Evidence on Virtual Reality-Based Therapies for Psychiatric Disorders: Meta-Review of Meta-Analyses

Mental health in the virtual world: Challenges and opportunities in the metaverse era

Current rates of mental illness are worrisome. Mental illness mainly affects females and younger age groups. The use of the internet to deliver mental health care has been growing since 2020 and includes the implementation of novel mental health treatments using virtual reality, augmented reality, and artificial intelligence. A new three dimensional digital environment, known as the metaverse, has emerged as the next version of the Internet. Artificial intelligence, augmented reality, and virtual reality will create fully immersive, experiential, and interactive online environments in the metaverse. People will use a unique avatar to do anything they do in their "real" lives, including seeking and receiving mental health care. In this opinion review, we reflect on how the metaverse could reshape how we deliver mental health treatment, its opportunities, and its challenges.

Effects of a Serious Game for Adolescent Mental Health on Cognitive Vulnerability: Pilot Usability Study

Background

Adolescent mental health is of utmost importance. E-mental health interventions, and serious games in particular, are appealing to adolescents and can have beneficial effects on their mental health. A serious game aimed at improving cognitive vulnerability (ie, beliefs or attitudes), which can predispose an individual to mental health problems, can contribute to the prevention of these problems in adolescents.

Objective

This study aimed to assess the feasibility of the prototype of a serious game called "Silver."

Methods

The prototype of the serious game was developed using a user-centered participatory design. The prototype of Silver focused on 1 aspect of a serious game for improving cognitive vulnerability in adolescents, that is, the recognition and identification of cognitive distortions. Through the game, players were required to identify and classify the character's thoughts as helpful or unhelpful. Upon successful advancement to the next level, the task becomes more challenging, as players must also identify specific types of cognitive distortions. A pre- and posttest uncontrolled design was used to evaluate the game, with a 1-week intervention phase in which participants were asked to play the game. Participants aged 12-16 years were recruited in schools. The outcomes of interest were the recognition of cognitive distortions and presence of participants' cognitive distortions. The game was also evaluated on its effects, content, and usefulness.

Results

A total of 630 adolescents played Silver and completed the assessments. Adolescents were significantly better at recognizing cognitive distortions at the pretest (mean 13.09, SD 4.08) compared to the posttest (mean 13.82, SD 5.09; t629=-4.00, P<.001). Furthermore, their cognitive distortions decreased significantly at the posttest (mean 38.73, SD 12.79) compared to the pretest (mean 41.43, SD 10.90; t629=7.98, P<.001). Participants also indicated that the game helped them recognize cognitive distortions. Many participants considered the game appealing (294/610, 48.2%) but boring (317/610, 52%) and preferred a more comprehensive game (299/610, 49%).

Conclusions

Findings from this study suggest that a serious game may be an effective tool for improving cognitive vulnerability in adolescents. The development of such a serious game, based on the prototype, is recommended. It may be an important and innovative tool for the universal prevention of mental health problems in adolescents. Future research on the effects of the game is warranted.

Virtual Reality Breathing Interventions for Mental Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Breathing exercises have been shown to reduce mental health problems among clinical and non-clinical populations. Although virtual reality (VR) breathing interventions are assumed to have potential benefits, it remains unclear whether VR breathing interventions are more effective at improving mental health than non-VR breathing interventions. We conducted a systematic literature search in six electronic databases (Web of Science, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, Scopus, and PubMed) from inception to 30th September, 2022. We included randomized controlled trials in adults evaluating effects of VR compared to non-VR breathing interventions on primary outcomes of mental health (stress, anxiety and mood), and secondary outcomes of physiological stress measures (e.g., heart rate (HR), heart rate variability (HRV)). Within these selected studies, we explored differences in likeability and future use between VR and non-VR breathing interventions. 2.848 records were identified of which 65 full-text articles were assessed. Six RCTs were included, of which five were suitable for meta-analyses. Comparing VR to non-VR breathing interventions, there were no significant differences in overall mental health, stress, anxiety or mood, nor in HR or HRV. There was no evidence that participants liked VR breathing interventions more than non-VR, nor would use them more in the future. These results suggest that there is no evidence that VR breathing interventions are more effective than non-VR in improving mental health outcomes, HR, HRV. Further research is required to determine whether there may be advantages to longer-term VR-implementation and practice, and explore possible mechanisms.

