Examining the Efficacy of Extended Reality-Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial.

BACKGROUND: Major depressive disorder (MDD) is a global concern with increasing prevalence. While many evidence-based psychotherapies (EBPs) have been identified to treat MDD, there are numerous barriers to patients accessing them. Virtual reality (VR) has been used as a treatment enhancement for a variety of mental health disorders, but few studies have examined its clinical use in treating MDD. Behavioral activation (BA) is a simple yet effective and established first-line EBP for MDD that has the potential to be easily enhanced and adapted with VR technology. A previous report by our group explored the feasibility and acceptability of VR-enhanced BA in a small clinical proof-of-concept pilot. This study examines the clinical efficacy of a more immersive extended reality (XR)-enhanced BA (XR-BA) prototype. This is the first clinical efficacy test of an XR-BA protocol. OBJECTIVE: This study examined whether XR-BA was feasible and efficacious in treating MDD in an ambulatory telemedicine clinic. METHODS: A nonblinded between-subject randomized controlled trial compared XR-BA to traditional BA delivered via telehealth. The study used a previously established, brief 3-week, 4-session BA EBP intervention. The experimental XR-BA participants were directed to use a Meta Quest 2 (Reality Labs) VR headset to engage in simulated pleasant or mastery activities and were compared to a control arm, which used only real-life mastery or pleasant activities as between-session homework. The Patient Health Questionnaire (PHQ)-9 was the primary outcome measure. Independent-sample and paired-sample t tests (2-tailed) were used to determine statistical significance and confirmed using structural equation modeling. RESULTS: Overall, 26 participants with MDD were randomized to receive either XR-BA (n=13, 50%) or traditional BA (n=13, 50%). The mean age of the 26 participants (n=6, 23% male; n=19, 73% female; n=1, 4% nonbinary or third gender) was 50.3 (SD 17.3) years. No adverse events were reported in either group, and no substantial differences in dropout rates or homework completion were observed. XR-BA was found to be statistically noninferior to traditional BA (t18.6=-0.28; P=.78). Both the XR-BA (t9=2.5; P=.04) and traditional BA (t10=2.3; P=.04) arms showed a statistically significant decrease in PHQ-9 and clinical severity from the beginning of session 1 to the beginning of session 4. There was a significant decrease in PHQ-8 to PHQ-9 scores between the phone intake and the beginning of session 1 for the XR-BA group (t11=2.6; P=.03) but not the traditional BA group (t11=1.4; P=.20). CONCLUSIONS: This study confirmed previous findings that XR-BA may be a feasible, non-inferior, and acceptable enhancement to traditional BA. Additionally, there was evidence that supports the potential of XR to enhance expectation or placebo effects. Further research is needed to examine the potential of XR to improve access, outcomes, and barriers to MDD care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05525390; https://clinicaltrials.gov/study/NCT05525390.

Best Practices for Research in Virtual and Augmented Reality in Dermatology.

Virtual reality (VR) and augmented reality (AR) technologies have advanced rapidly in recent years. These cutting-edge technologies provide dermatology researchers, educators, proceduralists, and patients with opportunities in new scientific horizons. VR is a technology that facilitates immersive human experiences by allowing users to connect with various simulated environments through natural head and hand movements, whereas AR supplements a user's perception of their real environment with virtual elements. Despite technological advancements, there is limited literature on the methodological steps for conducting rigorous VR and AR research in dermatology. Effective storyboarding, user-driven design, and interdisciplinary teamwork play a central role in ensuring that VR/AR applications meet the specific needs of dermatology clinical and research teams. We present a step-by-step approach for their design, team composition, and evaluation in dermatology research, medical education, procedures, and habit formation strategies. We also discuss current VR and AR dermatology applications and the importance of ethical and safety considerations in deploying this new technology.

From 65 to 103, Older Adults Experience Virtual Reality Differently Depending on Their Age: Evidence from a Large-Scale Field Study in Nursing Homes and Assisted Living Facilities.

