Most of us experience some level of stress and anxiety in our lives. It can be relatively mild or extremely severe and debilitating — or anywhere along the spectrum. Some examples include general stress at work, relationship issues, fears and phobias, depression and other anxiety disorders, including post-traumatic stress disorder (PTSD).
An estimated one in five people in the U.S. have a diagnosable mental disorder. Even those who don’t can still experience significant stress and anxiety. Psychological conditions and mental health disorders affect our daily lives, and cost an estimated $467 billion in the U.S. in lost productivity and medical expenses ($2.5 trillion globally).
For many disorders, there are highly effective treatments that don’t require drugs. But many doctors still tend to over-prescribe medications that are either not effective, have disturbing side effects or are completely unnecessary.
Part of the problem is a lack of specific training of family physicians in mental health, combined with the difficulty to find and access qualified mental health practitioners. While severe disorders may still require pharmacological intervention, techniques such as cognitive behavioral therapy (CBT) and exposure therapy (ET) are highly effective in conditions such as anxiety disorder, panic disorder, phobias, PTSD and obsessive compulsive disorder (OCD) when administered by a qualified practitioner.
Can virtual reality become a global mental health treatment platform?
Virtual reality (VR) has been used for decades as a tool for therapists to administer virtual reality exposure therapy (VRET) in a safe and controlled manner. Due to cost and technology limitations, it has not been widely available, to date. With the advent of affordable mobile VR headsets, such as the Gear VR, there is a new opportunity to applytelemedicine to decentralize mental health treatment, reaching more patients and improving lives around the world.
A key challenge today is the lack of clinical evidence and data to support if and how VR can be used to administer effective treatment both in the clinic (expanded use) and remotely. Companies wishing to penetrate this market will need to conduct well-designed, randomized, controlled, properly powered clinical studies in order to change or influence treatment paradigms. There will undoubtedly be a flood of VR apps in the coming months and years attempting to solve these mental health issues.
For many disorders, there are highly effective treatments that don’t require drugs.
Some examples might include remote teletherapy by qualified practitioners who use VR as a supplementary tool, in-clinic VR therapy, virtual therapists created using artificial intelligence or patient-directed VR therapy in the absence of a professional therapist. It remains to be seen which options can deliver real, effective and sustaining treatment to mental health patients across the world, or even people with no diagnosable disorder who want to reduce generalized stress and anxiety in their lives.
Cognitive behavioral therapy and exposure therapy
Briefly, CBT is a psychotherapeutic treatment administered by a therapist trained in mental health disorders and specifically in CBT. Patients typically attend a limited number of sessions that focus on a specific problem, helping the patient identify, recognize and change disturbing thought patterns and feelings that are leading to negative or destructive beliefs and behaviors. There often is an avoidance behavior that stems from the anxiety.
For example, if a person spends a lot of time thinking about plane crashes and accidents, they might avoid air travel. Or if they worry about how others perceive them in public, they may avoid social situations and become isolated, leading to depression and other issues.
CBT can be thought of as a set of tools one can use to overcome these limitations, providing a way to cope with their thoughts and feelings effectively. CBT goes hand in hand with ET, which gradually encourages patients to face the troubling thoughts and fears directly. Over time, this effectively lowers the peak anxiety the person experiences when they are exposed to whatever causes the anxiety.
Virtual reality is now convincing enough to simulate many of these anxiety-inducing stimuli, and is a safe, controllable and effective way to conduct various types of ET and CBT. Although ET is an obvious fit with VR, there are many other psychiatric conditions, such as childhood developmental disorders and autism, where VR may play a more dominant role in the future.
Treating PTSD using virtual reality
Virtual reality has been used fairly extensively to deliver prolonged exposure therapy (PET) for PTSD since the 1990s, mostly for the treatment of soldiers and war veterans. Dr. Albert “Skip” Rizzo, director of Medical Virtual Reality at the Institute for Creative Technology at the University of Southern California, is a leader in this field. His application, called Bravemind, was developed in partnership with Virtually Better, who sells the product to institutions around the world.
The Canadian government purchased two copies of this software in 2014 for $17,000 each. The system consists of various components, such as the VR environment, which is controllable and customizable, a vibrotactile platform, which delivers sensations associated with explosions and firefights and even a scent machine, which can emit smells like diesel fuel, garbage and gunpowder at specific times during the simulation to increase immersion. There have been a number of clinical studies (completed and ongoing) that investigate the safety and effectiveness of Bravemind.
A recently published study found that the VR therapy alone was as good as a combination of drug therapy and VR therapy. In fact, one of the drugs studied led to a worse outcome for patients. There is another clinical trial ongoing that is investigating the use of Bravemind VR therapy in military sexual trauma.
Military funding has allowed rigorous studies to be conducted. However, smaller private companies developing VR therapy applications with limited budgets must still demonstrate clinical efficacy if they hope to penetrate this market. I have spoken with one such company operating in the Netherlands who is attempting to tackle PTSD in a different, but scientifically based, way.
There are an estimated 7.7 million people in the U.S. with PTSD.
