Automated VR therapy for improving positive self-beliefs and psychological well-being in young patients with psychosis: a proof of concept evaluation of Phoenix VR self-confidence therapy.

BACKGROUND: Low self-confidence in patients with psychosis is common. This can lead to higher symptom severity, withdrawal from activities, and low psychological well-being. There are effective psychological techniques to improve positive self-beliefs but these are seldom provided in psychosis services. With young people with lived experience of psychosis we developed a scalable automated VR therapy to enhance positive-self beliefs. AIMS: The aim was to conduct a proof of concept clinical test of whether the new VR self-confidence therapy (Phoenix) may increase positive self-beliefs and psychological well-being. METHOD: Twelve young patients with non-affective psychosis and with low levels of positive self-beliefs participated. Over 6 weeks, patients were provided with a stand-alone VR headset so that they could use Phoenix at home and were offered weekly psychologist meetings. The outcome measures were the Oxford Positive Self Scale (OxPos), Brief Core Schema Scale, and Warwick-Edinburgh Well-being Scale (WEMWBS). Satisfaction, adverse events and side-effects were assessed. RESULTS: Eleven patients provided outcome data. There were very large end-of-treatment improvements in positive self-beliefs (OxPos mean difference = 32.3; 95% CI: 17.3, 47.3; Cohen's d=3.0) and psychological well-being (WEMWBS mean difference = 11.2; 95% CI: 8.0, 14.3; Cohen's d=1.5). Patients rated the quality of the VR therapy as: excellent (n=9), good (n=2), fair (n=0), poor (n=0). An average of 5.3 (SD=1.4) appointments were attended. CONCLUSIONS: Uptake of the VR intervention was high, satisfaction was high, and side-effects extremely few. There were promising indications of large improvements in positive self-beliefs and psychological well-being. A randomized controlled clinical evaluation is warranted.

#HealthyLifestyle: A Q methodology analysis of why young adults like to use social media to access health information.

Social media has become an integral part of modern society. Many people now turn to social media platforms to share or gain knowledge about best practices for personal health. This new form of health information dissemination has greatly increased in popularity especially among young adults. Currently, more research is needed to identify why so many individuals choose to turn to social media for health information. Using Q methodology, this study aimed to uncover the attitudes, opinions, and beliefs of young adults who engage with social media as a means of obtaining health and fitness information. Results revealed four primary factors: the Health Connoisseurs, the Health Enthusiasts, the Loyalists, and the Virtual Befrienders. Each group possessed different motivations for accessing health-related content on social media. The insights gained from this study can benefit public health institutions, advertisers, and social media content creators as they disseminate health information on social media platforms.

Randomised controlled trial of automated VR therapy to improve positive self-beliefs and psychological well-being in young people diagnosed with psychosis: a study protocol for the Phoenix VR self-confidence therapy trial.

INTRODUCTION: The confidence of young people diagnosed with psychosis is often low. Positive self-beliefs may be few and negative self-beliefs many. A sense of defeat and failure is common. Young people often withdraw from many aspects of everyday life. Psychological well-being is lowered. Psychological techniques can improve self-confidence, but a shortage of therapists means that very few patients ever receive such help. Virtual reality (VR) offers a potential route out of this impasse. By including a virtual coach, treatment can be automated. As such, delivery of effective therapy is no longer reliant on the availability of therapists. With young people with lived experience, we have developed a staff-assisted automated VR therapy to improve positive self-beliefs (Phoenix). The treatment is based on established cognitive behavioural therapy and positive psychology techniques. A case series indicates that this approach may lead to large improvements in positive self-beliefs and psychological well-being. We now aim to conduct the first randomised controlled evaluation of Phoenix VR. METHODS AND ANALYSIS: 80 patients with psychosis, aged between 16 and 30 years old and with low levels of positive self-beliefs, will be recruited from National Health Service (NHS) secondary care services. They will be randomised (1:1) to the Phoenix VR self-confidence therapy added to treatment as usual or treatment as usual. Assessments will be conducted at 0, 6 (post-treatment) and 12 weeks by a researcher blind to allocation. The primary outcome is positive self-beliefs at 6 weeks rated with the Oxford Positive Self Scale. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention to treat. ETHICS AND DISSEMINATION: The trial has received ethical approval from the NHS Health Research Authority (22/LO/0273). A key output will be a high-quality VR treatment for patients to improve self-confidence and psychological well-being. TRIAL REGISTRATION NUMBER: ISRCTN10250113.