There is growing interest in applications of virtual reality (VR) to improve the lives of older adults, but the limited research on older adults and VR largely treats older adults as a monolith, ignoring the substantial differences across 65 to 100+ year olds that may affect their experience of VR. There are also few existing studies examining the experiences and challenges facing those who facilitate VR for older adults (e.g., caregiving staff). We address these limitations through two studies. In study 1, we explore variation within older adults' experiences with VR through a field study of VR use among a large (N = 245) and age-diverse (Mage = 83.6 years, SDage = 7.9, range = 65-103 years) sample of nursing home and assisted living facility residents across 10 U.S. states. Age was negatively associated with the extent to which older adults enjoyed VR experiences. However, the negative relationship between age and older adults' attitudes toward VR was significantly less negative than the relationship between age and their attitudes toward other technologies (cell phones and voice assistants). In study 2, we surveyed caregiving staff (N = 39) who facilitated the VR experiences for older adult residents and found that the caregiving staff generally enjoyed the activity relative to other activities and felt it to be beneficial to their relationship with residents.

Exploring the Relationship Between Attribute Discrepancy and Avatar Embodiment in Immersive Social Virtual Reality.

Social virtual reality (VR) is an emerging set of platforms where users interact while embodying avatars. Given that VR headsets track real physical movements and map them onto one's avatar body, the nature of one's digital representation is an important aspect of social VR. However, little is known about how the visual proximity of an avatar to the self shapes user experience in naturalistic, social VR environments. In this article, we use this context to explore how embodiment is influenced by the perceived differences between the physical attributes of a user and the virtual attributes of their avatar. We selected a number of attributes for this measure that have been shown to be important for customization and representation in VR. Participants created an avatar, spent time in social VR, and reported on their experience in a questionnaire. Our results demonstrate a significant negative association between attribute discrepancy and avatar embodiment, the psychological experience of one's virtual body as their own body. We discuss implications for theories of self-representation and suggest urgency on the part of games and VR designers to improve the methods of creating avatars.

Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial.

BACKGROUND: Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD. OBJECTIVE: We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD. METHODS: A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire-9. RESULTS: Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant's clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire-9 score. CONCLUSIONS: The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/24331.

Facial Appearance Dissatisfaction Explains Differences in Zoom Fatigue.

Viewing self-video during videoconferences potentially causes negative self-focused attention that contributes to virtual meeting (VM) or "Zoom" fatigue. The present research examines this proposition, focusing on facial dissatisfaction-feeling unhappy about one's own facial appearance-as a potential psychological mechanism of VM fatigue. A study of survey responses from a panel of 613 adults found that VM fatigue was 14.9 percent higher for women than for men, and 11.1 percent higher for Asian than for White participants. These gender and race/ethnicity differences were found to be mediated by facial dissatisfaction. This study replicates earlier VM fatigue research, extends the theoretical understanding of facial dissatisfaction as a psychological mechanism of VM fatigue, and suggests that practical approaches to mitigating VM fatigue could include implementing technological features that reduce self-focused attention during VMs (e.g., employing avatars).

Virtual Animals as Diegetic Attention Guidance Mechanisms in 360-Degree Experiences.

360-degree experiences such as cinematic virtual reality and 360-degree videos are becoming increasingly popular. In most examples, viewers can freely explore the content by changing their orientation. However, in some cases, this increased freedom may lead to viewers missing important events within such experiences. Thus, a recent research thrust has focused on studying mechanisms for guiding viewers' attention while maintaining their sense of presence and fostering a positive user experience. One approach is the utilization of diegetic mechanisms, characterized by an internal consistency with respect to the narrative and the environment, for attention guidance. While such mechanisms are highly attractive, their uses and potential implementations are still not well understood. Additionally, acknowledging the user in 360-degree experiences has been linked to a higher sense of presence and connection. However, less is known when acknowledging behaviors are carried out by attention guiding mechanisms. To close these gaps, we conducted a within-subjects user study with five conditions of no guide and virtual arrows, birds, dogs, and dogs that acknowledge the user and the environment. Through our mixed-methods analysis, we found that the diegetic virtual animals resulted in a more positive user experience, all of which were at least as effective as the non-diegetic arrow in guiding users towards target events. The acknowledging dog received the most positive responses from our participants in terms of preference and user experience and significantly improved their sense of presence compared to the non-diegetic arrow. Lastly, three themes emerged from a qualitative analysis of our participants' feedback, indicating the importance of the guide's blending in, its acknowledging behavior, and participants' positive associations as the main factors for our participants' preferences.

Effect of Virtual Reality Perspective-Taking on Related and Unrelated Contexts.