Counseling Psychological Understanding and Considerations of the Metaverse: A Theoretical Review

The COVID-19 pandemic has triggered the interest in and demand for online platforms that can replace traditional face-to-face activities. Accordingly, metaverses have been increasingly used across society, especially in the Mental health field. This broad use of metaverses is now recognized as a major trend that will drive various industries across healthcare and society. In response to this societal change, this study provides a theoretical framework for understanding and applying metaverses as therapeutic spaces in mental health fields through a conceptualization and characterization of metaverses for a range of technologies and services. The value of metaverses as a human-centered "field of experience" was identified and proposed based on the essential aspect of the user, the human being, rather than from the technology used. According to existing psychotherapeutic theories, four therapeutic concepts for the metaverse were proposed: metaverse as an "average expectable environment" in the developmental and therapeutic categories of the self, a transitional stage for adaptation to reality, a creative space for memory and communication for the self, and an expanded or "surplus" reality. This work is expected to be a useful basis for expanding new psychotherapeutic strategies and methods as therapeutic spaces for maintaining mental health through the metaverse.

The Role of Immersive Virtual Reality and Augmented Reality in Medical Communication: A Scoping Review

Communication between clinicians and patients and communication within clinical teams is widely recognized as a tool through which improved patient outcomes can be achieved. As emerging technologies, there is a notable lack of commentary on the role of immersive virtual reality (VR) and augmented reality (AR) in enhancing medical communication. This scoping review aims to map the current landscape of literature on this topic and highlights gaps in the evidence to inform future endeavors. A comprehensive search strategy was conducted across 3 databases (PubMed, Web of Science, and Embase), yielding 1000 articles, of which 623 were individually screened for relevance. Ultimately, 22 articles were selected for inclusion and review. Similarities across the cohort of studies included small sample sizes, observational study design, use of questionnaires, and more VR studies than AR. The majority of studies found these technologies to improve medical communication, although user tolerability limitations were identified. More studies are required, presenting more robust findings, in order to draw more definitive conclusions and stronger recommendations for use of immersive VR/AR in clinical environments.

Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders

This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.

Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies.

OBJECTIVE

Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects.

METHODS

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses.

RESULTS

Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported "no adverse effects" but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever.

CONCLUSIONS

An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported.

Effects of Health Education Using Virtual Reality for Adolescents: A Systematic Review and Meta-Analysis

PURPOSE

This study aimed to evaluate the effects of health interventions using virtual reality (VR) on improving knowledge, attitudes, and skills; and inducing behavioral change among adolescents.

METHODS

This study is a systematic review and meta-analysis following PRISMA guidelines. We searched Cochrane, MEDLINE, Embase, CINAHL, Scopus, Web of Science, and Korean databases between database inception and April 10, 2021. Based on heterogeneity, a random- or fixed-effects model was used, as appropriate, to calculate effect sizes in terms of the standardized mean difference (SMD) and odds ratio (OR). Studies were selected if they verified the effects of health education using VR on adolescents; there was an appropriate control group; and if the effects of education were reported in terms of changes in knowledge, attitudes, skills, or behaviors.

RESULTS

This analysis included six studies (n = 1,086). The intervention groups showed greater responses in knowledge and attitudes (SMD = 0.57, 95% confidence interval (CI) [0.12 to 1.02]), skills related to health behavior (SMD = -0.45, 95% CI [-0.71 to -0.19]), and behavioral change after 12 months (OR = 2.36, 95% CI [1.03 to 5.41]).

CONCLUSION

The results confirm the effectiveness of health interventions using virtual reality (VR). Although the analysis include a small number of studies, a case can be made for health interventions using VR to be utilized as educational methods and strategies to prevent risky behaviors among adolescents.

Using 360-degree immersive videos to assess multiple transdiagnostic symptoms: A study focusing on fear of negative evaluation, paranoid thoughts, negative automatic thoughts, and craving

Over the last 20 years, virtual reality (VR) has gained a great interest for both assessment and treatment of various psychopathologies. However, due to high costs and material specificity, VR remains disadvantageous for clinicians. Adopting a multiple transdiagnostic approach, this study aims at testing the validity of a 360-degree immersive video (360IV) for the assessment of five common psychological symptoms (fear of negative evaluation, paranoid thoughts, negative automatic thoughts, craving for alcohol and for nicotine). A 360IV was constructed in the Darius Café and included actors behaving naturally. One hundred and fifty-eight adults from the general population were assessed in terms of their proneness towards the five symptoms, were then exposed to the 360IV and completed measures for the five state symptoms, four dimensions of presence (place, plausibility, copresence and social presence illusions) and cybersickness. Results revealed that the five symptoms occurred during the immersion and were predicted by the participants' proneness towards these symptoms. The 360IV was also able to elicit various levels of the four dimensions of presence while producing few cybersickness. The present study provides evidence supporting the use of the 360IV as a new accessible, ecological, and standardized tool to assess multiple transdiagnostic symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-023-00779-y.