The Oxford Positive Self Scale: psychometric development of an assessment of cognitions associated with psychological well-being.

BACKGROUND: Developing, elaborating, and consolidating positive views of the self is a plausible route to increased psychological well-being. We set out to provide an assessment of positive self-beliefs that could be used in research and clinical practice. METHODS: A non-probability online survey was conducted with 2500 UK adults, quota sampled to match the population for age, gender, ethnicity, income, and region. Exploratory factor analysis of a 94-item pool - generated with guidance from people with lived experience of mental health difficulties - was conducted to develop the Oxford Positive Self Scale (OxPos). The item pool was further reduced using regularised structural equation modelling (SEM) before confirmatory factor analysis. Optimal cut-off scores were developed using receiver operating characteristic curves. Additional validations were carried out with two further general population cohorts (n = 1399; n = 1693). RESULTS: A 24-item scale was developed with an excellent model fit [robust χ2 = 995.676; df = 246; CFI = 0.956; TLI = 0.951; RMSEA = 0.049 (0.047, 0.052); SRMR = 0.031]. The scale comprises four factors: mastery; strength; enjoyment; and character. SEM indicated that the scale explains 68.6% of variance in psychological well-being. The OxPos score was negatively correlated with depression (r = -0.49), anxious avoidance (r = -0.34), paranoia (r = -0.23), hallucinations (r = -0.20), and negative self-beliefs (r = -0.50), and positively correlated with psychological well-being (r = 0.79), self-esteem (r = 0.67), and positive social comparison (r = 0.72). Internal reliability and test-retest reliability were excellent. Cut-offs by age and gender were generated. A short-form was developed, explaining 96% of the full-scale variance. CONCLUSIONS: The new open access scale provides a psychometrically robust assessment of positive cognitions that are strongly connected to psychological well-being.

Injection fears and COVID-19 vaccine hesitancy.

BACKGROUND: When vaccination depends on injection, it is plausible that the blood-injection-injury cluster of fears may contribute to hesitancy. Our primary aim was to estimate in the UK adult population the proportion of COVID-19 vaccine hesitancy explained by blood-injection-injury fears. METHODS: In total, 15 014 UK adults, quota sampled to match the population for age, gender, ethnicity, income and region, took part (19 January-5 February 2021) in a non-probability online survey. The Oxford COVID-19 Vaccine Hesitancy Scale assessed intent to be vaccinated. Two scales (Specific Phobia Scale-blood-injection-injury phobia and Medical Fear Survey-injections and blood subscale) assessed blood-injection-injury fears. Four items from these scales were used to create a factor score specifically for injection fears. RESULTS: In total, 3927 (26.2%) screened positive for blood-injection-injury phobia. Individuals screening positive (22.0%) were more likely to report COVID-19 vaccine hesitancy compared to individuals screening negative (11.5%), odds ratio = 2.18, 95% confidence interval (CI) 1.97-2.40, p < 0.001. The population attributable fraction (PAF) indicated that if blood-injection-injury phobia were absent then this may prevent 11.5% of all instances of vaccine hesitancy, AF = 0.11; 95% CI 0.09-0.14, p < 0.001. COVID-19 vaccine hesitancy was associated with higher scores on the Specific Phobia Scale, r = 0.22, p < 0.001, Medical Fear Survey, r = 0.23, p = <0.001 and injection fears, r = 0.25, p < 0.001. Injection fears were higher in youth and in Black and Asian ethnic groups, and explained a small degree of why vaccine hesitancy is higher in these groups. CONCLUSIONS: Across the adult population, blood-injection-injury fears may explain approximately 10% of cases of COVID-19 vaccine hesitancy. Addressing such fears will likely improve the effectiveness of vaccination programmes.

Virtual reality (VR) therapy for patients with psychosis: satisfaction and side effects.