Virtual reality perspective-taking (VRPT) experiences effectively increase both empathy and prosocial behaviors toward related social targets (e.g., cutting down a tree in virtual reality increases concern for the environment). This project tests the prediction that empathy is analogous to a muscle that increases with practice and can transfer to unrelated contexts instead of being a mental state that increases only for a specific context or target. This study examines the extent to which VRPT experiences can train empathic skills that are applied to unrelated social targets and contexts. Two thirds of the participants engaged in VRPT experiences either showing what it is like to become homeless or how ocean acidification affects the marine environment. A third of the participants were in the control condition and did not complete a VRPT task. Results replicate previous findings showing that VRPT tasks increase related context empathy and prosocial behaviors; however, the results on VRPTs effect on empathy and prosocial behaviors for unrelated contexts were mixed. The VRPT ocean acidification task was more effective at inducing empathy for the homeless, an unrelated social target, than the control condition, but the empathy-transfer effect did not occur from the homeless context to the ocean context. Replicating previous work, participants who experienced what it is like to become homeless signed a petition supporting the homeless at significantly higher rates than participants in the control condition. These findings show that transfer of empathy from one context to another is possible, but this transfer does not occur for all contexts.

Virtual reality and the psychology of climate change.

Researchers and practitioners have used virtual reality (VR) as a tool to understand attitudes and behaviors around climate change for decades. As VR has become more immersive, mainstream, and commercially available, it has also become a medium for education about climate issues, a way to indirectly expose users to novel stimuli, and a tool to tell stories about antienvironmental activity. This review explicates the relationship between VR and climate change from a psychological perspective and offers recommendations to make virtual experiences engaging, available, and impactful for users. Climate change is perhaps the most urgent global issue of our lifetime with irreversible consequences. It therefore requires innovative experiential approaches to teach its effects and modify attitudes in support of proenvironmental actions.

The effect of water immersion on vection in virtual reality.

Research about vection (illusory self-motion) has investigated a wide range of sensory cues and employed various methods and equipment, including use of virtual reality (VR). However, there is currently no research in the field of vection on the impact of floating in water while experiencing VR. Aquatic immersion presents a new and interesting method to potentially enhance vection by reducing conflicting sensory information that is usually experienced when standing or sitting on a stable surface. This study compares vection, visually induced motion sickness, and presence among participants experiencing VR while standing on the ground or floating in water. Results show that vection was significantly enhanced for the participants in the Water condition, whose judgments of self-displacement were larger than those of participants in the Ground condition. No differences in visually induced motion sickness or presence were found between conditions. We discuss the implication of this new type of VR experience for the fields of VR and vection while also discussing future research questions that emerge from our findings.

Facial expressions contribute more than body movements to conversational outcomes in avatar-mediated virtual environments.

This study focuses on the individual and joint contributions of two nonverbal channels (i.e., face and upper body) in avatar mediated-virtual environments. 140 dyads were randomly assigned to communicate with each other via platforms that differentially activated or deactivated facial and bodily nonverbal cues. The availability of facial expressions had a positive effect on interpersonal outcomes. More specifically, dyads that were able to see their partner's facial movements mapped onto their avatars liked each other more, formed more accurate impressions about their partners, and described their interaction experiences more positively compared to those unable to see facial movements. However, the latter was only true when their partner's bodily gestures were also available and not when only facial movements were available. Dyads showed greater nonverbal synchrony when they could see their partner's bodily and facial movements. This study also employed machine learning to explore whether nonverbal cues could predict interpersonal attraction. These classifiers predicted high and low interpersonal attraction at an accuracy rate of 65%. These findings highlight the relative significance of facial cues compared to bodily cues on interpersonal outcomes in virtual environments and lend insight into the potential of automatically tracked nonverbal cues to predict interpersonal attitudes.

Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report.

BACKGROUND: Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one's ability to engage in behavioral activation, with COVID-19 "shelter-in-place" and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times. OBJECTIVE: The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention. METHODS: The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales. RESULTS: The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant's depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression). CONCLUSIONS: The implications of these findings for future research are discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316.

Personal identifiability of user tracking data during observation of 360-degree VR video.

Virtual reality (VR) is a technology that is gaining traction in the consumer market. With it comes an unprecedented ability to track body motions. These body motions are diagnostic of personal identity, medical conditions, and mental states. Previous work has focused on the identifiability of body motions in idealized situations in which some action is chosen by the study designer. In contrast, our work tests the identifiability of users under typical VR viewing circumstances, with no specially designed identifying task. Out of a pool of 511 participants, the system identifies 95% of users correctly when trained on less than 5 min of tracking data per person. We argue these results show nonverbal data should be understood by the public and by researchers as personally identifying data.

Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine.

PROBLEM: Racism and bias are fundamental causes of health inequities, and they negatively affect the climate of academic medical institutions across the United States. APPROACH: In 2019, the Zucker School of Medicine and Northwell Health piloted a virtual reality (VR) racism experience as a component of professional development for medical school and health system leaders, faculty, and staff. Participants experienced a 60-minute, interactive, large-group session on microaggressions and, as individuals, a 20-minute VR module. These were followed by group reflection and debriefing. The sessions, developed in collaboration with a VR academic team, represented a response to institutional climate assessment surveys, which indicated the need for expanded professional training on cross-cultural communication and enhancing inclusion. OUTCOMES: In October 2019, 112 faculty and staff participated in the workshop. On a postworkshop survey, completed by 76 participants (67.9%), most respondents (90.8%) reported feeling engaged in the VR experience. Additionally, the majority agreed that VR was an effective tool for enhancing empathy (94.7%), that the session enhanced their own empathy for racial minorities (85.5%), and that their approach to communication would change (67.1%). In open-ended responses, participants frequently conveyed enthusiasm, powerful emotional and physiologic responses, and enhanced empathy. They also suggested more time for follow-up discussions. NEXT STEPS: Next steps include assessing the scalability of the VR module; determining effective complementary engagements; and measuring the module's longitudinal effects on racial empathy, discrimination, and institutional climate. As VR becomes more common in medical education, developing VR modules to address other forms of discrimination (e.g., sexism, homophobia) could also benefit the institutional climates of medical schools and health systems as academic medicine continues to build toward health equity.

The future is now: Age-progressed images motivate community college students to prepare for their financial futures.

Part of the challenge young people face when preparing for lifelong financial security is visualizing the far-off future. Age-progression technology has been shown to motivate young people to save for retirement. The current study applied age progression for motivating socioeconomically diverse community college students as part of a college planning course. We recruited 106 students enrolled in a mandatory "Transitioning to College" course and randomly assigned them to view age-progressed or same-aged digital avatars. Compared to controls, age-progressed participants gave more correct answers and exhibited higher confidence (i.e., fewer "don't know" responses) on a financial literacy test. Confidence mediated the effect of age progression on correct responses, but not the other way around, pointing to financial confidence as a precursor to effective financial education. Students also reported interest in attending more long-term financial planning workshops (e.g., investing and retirement) available through their college. No differences were observed in financial planning for the near term (e.g., student aid and credit cards). The current study demonstrates the viability of age progression as a practical, inexpensive, and scalable intervention. Findings also illustrate the significance of this intervention for reducing pervasive socioeconomic and age disparities in financial knowledge and enhancing long-term financial prospects across future generations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Virtual Reality-Delivered Mirror Visual Feedback and Exposure Therapy for FND: A Midpoint Report of a Randomized Controlled Feasibility Study.

OBJECTIVE: The aim was to provide preliminary feasibility, safety, and efficacy data for a personalized virtual reality-delivered mirror visual feedback (VR-MVF) and exposure therapy (VR-ET) intervention for functional neurological disorder (FND). METHODS: Midpoint results of a single-blind, randomized controlled pilot are presented. Fourteen adults were randomly assigned to eight weekly 30-minute VR sessions-seven in the treatment arm and seven in the control arm. The treatment arm consisted of an immersive avatar-embodied VR-MVF treatment, plus optional weekly VR-ET starting at session 4 if participants had identifiable FND triggers. The control arm received equally immersive nonembodied sessions involving exploration of a virtual interactive space. Feasibility was measured by acceptability of randomization, completion rates, side effects, adverse events, and integrity of blinding procedures. Exploratory primary and secondary outcome measures were weekly symptom frequency and the Oxford Handicap Scale, respectively. RESULTS: Two early dropouts occurred in the treatment arm, resulting in an 86% completion rate (N=12/14). No side effects or adverse events were reported. Blind assessment at study end indicated that two of the seven treatment arm and three of the seven control arm participants incorrectly guessed their assignment. Changes in mean symptom frequency and disability were reported, but data will not be statistically analyzed until study end. CONCLUSIONS: This study is the first to report on MVF and VR for treatment of FND. Results generated thus far support feasibility and justify continuation of the study and further investigation into the efficacy of VR interventions for FND.