Using the Theoretical Domains Framework to Inform the Implementation of Therapeutic Virtual Reality into Mental Healthcare

Evidence supporting the efficacy of therapeutic virtual reality (VR) for mental health conditions is rapidly growing. However, little is known about how best to implement VR, or the challenges perceived by treatment providers. This study aimed to (1) synthesis perspectives of staff working in private mental healthcare and (2) use the Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) to identify mechanisms of change targets and intervention functions to facilitate its clinical implementation. Semi-structured interviews were conducted with clinicians (n = 14) and service managers (n = 5) working in a major private mental health hospital in Victoria, Australia. Transcripts were coded using framework analysis to identify relevant TDF domains. Specific belief statements were generated and coded as a barrier and/or facilitator and thematically organised within domains. Domains were ranked for importance based on frequency, elaboration, and evidence of conflicting beliefs. Using the BCW, domains were mapped to their respective COM-B components and indicated intervention functions. A total of 11 TDF domains were identified as relevant to early-stage implementation of therapeutic VR. Three domains were judged as highly important (beliefs about consequences; environmental context and resources; knowledge), while seven domains were judged as moderately important (social/professional role and identity; emotions; skills; memory, attention, and decision processes; intentions; beliefs about capabilities; social influences). Based on current data, we propose a theory-informed roadmap to promote VR uptake in mental healthcare services. A priority for intervention development should be addressing knowledge gaps and attitudinal barriers (e.g., safety concerns) with education and training.

Effects of Fetal Images Produced in Virtual Reality on Maternal-Fetal Attachment: Randomized Controlled Trial

BACKGROUND

Maternal-fetal attachment (MFA) has been reported to be associated with the postpartum mother-infant relationship. Seeing the fetus through ultrasound might influence MFA, and the effect could be increased by more realistic images, such as those generated in virtual reality (VR).

OBJECTIVE

The aim was to determine the effect of fetal images generated in VR on MFA and depressive symptoms through a prenatal-coaching mobile app.

METHODS

This 2-arm parallel randomized controlled trial involved a total of 80 pregnant women. Eligible women were randomly assigned to either a mobile app-only group (n=40) or an app plus VR group (n=40). The VR group experienced their own baby's images generated in VR based on images obtained from fetal ultrasonography. The prenatal-coaching mobile app recommended health behavior for the pregnant women according to gestational age, provided feedback on entered data for maternal weight, blood pressure, and glucose levels, and included a private diary service for fetal ultrasound images. Both groups received the same app, but the VR group also viewed fetal images produced in VR; these images were stored in the app. All participants filled out questionnaires to assess MFA, depressive symptoms, and other basic medical information. The questionnaires were filled out again after the interventions.

RESULTS

Basic demographic data were comparable between the 2 groups. Most of the assessments showed comparable results for the 2 groups, but the mean score to assess interaction with the fetus was significantly higher for the VR group than the control group (0.4 vs 0.1, P=.004). The proportion of participants with an increased score for this category after the intervention was significantly higher in the VR group than the control group (43% vs 13%, P=.005). The feedback questionnaire revealed that scores for the degree of perception of fetal appearance all increased after the intervention in the VR group.

CONCLUSIONS

The use of a mobile app with fetal images in VR significantly increased maternal interaction with the fetus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04942197; https://clinicaltrials.gov/ct2/show/NCT04942197.

Metaverse!

This study aimed to synthesize the literature on Metaverse to highlight its current research, opportunities, and applications in e-healthcare and education to reduce inequalities and for delivering fair and equal opportunities and solutions. The authors employed preferred reporting items for systematic reviews and meta-analyses (PRISMA) to rapidly map the field of a metaverse in health and education. Two major application domains emerged in the literature from the 88 research publications, which include (1) Metaverse in healthcare and (2) Metaverse in education. This study will act as a road map to help academics who desire to continue their research work in the Metaverse for various healthcare and educational services. However, its implementation is required in the future to improve mental healthcare and the effectiveness of mental health services, particularly in low and medium-income (LMIC) and conflict-affected areas.

Virtual reality for healthcare: A scoping review of commercially available applications for head-mounted displays

Objective

This scoping review aimed to describe the scope of commercially available virtual reality (VR) healthcare applications for mainstream head-mounted displays (HMD)s.

