The cognitive-behavioral therapy–based treatment was particularly effective for patients with the highest level of avoidance of everyday situations.
Courtesy University of Oxford
Dr. Daniel Freeman
“Virtual reality is an inherently therapeutic medium which could be extremely useful in mental health services,” study investigator Daniel Freeman, PhD, DClinPsy, professor of clinical psychology, University of Oxford (England), told this news organization. “This intervention is coming; the question really is when.”
The study was published online in The Lancet Psychiatry.
Real-world feel
Immersive VR involves interactive three-dimensional computer-generated environments that produce the sensation of being in the real world.
For patients with psychosis, dealing with the real world can be an anxious experience, particularly if they have verbal or auditory hallucinations.
Some may develop agoraphobia and start to avoid places or situations. A virtual environment allows patients to practice dealing with situations that make them anxious or uncomfortable and to learn to reengage in everyday situations.
The study included 346 patients diagnosed with schizophrenia or a related disorder. The mean age of the patients was 37.2 years (67% were men, 85% were White). Most were single and unemployed. All were receiving treatment for psychosis and had difficulty going out because of anxiety.
The researchers randomly assigned 174 participants to an automated VR cognitive therapy intervention (gameChange) plus usual care and 172 to usual care alone. Trial assessors were blinded to group allocation.
The gameChange intervention was delivered in six sessions that were conducted over a 6-week period. Each session involved 30 minutes of VR.
A session begins when participants enter the virtual therapist’s office. They are met by a coach who guides them through the therapy. They can choose from among six VR social situations. These include a cafe, a general practice waiting room, a pub, a bus, opening the front door of their home onto the street, or entering a small local shop.
Each scenario has five levels of difficulty that are based on the number and proximity of people in the social situation and the degree of social interaction. Users can work their way through these various levels.
The virtual sessions took place in patients’ homes in about 50% of cases; the remainder were conducted in the clinic. A mental health worker was in the room during the therapy.
Between virtual sessions, participants were encouraged to apply what they learned in the real world, for example, by spending time in a pub.
Usual care typically included regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist.
Widely applicable?
The primary outcome was the eight-item Oxford Agoraphobic Avoidance Scale (O-AS) questionnaire. This scale assesses distress and avoidance related to performing increasingly difficult everyday tasks.
The researchers assessed patients at baseline, at the conclusion of the 6-week treatment, and at 26 weeks.
Compared with the group that received usual care alone, the VR therapy group demonstrated a significant reduction in both agoraphobic avoidance (O-AS adjusted mean difference, -0.47; 95% confidence interval [CI], –0.88 to –0.06; Cohen’s d, –0.18; P = .026) and distress (–4.33; 95% CI, –7.78 to –0.87; Cohen’s d, –0.26; P = .014) at 6 weeks.
This translates to being able to do about 1.5 more activities on the O-AS, such as going to a shopping center alone, said Dr. Freeman.
Further analyses showed that VR therapy was especially effective for patients with severe agoraphobia. On average, these patients could complete two more O-AS activities at 26 weeks, said Dr. Freeman.
The authors believe the intervention worked by reducing defense behaviors, such as avoiding eye contact and fearful thoughts.
There was no significant difference in occurrence of adverse events between the study groups. These events, which were mild, transient, and did not affect the outcome, included side effects such as claustrophobia when using headsets.
The intervention would likely work for patients with agoraphobia who do not have psychosis, said Dr. Freeman. “Agoraphobia is often the final common pathway in lots of mental health conditions.”
Automated VR not only addresses the problem of patients being too afraid to leave home for in-person treatment but may also help address the shortage of trained mental health care providers.
The intervention is available at pilot implementation sites in the United Kingdom and a few sites in the United States, he said.