtual reality cognitive behavior therapy (VR CBT) using low-cost (cardboard) virtual reality goggles compared with a wait-list control group and to determine its user friendliness.

DESIGN, SETTING, AND PARTICIPANTS

In a single-blind randomized clinical trial, participants were enrolled between March 24 and September 28, 2017, and randomly assigned (1:1) by an independent researcher to either VR CBT app or a wait-list control group. A total of 193 individuals aged 18 to 65 years from the Dutch general population with acrophobia symptoms and access to an Android smartphone participated. The 6 animated modules of the VR-CBT app and gamified virtual reality environments were delivered over a 3-week period in participants' natural environment. Assessments were completed at baseline, immediately after treatment, and at 3-month follow-up. Analysis began April 6, 2018, and was intention to treat.

INTERVENTION

Self-guided app-based VR CBT.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the Acrophobia Questionnaire. The hypothesis was formulated prior to data collection.

RESULTS

In total, 193 participants (129 women [66.84%]; mean [SD] age, 41.33 [13.64] years) were randomly assigned to intervention (n = 96) or a wait-list control group (n = 97). An intent-to-treat analysis showed a significant reduction of acrophobia symptoms at posttest at 3 months for the VR-CBT app compared with the controls (b = -26.73 [95% CI, -32.12 to -21.34]; P < .001; d = 1.14 [95% CI, 0.84 to 1.44]). The number needed to treat was 1.7. Sensitivity and robustness analysis confirmed these findings. Pretreatment attrition was 22 of 96 (23%) because of smartphone incompatibility. Of the 74 participants who started using the VR-CBT app, 57 (77%) completed the intervention fully.

CONCLUSIONS AND RELEVANCE

A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions. To our knowledge, this study is the first to show that virtual reality acrophobia treatment can be done at home without the intervention of a therapist.

TRIAL REGISTRATION

Trialregister.nl identifier: NTR6442.

Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

BACKGROUND

There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators.

OBJECTIVE

This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions.

METHODS

We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3.

RESULTS

The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers' justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention's intended effects.

CONCLUSIONS

Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

The Potential of Consumer-Targeted Virtual Reality Relaxation Applications: Descriptive Usage, Uptake and Application Performance Statistics for a First-Generation Application

Virtual Reality (VR) technology can be used to create immersive environments that promote relaxation and distraction, yet it is only with the recent advent of consumer VR platforms that such applications have the potential for widespread dissemination, particularly in the form of consumer-targeted self-help applications available at regular digital marketplaces. If widely distributed and used as intended, such applications have the potential to make a much-needed impact on public mental health. In this study, we report real-world aggregated uptake, usage and application performance statistics from a first-generation consumer-targeted VR relaxation application which has been publicly available for almost 2 years. While a total of 40,000 unique users signals an impressive dissemination potential, average session duration was lower than expected, and the data suggests a low number of recurrent users. Usage of headphones and auxiliary input devices was relatively low, and some application performance issues were evident (e.g., lower than intended framerate and occurrence of overheating). These findings have important implications for the design of the future VR relaxation applications, revealing primarily that user engagement needs to be addressed in the early stage of development by including features that promote prolonged and recurrent use (e.g., gamification elements).