Methods

A search was conducted during late April and early May 2022 over five major VR app stores using "health," "healthcare," "medicine," and "medical" as keywords. Apps were screened based on their title and description sections. Metadata collected included: title, description, release date, price (free or paid), multilingual support, VR app store availability, and HMD support.

Results

The search yielded 1995 apps, out of which 60 met the inclusion criteria. The analysis showed that the number of healthcare VR apps has been steadily increasing since 2016, but no developer has released more than two apps so far. Most of the reviewed apps can run on HTC Vive, Oculus Quest, and Valve Index. Thirty-four (56.7%) apps had a free version, and 12 (20%) apps were multilingual, i.e., supported languages other than English. The reviewed apps fell into eight major themes: life science education (3D anatomy, physiology and pathology, biochemistry, and genetics); rehabilitation (physical, mental, and phobia therapy); public health training (safety, life-saving skills, and management); medical training (surgical and patient simulators); role-playing as a patient; 3D medical imagery viewing; children's health; and online health communities.

Conclusions

Although commercial healthcare VR is still in its early phases, end-users can already access a broad range of healthcare VR apps on mainstream HMDs. Further research is needed to assess the usefulness and usability of existing apps.

Technology and Mental Health: State of the Art for Assessment and Treatment

Technology is ubiquitous in society and is now being extensively used in mental health applications. Both assessment and treatment strategies are being developed and deployed at a rapid pace. The authors review the current domains of technology utilization, describe standards for quality evaluation, and forecast future developments. This review examines technology-based assessments of cognition, emotion, functional capacity and everyday functioning, virtual reality approaches to assessment and treatment, ecological momentary assessment, passive measurement strategies including geolocation, movement, and physiological parameters, and technology-based cognitive and functional skills training. There are many technology-based approaches that are evidence based and are supported through the results of systematic reviews and meta-analyses. Other strategies are less well supported by high-quality evidence at present, but there are evaluation standards that are well articulated at this time. There are some clear challenges in selection of applications for specific conditions, but in several areas, including cognitive training, randomized clinical trials are available to support these interventions. Some of these technology-based interventions have been approved by the U.S. Food and Drug administration, which has clear standards for which types of applications, and which claims about them, need to be reviewed by the agency and which are exempt.

Virtual reality-based theory of mind intervention in schizophrenia: Preliminary efficacy results

BACKGROUND

In recent years, a growing body of literature has supported the core nature and functional significance of Theory of Mind (ToM) deficit in schizophrenia. These findings have made ToM impairment a promising treatment target. However, despite the encouraging results, its complexity makes it difficult to develop new interventions and even to understand the exact nature and scope of the deficit. Yet, further investigation has suggested that using modern technology and multilevel assessment may help solve the problem.

METHODS

Virtual Reality-based Theory of Mind Intervention (VR-ToMIS) is a recently developed structured method using the combination of cognitive and behavioral therapeutic techniques and the advantages of Virtual Reality (VR) technology. A controlled study with a three-month follow-up was conducted with 42 patients (suffering from schizophrenia or schizo-affective disorder) randomly assigned to either an experimental (VR-ToMIS) or control group (passive-VR). Repeated two-way factorial analysis of covariance was used to evaluate the effects of VR-ToMIS on symptoms, neuro- and social cognition, pragmatic skills, and quality of life when the effect of IQ was controlled.

RESULTS

Patients participating in VR-ToMIS showed significant improvements in all types of ToM tasks (except for hyper-ToM task, based on the results of Cartoon test, Faux pas test and and Baron-Cohen Minds in the Eyes Test) compared to the control group with moderate to large effect sizes. In the case of negative and cognitive symptoms, significant between-group differences were also supported. Improvement was moderated by IQ in the case of higher-order ToM, manner, and relevance implicatures. Results were proved to be sustainable three months after the treatment.

CONCLUSION

Although the presented results are considered preliminary, they support the potential of the integration of modern technology and traditional methods for future interventions.

Future of mental health in the metaverse

The metaverse and non-fungible tokens (NFTs) were some of the hottest tech terms in 2021, according to a Google Trends search. Our review aims to describe the metaverse and NFTs in the context of their potential application in the treatment of mental health disorders. Advancements in technology have been changing human lives at an ever-increasing pace. Metaverse, also known as the three-dimensional (3D) internet, is the convergence of virtual reality (VR) and physical reality in a digital space. It could potentially change the internet as we know it, with NFTs as the key building blocks in the new expansive virtual ecosystem. This immersive 3D virtual world boasts the features of the real world with the added ability to change the surrounding environment according to individual needs and requirements. VR, augmented reality (AR) and mixed reality (MR) have been employed as tools in the treatment of various mental health disorders for the past decade. Studies have reported positive results on their effectiveness in the diagnosis and treatment of mental health disorders. VR/AR/MR have been hailed as a solution to the acute shortage of mental health professionals and the lack of access to mental healthcare. But, on the flip side, young adults tend to spend a significant amount of time playing 3D immersive games and using social media, which can lead to insecurity, anxiety, depression, and behavioural addiction. Additionally, endless scrolling through social media platforms negatively affects individuals' attention span as well as aggravating the symptoms of adolescents with attention deficit hyperactivity disorder.

