VR for Mental Health — Part 3: Post-traumatic stress disorder and depression

Written by Caitlín Hastings

This is the third instalment of our multi-part literature review on applying Virtual Reality (VR) to mental health interventions:

1. An overview of VR mental health interventions
2. Anxiety disorders
3. Post-traumatic stress disorder and depression
4. Eating disorders
5. Substance use disorder

Introduction

Over the past few years, Animorph have been exploring how the cutting-edge capabilities of Extended Reality (XR) may help to address medical challenges. We have embarked on an investigation of evidence-based research and are pleased to share our findings with the public.

Beyond our investigation of anxiety, the literature in VR has been expanding in other areas of mental health. Anxiety research has provided insights on how VR can be adapted for assessment and intervention and this has informed research in other disorders. In this section, we will examine the current research in post-traumatic stress disorder and depression.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a condition where people suffer symptoms of avoidance, intrusive memories, hyperarousal, and alterations in mood and cognition after exposure to a traumatic event (death, combat, sexual or physical assault) (1). PTSD may be considered an anxiety disorder but is discussed here as it is under Trauma- and Stressor-related disorders in the DSM-5. Current common treatments for PTSD include Cognitive Behavioural Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR) and exposure therapy (which can be imagined) (2). Like in anxiety, exposure therapy in PTSD is based on emotional processing theory (EPT) (3) — which suggests that exposing to trauma and modifying fear structures is key to overcoming them.

As with other disorders, in vivo exposure therapy carries the usual restrictions of safety, availability of the environment, and cost. Virtual Reality Exposure Therapy (VRET) then has an advantage; especially as it has been shown to elicit similar emotional responses as in vivo situations (4). Scenarios can be adapted to suit the patient group e.g. jungle for Vietnam veterans, desert terrain for Middle Eastern conflict veterans, or an urban scene for individuals who may have experienced a physical assault. Another advantage of VRET, is that it has been shown to be successful in patients unresponsive to imagined exposure therapy (5). One of the symptoms of PTSD is difficulty in recalling the traumatic event, and so some patients may find imagined exposure therapy particularly hard (6). Finally, some studies have also found that patients may prefer VRET to traditional exposure therapies (7). However, as will be discussed, results from VRET studies with PTSD have been mixed and there is no consensus on how long effects may last in comparison with standard treatment; it may require further research to build up a clear picture of its efficacy.

(There are two other virtual trauma interventions — Multi-Modular Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), which is based on EMDR, and Action Centred Exposure Therapy (ACET), based on an inhibitory learning model. There is very little research to date with these interventions, hence we will focus on VRET in this review. The scoping review by Knaust et al. (8) discusses 3MDR and ACET interventions in a little more detail. The authors have predicted that focus may shift to 3MDR in the future.)

Small early studies with VR and PTSD showed promising results; Vietnam veterans with chronic treatment-resistant PTSD displayed improvement in symptoms with VRET (9, 10). VRET has also been used in other scenarios, such as with individuals who experienced PTSD after road traffic accidents — again showing a reduction in symptoms. However, the sample was small and there was no control condition (11). Another study focussed on patients from the 9/11 disaster (12). It was found that there was a significant decline in symptoms with VRET, this was compared to waitlist and maintained at 6-month follow-up. The participants experienced trauma in a variety of ways (firefighters, civilians, and disaster workers) suggesting that the VR stimuli were effective in all these cases to some extent. Military sexual trauma has also been examined in a study by Loucks et al. (13). It was found there was an improvement in symptoms, and these were maintained at a 3-month follow-up, where the percentage of participants meeting PTSD criteria continued to decline from 53% to 33%. However, it should be noted that there is a strong bias in the literature for military trauma and these studies are not replicated.

Other studies have looked at VRET augmented with medication — D-cycloserine (DCS). (This medication has been used to improve the efficacy and durability of exposure therapy by enhancing neuroplasticity). One double blind placebo-controlled study looked at 156 Iraq/Afghanistan veterans and found there was a reduction in symptoms that was maintained at 3-, 6- and 12-months follow-up (14). There was no overall difference related to medication use, but secondary measures did show improvements in biomarkers of startle and cortisol. Another smaller randomised controlled trial (RCT) with 25 patients also found promising results with DCS and VRET, when compared with placebo (15). Patients on the medication had earlier and greater improvements, which were maintained at 6 months follow-up. It should be noted however, there was no control condition for VRET in either of these studies.

The first study to compare VRET to another active treatment (present-centred therapy) was with Vietnam veterans and did not find any significant difference post-treatment, although it did note a moderate advantage for VRET at 6-months post-treatment (16). An RCT compared prolonged exposure, VRET and wait list for 162 active duty soldiers (17). Prolonged exposure and VRET were found to have significant reduction in symptoms compared with wait list, but prolonged exposure was found to have greater symptom reduction at 3- and 6-month follow-up when compared with VRET. This indicates that prolonged exposure therapy may have an advantage with symptom recovery when treatment ends. It was proposed that improved VR content in the future may help with a sense of presence and therefore emotional engagement (18). It was this need for better VR content that led to the development of the ‘Bravemind’ system, funded by the US Department of Defense in 2011. This system aimed to diversify the VR scenario content and make it more customisable to suit the broad range of users with varied trauma experiences (19). This is currently distributed over 60 sites and used with veterans of the Iraq and Afghanistan wars.