BACKGROUND: Automated virtual reality therapies are being developed to increase access to psychological interventions. We assessed the experience with one such therapy of patients diagnosed with psychosis, including satisfaction, side effects, and positive experiences of access to the technology. We tested whether side effects affected therapy. METHODS: In a clinical trial 122 patients diagnosed with psychosis completed baseline measures of psychiatric symptoms, received gameChange VR therapy, and then completed a satisfaction questionnaire, the Oxford-VR Side Effects Checklist, and outcome measures. RESULTS: 79 (65.8%) patients were very satisfied with VR therapy, 37 (30.8%) were mostly satisfied, 3 (2.5%) were indifferent/mildly dissatisfied, and 1 (0.8%) person was quite dissatisfied. The most common side effects were: difficulties concentrating because of thinking about what might be happening in the room (n = 17, 14.2%); lasting headache (n = 10, 8.3%); and the headset causing feelings of panic (n = 9, 7.4%). Side effects formed three factors: difficulties concentrating when wearing a headset, feelings of panic using VR, and worries following VR. The occurrence of side effects was not associated with number of VR sessions, therapy outcomes, or psychiatric symptoms. Difficulties concentrating in VR were associated with slightly lower satisfaction. VR therapy provision and engagement made patients feel: proud (n = 99, 81.8%); valued (n = 97, 80.2%); and optimistic (n = 96, 79.3%). CONCLUSIONS: Patients with psychosis were generally very positive towards the VR therapy, valued having the opportunity to try the technology, and experienced few adverse effects. Side effects did not significantly impact VR therapy. Patient experience of VR is likely to facilitate widespread adoption.

The food and beverage cues in digital marketing model: special considerations of social media, gaming, and livestreaming environments for food marketing and eating behavior research.

Digital marketing to children, teens, and adults contributes to substantial exposure to cues and persuasive messages that drive the overconsumption of energy dense foods and sugary beverages. Previous food marketing research has focused on traditional media, but less is known about how marketing techniques translate within digital platforms, such as social media, livestreaming, and gaming. Building upon previous theories and models, we propose a new model entitled food and beverage cues in digital marketing (FBCDM). The FBCDM model specifies key marking elements and marketing integration strategies that are common on digital platforms and are hypothesized to enhance the effects of advertising and incentive sensitization process. FBCDM also categorizes measurable outcomes into three domains that include brand, food, and social outcomes. Additionally, repeated marketing exposure and the resulting outcomes are hypothesized to have long term consequences related to consumer markets, consumption behavior, culture, and health. We include a discussion of what is currently known about digital marketing exposure within the outcome domains, and we highlight gaps in research including the long-term consequences of digital marketing exposure. The FBCDM model provides a conceptual framework to guide future research to examine the digital marketing of food and beverages to children and adolescents in order to inform government and industry policies that restrict the aggressive marketing of products associated with obesity and adverse diet related outcomes.

Agoraphobic avoidance in patients with psychosis: Severity and response to automated VR therapy in a secondary analysis of a randomised controlled clinical trial.

BACKGROUND: The social withdrawal of many patients with psychosis can be conceptualised as agoraphobic avoidance due to a range of long-standing fears. We hypothesised that greater severity of agoraphobic avoidance is associated with higher levels of psychiatric symptoms and lower levels of quality of life. We also hypothesised that patients with severe agoraphobic avoidance would experience a range of benefits from an automated virtual reality (VR) therapy that allows them to practise everyday anxiety-provoking situations in simulated environments. METHODS: 345 patients with psychosis in a randomised controlled trial were categorised into average, moderate, high, and severe avoidance groups using the Oxford Agoraphobic Avoidance Scale. Associations of agoraphobia severity with symptom and functioning variables, and response over six months to brief automated VR therapy (gameChange), were tested. RESULTS: Greater severity of agoraphobic avoidance was associated with higher levels of persecutory ideation, auditory hallucinations, depression, hopelessness, and threat cognitions, and lower levels of meaningful activity, quality of life, and perceptions of recovery. Patients with severe agoraphobia showed the greatest benefits with gameChange VR therapy, with significant improvements at end of treatment in agoraphobic avoidance, agoraphobic distress, ideas of reference, persecutory ideation, paranoia worries, recovering quality of life, and perceived recovery, but no significant improvements in depression, suicidal ideation, or health-related quality of life. CONCLUSIONS: Patients with psychosis with severe agoraphobic avoidance, such as being unable to leave the home, have high clinical need. Automated VR therapy can deliver clinical improvement in agoraphobia for these patients, leading to a number of wider benefits.

Eye-Tracking and Adolescent Interest in Alcohol Responsibility Messages: The Message Matters.

OBJECTIVE: Through the use of eye-tracking technology, this study explores the efficacy of current alcohol responsibility messages viewed by adolescents and proposes the development of new alcohol warning message design. METHOD: An adolescent sample (N = 121; 72 males) was shown 14 advertisements (4 alcohol, 10 non-alcohol) in randomized order featuring messages modified by type size, type contrast, and message content (a 2 × 2 × 2 factorial design). RESULTS: Results suggested that modifying message content to include direct language and a consequence enhances recall and attention to alcohol responsibility messages among adolescents. No significant differences in attentional outcomes were observed for messages that included variances in type size or type contrast. CONCLUSIONS: Overall, to increase attention to and recall of alcohol responsibility messages, the greatest efficacy lies in varying the message itself, irrespective of size or contrast.