We aimed to explore the ramifications of expanding applications of the metaverse on mental health. So far, no other review has explored the future of mental health in the context of the metaverse.

Evidence on the acute and residual neurocognitive effects of cannabis use in adolescents and adults: a systematic meta-review of meta-analyses

BACKGROUND

Cannabis is among the most consumed psychoactive substances world-wide. Considering changing policy trends regarding the substance, it is crucial to understand more clearly its potential acute and residual adverse effects from a public health viewpoint. Cognitive function is one of the targeted areas with conflicting findings. This meta-review measured the magnitude of acute and residual effects of cannabis on cognition in adolescents and adults provided by meta-analyses and evaluated quality of evidence.

METHODS

A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyses were included if they quantitatively examined the performances of users from the general population on cognitive tasks.

RESULTS

The search retrieved 10 eligible meta-analyses (71 effects sizes, n = 43 761) with evidence ranging from low to moderate quality, which were categorized into domains of cognitive functions: executive functions (k = 7), learning and memory (k = 5), attention (k = 4), processing speed (k = 5), perceptual motor function (k = 2) and language (k = 2). Verbal learning and memory displayed the most robust evidence and were most impaired by acute cannabis intoxication that persisted after intoxication passed. Small-to-moderate acute and residual   adverse effects were reported for executive functioning. Cannabis use led to small deficits in inhibitory processes and flexibility, whereas small-to-moderate deficits were reported for working memory and decision-making. Evidence regarding processing speed and attention has shown that cannabis administration induced small-to-moderate adverse effects and residual neurocognitive deficits were observed in heavy cannabis-using youths. Results showed no significant difference between cannabis users and non-users on language, and small-to-moderate effects for simple motor skills.

CONCLUSION

Meta-analytical data on the acute effects of cannabis use on neurocognitive function have shown that cannabis intoxication leads to small to moderate deficits in several cognitive domains. These acute impairments accord with documented residual effects, suggesting that the detrimental effects of cannabis persist beyond acute intake.

The Potential Paradoxical Neurocognitive Effects of Cannabis Use in Patients with Psychotic Disorders: A Critical Meta-Review of Meta-Analytical Evidence

Background: The association between cannabis and cognitive functions has been thoroughly studied in psychotic disorders, but conflictual/paradoxical results have emerged. This critical meta-review examined the magnitude of effects of cannabis on neurocognitive functions in patients with psychotic disorders provided by meta-analyses and evaluated the quality of evidence. Methods: A systematic search of meta-analyses was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Results: The search retrieved six meta-analyses. Quality of evidence varied from very low to moderate quality. No neurocognitive difference was observed between cannabis users and nonusers in first episode of psychosis samples. Limited evidence showed no significant difference in language, psychomotor functioning, and verbal/visual learning/memory, apart from improvements in verbal and visual memory (recognition). Findings showed better neurocognitive performances in cannabis-using patients for planning/reasoning and working memory. There were tendencies toward significance for processing speed and attention. Most effect sizes showed small to moderate degrees of outperformances in cannabis users. Individuals with lifetime use appeared to show better neurocognitive functions. Conclusion: Evidence indicated nonuniform effects of cannabis use across cognitive domains, with some areas suggesting better cognitive performances in cannabis users, entitled the paradoxical effect of the dually diagnosed. Clinical significance of these findings should be interpreted cautiously.

Virtual Reality (VR) Technology for Treatment of Mental Health Problems during COVID-19: A Systematic Review

There was a surge in psychological distress and emotional burnout during the COVID-19 pandemic. Virtual reality (VR) is helpful as a psychological intervention whilst maintaining physical or social distancing. The present systematic review assessed the role of VR as a psychological intervention tool for mental health problems during the COVID-19 pandemic. We conducted a systematic review that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. This study used the search-related terms: (Virtual reality OR simulated-3D-environment OR VR) AND (covid! or corona!) AND (mental* OR psychologic* OR well* OR health*) AND (intervention) on six databases, i.e., MEDLINE, PsycINFO, Ovid Medline, EMBASE, ACM digital library, and Cochrane Central Register of Controlled Trials (CENTRAL) from the inception date until 23 June 2021. We finally included four studies in the systematic review out of the 379 references imported for screening. These studies reveal that VR is beneficial as a psychological tool for intervention in individuals with mental health problems. Immersed in the telepresence, interacting in a 3-D format compared to a 2-D layout, having a sense of enjoyment and engagement, activating an affective-motivational state, “escaping” to a virtual from the real world are pivotal faucets of VR as a psychological tool for intervention.