There has been minimal research into VR as an assessment tool for PTSD. However, one study did examine skin conductance reactivity as a diagnostic tool (20). Veterans who had served in Iraq and Afghanistan with PTSD showed more reactivity when watching combat events compared to veterans with no PTSD. This shows a potential, which could be further examined in future research. Research by Freeman et al. (21) has looked into predicting which individuals will develop PTSD. They recruited 106 participants who had attended hospital 4 weeks previously due to physical assault. These individuals were then immersed in a VR train ride; reactions and paranoid thinking about the neutral VR-characters were assessed (self-report and standard interviewer methods). It was found that responses to VR predicted the severity of paranoia and PTSD symptoms, as assessed by standard measures 6 months later.

There is also a need to have research looking into the prevention of PTSD, and VR may play an important role in prepping military personnel for deployment. The STress Resilience In Virtual Environments (STRIVE) study has attempted to do this (22). STRIVE uses similar scenarios to those used in the Bravemind study but allows for learning moments when a traumatic event occurs. This has been drawn from the strategies and content which is used in classroom-delivered resilience training programmes. The study has reported some positive initial ratings from military personnel and significant changes in Heart Rate Variability (HRV) (23). However, further research in this area is needed, especially with more varied samples and on topics outside of combat trauma.

As mentioned, VRET study results have been mixed, especially with the length of effect in comparison to standard treatment. Meta-analyses have echoed this, with a paper by Kothgassner et al. (24) showing that VRET was significantly better than wait list, but there was no difference between VRET and active comparators. Another meta-analysis showed moderate positive effects of VRET on PTSD, and this was in comparison with inactive and active control groups (25). However, it should be noted that the majority of research to date has had limitations with very small sample sizes; and the majority of participants are middle aged males, usually experiencing trauma as a result of combat or physical assault. Moreover, many studies lack true randomisation techniques and VRET has not been consistently compared to the same active interventions. Numerous studies do not empirically examine a sense of presence either, which is vital in VR research (26). There have been some promising results and in order to have a true comparison more research with larger and more varied samples, control measures and consistent standard interventions, is needed.

Depression

Depression is one of the most common psychiatric disorders affecting approximately 280 million people worldwide, and depressive symptoms are also frequently present in many other psychiatric disorders (27, 28). It is a condition with symptoms including low mood or anhedonia, change in appetite, sleep difficulties, psychomotor agitation or retardation, fatigue, concentration issues, worthlessness or guilt and suicidality (29). Despite its prevalence, there have been relatively few studies looking at assessment, intervention, or insight into this disorder with VR. In their review, Freeman et al. (30) identified only two studies using immersive VR with depression at the time. There have been studies looking at depressive symptoms in other disorders such as anxiety, PTSD, and psychosis (31, 32, 33, 34, 35). Some of these studies have had an effect on depressive symptoms, which indicates the potential for future VR research.

The first intervention study for depression using VR examined stress management with 22 participants in a quasi-experimental study (36). This looked at psychoeducation and incorporated VR relaxation practice. It was found that subjective stress, depression and anxiety were lowered. Another intervention focussing on depressive symptoms, worked on self-compassion (37). The study aimed to counteract self-criticism in depressive patients (n=15) by allowing them to practise self-compassion. The participants embodied a virtual adult body and delivered compassion to a virtual child. They then embodied the virtual child body and received compassion from a recording of themselves as the virtual adult. This led to significant reductions in depression severity and self-criticism, with a significant increase in self-compassion. Four patients showed clinically significant improvement. Finally, the COVID-19 pandemic has meant that many individuals have been confined to their homes and have been unable to partake in activities they enjoy. This is the basis of behavioural activation (BA), which encourages depression sufferers to engage in more pleasurable activities and decrease activities that maintain or increase risk of depression. A feasibility RCT with 13 participants allowed individuals to choose and experience activities, which they previously enjoyed in a VR environment (38). The protocol demonstrated a significant decrease in depression with the use of VR BA. This is encouraging and warrants further research with a larger sample size.

As expected, the shortage of research in this area has meant that there is also a lack of work looking at VR with different populations suffering depression. However, a study by Schleider et al., (39) is looking at VR with adolescent depression, and was completed in December 2021 with data cleaning and analysis underway. Participants (n=159), aged 12–16 years were randomised to 3 conditions — the VR Personality Project; a Web-based growth mindset (GM) intervention; or an active, Web-based control. The VR Personality Project teaches growth mindset (GM); the belief that personal attributes are malleable rather than fixed. The hope is that the sense of perceived control from VR will aid results. A review by Zhai et al. (40) has looked at VR interventions for depression in the geriatric population in long-term care facilities. While depression in the older population may look different in some aspects of the symptomatology, some VR interventions aimed at combatting place attachment do appear to have had some positive results.

Again, due to the lack of research there have not been any systematic reviews or meta-analyses looking at depression and VR alone. However, a meta-analysis by Fodor et al. (41), which examining the efficacy of VR for symptoms of anxiety and depression, found that VR was more effective than control, and that there were no major differences between VR and other active interventions. Although more research is needed before conclusions can be drawn, indications from studies suggest depressive symptoms can be targeted with VR. Suggestions for possible research is compiled in a review by Lindner et al. (42). They show that cognitive behavioural therapeutic (CBT) intervention and techniques used for depression currently are very easily adapted to use in VR. The hope is that with advances in technology and the growing interest in VR, the research into depression will be as successful as the research with anxiety.

Conclusion

Current research in the topics of depression and PTSD has shown innovation and creativity and has great potential in the future to create a lasting impact. However, in order to make solid inferences, larger and more diverse samples are needed as well as robust control measures. Depression is also lagging behind when compared with the research coming out in other mental health disorders and considering the scale of the disorder VR could have a substantial effect. We are confident that VR offers significant potential for further, more conclusive research.

The next instalment will focus on eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder.

References

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