The Influence of Parental Religiosity on the Health of Children during Late Adolescence/Early Adulthood: A Test of Mediation.

The present study explores whether adolescent religiosity, health-related behaviors, and marital stability mediate the association between parental religiosity and health. Using data from the National Longitudinal Study of Adolescent to Adult (Add) Health, I model potential direct and indirect effects between three measures of parental religiosity (i.e., parental institutional religiosity, parental personal religiosity, and parental religious affiliation); three sets of mediators indicating adolescent religiosity, health-related behaviors, and marital stability; and self-rated health during late adolescence/early adulthood. Overall, I found that parental institutional religiosity has a direct effect on the self-rated health of children during late adolescence/early adulthood, and that it influences self-rated health by reducing adolescent and parental smoking. I also found evidence for deleterious effects of parental institutional religiosity on health as well. Future research should explore variation in the influence of parental religiosity on self-rated health between various sociodemographic groups and between different stages of the life course.

Physician centricity in the deployment of digital solutions for neurological conditions.

The widespread deployment of telemedical approaches to managed care during the CoV2 pandemic has provided an opportunity for clinicians to engage in the development and refinement of this mode of delivery. This also represents a pivotal moment to help effect a paradigm shift in how new and more sophisticated digital health services are designed and delivered with the caregiver playing a guiding role. Building on momentum this way can allow the fuller potential of digital health to be realized by focusing on "end user pull" which balances the omnipresent "technology push" of the consumer product and medical device industries. Perhaps nowhere is this more critical than in the care of neurological illnesses where patient-provider interactions must be managed frequently and rely on a complex battery of data measures. The emergent role of the physician-entrepreneur can be envisioned, complimenting established physician-scientist career paths and represents a timely and opportune moment to refine medical education curricula.

Freedom to Stay-at-Home? Countries Higher in Relational Mobility Showed Decreased Geographic Mobility at the Onset of the COVID-19 Pandemic.

In this paper, we examine whether relational mobility (RM) (the ability for individuals to voluntarily form and terminate relationships within a given social environment) on a country level related to individuals' tendencies to restrict their movement following the onset of the global COVID-19 pandemic and following the issuance of stay-at-home orders in their country. We use data on geographic mobility, composed of records of geolocation information provided via mobile phones, to examine changes in geographic mobility at the onset of the COVID-19 pandemic. We show that individuals in countries with higher RM tended to decrease their geographic mobility more than those in countries with lower RM following the onset of the COVID-19 pandemic. Similar results were found for wealth gross domestic product (GDP), but were independent of RM. These results suggest that individuals in countries with higher RM were more responsive to calls to reduce geographic mobility.

Effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group, randomised controlled trial.