Qualitative Validation of a Novel VR Program for Irritable Bowel Syndrome: A VR1 Study

INTRODUCTION

Although gut-directed psychotherapies are effective for irritable bowel syndrome (IBS), they are rarely prescribed, given a paucity of trained clinicians. Virtual reality (VR) offers a solution by allowing patients to self-practice these techniques in a standardized manner.

METHODS

A multidisciplinary team developed IBS/VR, a program that transports users into immersive VR worlds that teach patients about the brain-gut axis, cognitive behavioral therapy, and gut-directed meditation. We tested IBS/VR in Rome IV IBS patients and used inductive analysis to evaluate perceptions and identify recommendations.

RESULTS

We achieved thematic saturation after 9 interviews; 3 additional interviews revealed no emergent themes. After making 23 software changes based on patient feedback, we conducted 3 additional interviews which confirmed thematic saturation (N = 15 total).

DISCUSSION

This study offers initial validation of the first VR program designed for IBS.

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.

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.

Effects of Virtual Reality-Based Relaxation Techniques on Psychological, Physiological, and Biochemical Stress Indicators

Various relaxation techniques could benefit from merging with virtual reality (VR) technologies, as these technologies are easily applicable, involving, and user-friendly. To date, it is unclear which relaxation technique using biofeedback combined with VR technology is the most effective. The study aimed to compare the effectiveness of brief VR-based biofeedback-assisted relaxation techniques including electroencephalographic biofeedback, mindfulness-based biofeedback, galvanic skin response biofeedback, and respiratory biofeedback. Forty-three healthy volunteers (age 34.7 ± 7.2 years), comprising 28 (65%) women and 15 (35%) men, were enrolled in the study. All the participants were exposed to four distinct relaxation sessions according to a computer-generated random sequence. The efficacy of relaxation methods was evaluated by examining psychological, physiological, and biochemical stress indicators. All VR-based relaxation techniques reduced salivary steroid hormone (i.e., cortisol, cortisone, and total glucocorticoid) levels and increased galvanic skin response values. Similarly, all interventions led to a significantly reduced subjectively perceived psychological strain level. Three out of the four interventions (i.e., electroencephalographic, respiratory, and galvanic skin response-based biofeedback relaxation sessions) resulted in a decreased self-reported fatigue level. We suggest that newly developed VR-based relaxations techniques are potential tools for stress reduction and might be particularly suitable for individuals who are not capable of adhering to a strict and time-consuming stress management intervention schedule.

Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis

Background

Stroke remains one of the major chronic illnesses worldwide that health care organizations will need to address for the next several decades. Individuals poststroke are subject to levels of cognitive impairment and mental health problems. Virtual reality (VR)-based therapies are new technologies used for cognitive rehabilitation and the management of psychological outcomes.

Objective

This study performed a meta-analysis to evaluate the effects of VR-based therapies on cognitive function and mental health in patients with stroke.

Methods

A comprehensive database search was performed using PubMed, MEDLINE (Ovid), Embase, Cochrane Library, and APA PsycINFO databases for randomized controlled trials (RCTs) that studied the effects of VR on patients with stroke. We included trials published up to April 15, 2021, that fulfilled our inclusion and exclusion criteria. The literature was screened, data were extracted, and the methodological quality of the included trials was assessed. Meta-analysis was performed using RevMan 5.3 software.

Results

A total of 894 patients from 23 RCTs were included in our meta-analysis. Compared to traditional rehabilitation therapies, the executive function (standard mean difference [SMD]=0.88, 95% confidence interval [CI]=0.06-1.70, P=.03), memory (SMD=1.44, 95% CI=0.21-2.68, P=.02), and visuospatial function (SMD=0.78, 95% CI=0.23-1.33, P=.006) significantly improved among patients after VR intervention. However, there were no significant differences observed in global cognitive function, attention, verbal fluency, depression, and the quality of life (QoL).

Conclusions

The findings of our meta-analysis showed that VR-based therapies are efficacious in improving executive function, memory, and visuospatial function in patients with stroke. For global cognitive function, attention, verbal fluency, depression, and the QoL, further research is required.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021252788; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=252788

[Virtual reality in teaching of psychiatry and psychotherapy at medical school]

Hintergrund

Ausbildung und Lehre müssen sich den Gegebenheiten insbesondere in Corona-Zeiten anpassen, zumal neue digitale Technologien zur Verfügung stehen. Ärztliche Interaktions- und Explorationstechniken sind die wichtigsten Werkzeuge, die Medizinstudierende im Fach Psychiatrie und Psychotherapie zu erwerben haben.

Ziel der Arbeit

Avatare in virtueller Realität (VR) können grundsätzlich alle Krankheitsbilder in unterschiedlichen Schweregraden zu jeder Zeit repräsentieren.

Material und Methoden

Im Bochumer Avatar-Explorationsprojekt (AVEX) treten Studierende in den Dialog mit „psychisch kranken“ Avataren und versuchen, unter Anleitung und Supervision Diagnose, Differenzialdiagnose und Behandlungsempfehlungen zu erarbeiten.

Ergebnisse und Diskussion

Dadurch können die Studierenden auch seltene oder schwere psychiatrische Krankheitsbilder durch VR vermittelt kennenlernen. Dieser Übersichtsartikel stellt erste Erfahrungen insbesondere in Aufbau und Entwicklung sowie bez. der technologischen Herausforderungen dar.

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

As the COVID-19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies - such as smartphone apps, vir-tual reality, chatbots, and social media - have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for "digital phenotyping" and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self-management of psychological well-being and early intervention, along with more nascent research supporting their use in clinical management of long-term psychiatric conditions - including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders - as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real-world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.

Perspectives fondamentale, clinique et sociétale de l’utilisation des personnages virtuels en santé mentale

Avec l’attrait engendré par les avancées en informatique et en intelligence artificielle, les personnages virtuels (c.-à-d. personnages représentés numériquement d’apparence humaine ou non) sont pressentis comme de futurs prestataires de soins en santé mentale. À ce jour, l’utilisation principale de tels personnages est toutefois marginale et se limite à une aide complémentaire à la pratique des cliniciens. Des préoccupations liées à la sécurité et l’efficacité, ainsi qu’un manque de connaissances et de compétences peuvent expliquer cette discordance entre ce que certains s’imaginent être l’utilisation future (voire futuriste) des personnages virtuels et leur utilisation actuelle. Un aperçu des récentes données probantes contribuerait à réduire cette divergence et à mieux saisir les enjeux associés à leur utilisation plus répandue en santé mentale.

Objectif Cet article vise à informer tous les acteurs impliqués, dont les cliniciens, quant au potentiel des personnages virtuels en santé mentale, et de les sensibiliser aux enjeux associés à leur usage.

Méthode Une recension narrative de la littérature a été réalisée afin de synthétiser les informations obtenues de la recherche fondamentale et clinique, et de discuter des considérations sociétales.

Résultats Plusieurs caractéristiques des personnages virtuels provenant de la recherche fondamentale ont le potentiel d’influencer les interactions entre un patient et un clinicien. Elles peuvent être regroupées en deux grandes catégories : les caractéristiques liées à la perception (p. ex. réalisme) et celles liées à l’attribution spontanée d’une catégorie sociale au personnage virtuel par un observateur (p. ex. genre). Selon la recherche clinique, plusieurs interventions ou évaluations utilisant des personnages virtuels ont montré divers degrés d’efficacité en santé mentale, et certains éléments de la relation thérapeutique (p. ex. alliance et empathie) peuvent d’ailleurs être présents lors d’une relation avec un personnage virtuel. De multiples enjeux socioéconomiques et éthiques doivent aussi être discutés en vue d’un développement et d’une utilisation plus accrue qui soient responsables et éthiques. Bien que l’accessibilité et la disponibilité des personnages virtuels constituent un avantage indéniable pour l’offre de services en santé mentale, certaines iniquités demeurent. L’accumulation de données biométriques (p. ex. rythme cardiaque) a également le potentiel d’enrichir le travail des cliniciens, mais aussi de mener au développement de personnages virtuels autonomes à l’aide de l’intelligence artificielle, ce qui pourrait conduire à certains dérapages (p. ex. erreurs de décision clinique). Quelques pistes de recommandations visant à éviter ces effets indésirables sont présentées.