BACKGROUND: The effectiveness of the COVID-19 vaccination programme depends on mass participation: the greater the number of people vaccinated, the less risk to the population. Concise, persuasive messaging is crucial, particularly given substantial levels of vaccine hesitancy in the UK. Our aim was to test which types of written information about COVID-19 vaccination, in addition to a statement of efficacy and safety, might increase vaccine acceptance. METHODS: For this single-blind, parallel-group, randomised controlled trial, we aimed to recruit 15 000 adults in the UK, who were quota sampled to be representative. Participants were randomly assigned equally across ten information conditions stratified by level of vaccine acceptance (willing, doubtful, or strongly hesitant). The control information condition comprised the safety and effectiveness statement taken from the UK National Health Service website; the remaining conditions addressed collective benefit, personal benefit, seriousness of the pandemic, and safety concerns. After online provision of vaccination information, participants completed the Oxford COVID-19 Vaccine Hesitancy Scale (outcome measure; score range 7-35) and the Oxford Vaccine Confidence and Complacency Scale (mediation measure). The primary outcome was willingness to be vaccinated. Participants were analysed in the groups they were allocated. p values were adjusted for multiple comparisons. The study was registered with ISRCTN, ISRCTN37254291. FINDINGS: From Jan 19 to Feb 5, 2021, 15 014 adults were recruited. Vaccine hesitancy had reduced from 26·9% the previous year to 16·9%, so recruitment was extended to Feb 18 to recruit 3841 additional vaccine-hesitant adults. 12 463 (66·1%) participants were classified as willing, 2932 (15·6%) as doubtful, and 3460 (18·4%) as strongly hesitant (ie, report that they will avoid being vaccinated for as long as possible or will never get vaccinated). Information conditions did not alter COVID-19 vaccine hesitancy in those willing or doubtful (adjusted p values >0·70). In those strongly hesitant, COVID-19 vaccine hesitancy was reduced, in comparison to the control condition, by personal benefit information (mean difference -1·49, 95% CI -2·16 to -0·82; adjusted p=0·0015), directly addressing safety concerns about speed of development (-0·91, -1·58 to -0·23; adjusted p=0·0261), and a combination of all information (-0·86, -1·53 to -0·18; adjusted p=0·0313). In those strongly hesitant, provision of personal benefit information reduced hesitancy to a greater extent than provision of information on the collective benefit of not personally getting ill (-0·97, 95% CI -1·64 to -0·30; adjusted p=0·0165) or the collective benefit of not transmitting the virus (-1·01, -1·68 to -0·35; adjusted p=0·0150). Ethnicity and gender were found to moderate information condition outcomes. INTERPRETATION: In the approximately 10% of the population who are strongly hesitant about COVID-19 vaccines, provision of information on personal benefit reduces hesitancy to a greater extent than information on collective benefits. Where perception of risk from vaccines is most salient, decision making becomes centred on the personal. As such, messaging that stresses the counterbalancing personal benefits is likely to prove most effective. The messaging from this study could be used in public health communications. Going forwards, the study highlights the need for future health campaigns to engage with the public on the terrain that is most salient to them. FUNDING: National Institute for Health Research (NIHR) Oxford Biomedical Research Centre and NIHR Oxford Health Biomedical Research Centre.

Effect of Remote Monitoring on Discharge to Home, Return to Activity, and Rehospitalization After Hip and Knee Arthroplasty: A Randomized Clinical Trial.

Importance: Hip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown. Objective: To evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty. Design, Setting, and Participants: Randomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8. Interventions: Eligible patients were randomized evenly to receive usual care (n = 153) or remote monitoring (n = 147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge. Main Outcomes and Measures: The primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations. Results: A total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P = .01). Conclusions and Relevance: In this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team. Trial Registration: ClinicalTrials.gov Identifier: NCT03435549.

Institutionally Based ImPACT Test® Normative Values May Differ from Manufacturer-Provided Normative Values.

OBJECTIVE: The necessity for pre-injury baseline computerized neurocognitive assessments versus comparing post-concussion outcomes to manufacturer-provided normative data is unclear. Manufacturer-provided norms may not be equivalent to institution-specific norms, which poses risks for misclassifying the presence of impairment when comparing individual post-concussion performance to manufacturer-provided norms. The objective of this cohort study was to compare institutionally derived normative data to manufacturer-provided normative values provided by ImPACT® Applications, Incorporated. METHOD: National Collegiate Athletic Association Division 1 university student athletes (n = 952; aged 19.2 ± 1.4 years, 42.5% female) from one university participated in this study by completing pre-injury baseline Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) assessments. Participants were separated into 4 groups based on ImPACT's age and gender norms: males <18 years old (n = 186), females <18 years old (n = 165), males >19 years old (n = 361) or females >19 years old (n = 240). Comparisons were made between manufacturer-provided norms and institutionally derived normative data for each of ImPACT's clinical composite scores: Verbal (VEM) and Visual (VIM) Memory, Visual Motor Speed (VMS), and Reaction Time (RT). Outcome scores were compared for all groups using a Chi-squared goodness of fit analysis. RESULTS: Institutionally derived normative data indicated above average performance for VEM, VIM, and VMS, and slightly below average performance for RT compared to the manufacturer-provided data (χ2 ≥ 20.867; p < 0.001). CONCLUSIONS: Differences between manufacturer- and institution-based normative value distributions were observed. This has implications for an increased risk of misclassifying impairment following a concussion in lieu of comparison to baseline assessment and therefore supports the need to utilize baseline testing when feasible, or otherwise compare to institutionally derived norms rather than manufacturer-provided norms.

Is Apostasy Heritable? A Behavior Genetics Study.

The present study explores whether genetic factors explain variation in the levels of apostasy - defined as a disengagement from religious belief, identity and/or practice - in a US-based sample during the transition from adolescence to early adulthood. I posit that genetic factors at least partially explain the variance of three measures of apostasy: disengagement from religious institutions, cessation of prayer and religious disaffiliation. I argue that genetic factors associated with risk-taking behaviors, externalizing behaviors and/or correlates of apostasy may all influence the likelihood of becoming an apostate during the transition from adolescence to early adulthood in the USA. Results reveal that genetic factors explain approximately 34% of the variance in cessation of prayer and 75% of the variance in religious disaffiliation. However, genetic factors do not influence disengagement from religious institutions. This study advances our knowledge of the etiology of apostasy and highlights the need to incorporate genetic data into social scientific research.

Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial.

BACKGROUND: Engaging, interactive, and automated virtual reality (VR) treatments might help solve the unmet needs of individuals with mental health disorders. We tested the efficacy of an automated cognitive intervention for fear of heights guided by an avatar virtual coach (animated using motion and voice capture of an actor) in VR and delivered with the latest consumer equipment. METHODS: We did a randomised trial of automated VR versus usual care. We recruited adults aged older than 18 years with a fear of heights by radio advertisements in Oxfordshire, UK. We diagnosed fear of heights if participants scored more than 29 on the Heights Interpretation Questionnaire (HIQ). We randomly allocated participants by computer in a 1:1 ratio to either automated VR delivered in roughly six 30-min sessions administered about two to three times a week over a 2-week period (intervention group) or to usual care (control group). Randomisation was stratified by severity of fear of heights. The research team, who were unaware of the random allocation, administered three fear-of-height assessments, at baseline (0 weeks), at the end of treatment (2 weeks), and at follow-up (4 weeks). The primary outcome measure was HIQ score (range 16-80, with higher scores indicating greater severity). This trial is registered with the ISRCTN registry, number ISRCTN11898283. FINDINGS: Between Nov 25, 2017, and Feb 27, 2018, 100 individuals were enrolled and underwent randomisation, of whom 49 were assigned to the VR treatment group and 51 to the control group. All participants completed the 4-week follow-up. The mean total treatment time in VR was 124·43 min (SD 34·23). Compared with participants in the control group, the VR treatment reduced fear of heights at the end of treatment (mean change score -24·5 [SD 13·1] in the VR group vs -1·2 [7·3] in the control group; adjusted difference -24·0, 95% CI -27·7 to -20·3; Cohen's d=2·0; p<0·0001). The benefit was maintained at follow-up (mean change score -25·1 [SD 13·9] in the VR group vs -1·5 [7·8] in the control group; adjusted difference -24·3, 95% CI -27·9 to -20·6; Cohen's d=2·0; p<0·0001). The number needed to treat to at least halve the fear of heights was 1·3. No adverse events were reported. INTERPRETATION: Psychological therapy delivered automatically by a VR coach can produce large clinical benefits. Evidence-based VR treatments have the potential to greatly increase treatment provision for mental health disorders. FUNDING: Oxford VR, and the National Institute of Health Research Oxford Health Biomedical Research Centre.

Valid but Invalid: Suboptimal ImPACT Baseline Performance in University Athletes.

PURPOSE: This study aimed to investigate the frequency of valid yet suboptimal Immediate Postconcussion Assessment and Cognitive Test (ImPACT) performance in university athletes and to explore the benefit of subsequent ImPACT administrations. METHODS: This descriptive laboratory study involved baseline administration of ImPACT to 769 university athletes per the institution's concussion management protocol. Testing was proctored in groups of ≤2 participants. Participants who scored below the 16th percentile according to ImPACT normative data were readministered the ImPACT test up to two additional times because these scores were thought to be potentially indicative of suboptimal effort or poor understanding of instructions. Descriptive analyses were used to examine validity indicators and individual Verbal and Visual Memory, Visual Motor Speed, and Reaction Time ImPACT composite scores in initial and subsequent administrations. RESULTS: On the basis of ImPACT's validity criteria, 1% (9/769) of administrations were invalid and 14.6% (112/769) had one or more composite score of <16th percentile but were considered valid. After one readministration, 71.4% (80/112) achieved scores of ≥16th percentile and an additional 18 of 32 scored ≥16th percentile after a third administration. Verbal Memory was most commonly <16th percentile on the first administration (43%), Verbal Memory and Visual Motor Speed on the second administration (44% each), and Visual Motor Speed alone on the third administration (50%). CONCLUSIONS: Approximately 16% of ImPACT records were flagged as invalid or had one or more composite scores of <16th percentile, potentially indicative of suboptimal performance. Upon readministration, 88% of those participants scored >16th percentile. Clinicians must be aware of suboptimal ImPACT performance as it limits the clinical utility of the baseline assessment. Further research is needed to address factors leading to "valid" but invalid baseline performance.