Conclusion L’emploi des personnages virtuels sera de plus en plus répandu en santé mentale en raison de leurs avantages prometteurs. Ainsi, il est souhaitable que tous les acteurs impliqués s’informent sur leur usage dans ce contexte, se sensibilisent aux enjeux spécifiques, participent activement aux discussions quant à leur développement et adoptent des recommandations uniformes en vue d’un usage sécuritaire et éthique en santé mentale.

Changes in Brain Activation through Cognitive-Behavioral Therapy with Exposure to Virtual Reality: A Neuroimaging Study of Specific Phobia

Background: Cognitive-behavioral therapy (CBT) with exposure is the treatment of choice for specific phobia. Virtual reality exposure therapy (VRET) has shown benefits for the treatment and prevention of the return of fear in specific phobias by addressing the therapeutic limitations of exposure to real images. Method: Thirty-one participants with specific phobias to small animals were included: 14 were treated with CBT + VRET (intervention group), and 17 were treated with CBT + exposure to real images (active control group). Participants’ scores in anxiety and phobia levels were measured at baseline, post-treatment, and 3-month follow-up, and brain activation was measured through functional magnetic resonance imaging (fMRI) baseline and post-treatment. Results: Both groups showed a significant decrease in anxiety and phobia scores after the therapy and were maintained until follow-up. There were no significant differences between both groups. Overall, fMRI tests showed a significant decrease in brain activity after treatment in some structures (e.g., prefrontal and frontal cortex) and other structures (e.g., precuneus) showed an increasing activity after therapy. However, structures such as the amygdala remained active in both groups. Conclusions: The efficacy of CBT + VRET was observed in the significant decrease in anxiety responses. However, the results of brain activity observed suggest that there was still a fear response in the brain, despite the significant decrease in subjective anxiety levels.

Psychiatry in the Digital Age: A Blessing or a Curse?

Social distancing and the shortage of healthcare professionals during the COVID-19 pandemic, the impact of population aging on the healthcare system, as well as the rapid pace of digital innovation are catalyzing the development and implementation of new technologies and digital services in psychiatry. Is this transformation a blessing or a curse for psychiatry? To answer this question, we conducted a literature review covering a broad range of new technologies and eHealth services, including telepsychiatry; computer-, internet-, and app-based cognitive behavioral therapy; virtual reality; digital applied games; a digital medicine system; omics; neuroimaging; machine learning; precision psychiatry; clinical decision support; electronic health records; physician charting; digital language translators; and online mental health resources for patients. We found that eHealth services provide effective, scalable, and cost-efficient options for the treatment of people with limited or no access to mental health care. This review highlights innovative technologies spearheading the way to more effective and safer treatments. We identified artificially intelligent tools that relieve physicians from routine tasks, allowing them to focus on collaborative doctor-patient relationships. The transformation of traditional clinics into digital ones is outlined, and the challenges associated with the successful deployment of digitalization in psychiatry are highlighted.

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose

Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.

Findings

There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.

Summary

This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.

The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.

Implementation of Therapeutic Virtual Reality Into Psychiatric Care: Clinicians' and Service Managers' Perspectives

Objectives: Virtual reality (VR) has emerged as a highly promising tool for assessing and treating a range of mental illnesses. However, little is known about the perspectives of key stakeholders in mental healthcare, whose support will be critical for its successful implementation into routine clinical practise. This study aimed to explore the perspectives of staff working in the private mental health sector around the use of therapeutic VR, including potential implementation barriers and facilitators. Methods: Semi-structured qualitative interviews were conducted with cross-disciplinary clinicians (n = 14) and service managers (n = 5), aged 28-70 years working in a major private mental health hospital in Victoria, Australia. Transcripts were analysed using general inductive coding to allow themes to naturally emerge. Results: Three major themes were identified: clinical factors (four subthemes), organisational factors (five subthemes), and professional factors (three subthemes). The themes encompassed enabling factors and potential barriers that need to be addressed for successful implementation of VR. Clinical factors highlighted the influence of knowledge or perceptions about appropriate clinical applications, therapeutic efficacy, safety and ethical concerns, and patient engagement. Organisational factors emphasised the importance of service contexts, including having a strong business case, stakeholder planning, recruitment of local opinion leaders to champion change, and an understanding of resourcing challenges. Professional factors highlighted the need for education and training for staff, and the influence of staff attitudes towards technology and perceived usability of VR. Conclusions: In addition to enabling factors, potential implementation barriers of therapeutic VR were identified, including resourcing constraints, safety and ethical concerns, negative staff attitudes towards technology and VR system limitations. Future dissemination should focus on addressing knowledge and skills gaps and attitudinal barriers through development of clinical guidelines, training programs, and implementation resources (e.g., adoption decision tools, consultation opportunities).