Beyond Care is working on a VR software solution for PTSD based on the principle of eye movement desensitization and reprocessing (EMDR). EMDR works by having a patient recall a traumatic memory, then having the patient follow a moving object with their eyes only at the same time. The dual task of memory recall plus eye movement taxes the working memory, causing the traumatic memory to become less clear and vivid.
Eventually, after repeating this process, the memory permanently loses its ability to trigger such intense emotional responses. After a successful pilot study, Beyond Care is now coordinating a patient trial in partnership with a Dutch University and a company specializing in delivering specialized psychological treatment over the Internet. The results of this study will determine if the new VR desensitization and reprocessing therapy, called Beyond Care PTSD, works and, more interestingly, whether it can be successfully delivered virtually, under the semi-supervision of a therapist.
Military PTSD is not the only type of PTSD: There are an estimated 7.7 million people in the U.S. with PTSD, many of whom suffer due to rape or sexual trauma in their past. It is highly likely that many of these cases go unreported and untreated, which is unfortunate because there are very effective treatments available. Beyond Care is initiating a study in this patient population, as well. Customizable applications such as Beyond Care PTSD will allow expanded access to therapy for all types of PTSD sufferers.
Treating phobias and anxiety disorders using virtual reality
Similar to PTSD, VR therapy has for many years been used in clinics for the treatment of phobias and other anxiety disorders. Anxiety disorders affect at least 40 million people in the U.S. and cost the country $42 billion per year. Because of the vast number of patients afflicted by some form of anxiety disorder, decentralization of treatment through telemedicine or self-guided therapy could make a huge difference.
Specific phobias affect about 19 million individuals in the U.S. A recently published meta-analysis of 14 clinical trials showed that VRET was similarly effective in treating specific phobias as real-life exposure therapy. Some examples of companies using VR to treat anxiety disorders are presented below.
The Virtual Reality Medical Center has a system for treating those afraid of flying. It includes software and hardware, complete with airplane seats and a subwoofer system to mimic the sights, sounds and feeling of flying.
Virtually Better also has software to treat fears such as flying, heights, public speaking and storms. This company has partnered with leading academic institutions, research and treatment facilities to undertake new R&D projects concerning childhood anxiety and childhood social phobias.
Anxiety disorders affect at least 40 million people in the U.S.
CleVR is a company in the Netherlands developing VR systems for fear of flying, heights and social phobias, also backed by scientific research. The company is undertaking a randomized controlled trial to study the use of VR as a therapist’s tool to treat psychosis and social phobia. Through proprietary dynamic virtual emotion technology, the overall atmosphere of the simulated social situations can be controlled.
Psious is a company in Spain that offers a clinical toolkit for therapists to administer and control VRET to treat patients with phobias; it includes VR hardware, a customizable software platform and biofeedback devices.
VirtualRet is another tool for psychologists and therapists to help evaluate and treat phobias such as public speaking, flying, heights, blood and public places. They provide a range of virtual environments, hardware and parallel services.
A company from Sweden called Mimerse is developing gamified psychological treatment tools for VR for the mass market in partnership with the Swedish Government and Stockholm University. Their first game, “Itsy,” is focused on treating arachnophobia without involvement from a real-world therapist. Coinciding with the game’s release on the Gear VR app store, a randomized controlled study is being conducted comparing VRET using Itsy versus real-world exposure therapy. Because the majority of phobia sufferers don’t receive professional treatment, mass market games like Itsy could offer immense value for individuals globally.
Virtual reality for stress relief and meditation
Whether or not a person suffers from a specific diagnosable mental health condition, most of us experience varying levels of stress and anxiety during our lives. Meditation is a great way for anyone to improve their mood and induce a state of relaxation. While meditation and relaxation may not be the sole treatment for any particular diagnosable condition, the general overall health benefits are thought to be positive for anyone, healthy or otherwise.
In addition to their work on phobias, Psious and VirtualRet also have solutions for generalized anxiety and relaxation. Another company developed DEEP, a unique meditative VR game where the user explores a strange and beautiful underwater world. The unique part is that the game is completely controlled through breathing (biofeedback). Correct breathing techniques are central to meditation and relaxation, and with the custom DEEP controller the user’s breathing coincides with what is seen in the virtual environment and controls how the user moves through it.
Unello Design has come up with some meditation and relaxation experiences for Google Cardboard and Oculus Rift. Eden River is a relaxing nature experience and Zen Zone is a guided meditation journey. Individuals also can explore “sound sculptures” using their 3D music apps.
Perhaps the most well-known relaxation app is Guided Meditation VR, created by Cubicle Ninjas. This app offers four relaxing immersive environments to enjoy during a guided meditation session.
The market for improving mental health through the use of VR has been well established based on decades of scientific research.
I had the pleasure of meeting their founder and CEO, Josh Farkas, at a We Are Wearables VR event in Toronto last October. Among a densely packed crowd of hundreds of people eating pizza and drinking beer, I sat down, put on an Oculus and headphones and tried the Costa Del Sol beach vacation VR experience. The environment was visually appealing and relaxing, but I was only in the experience for a few minutes so I didn’t have a chance to go through the guided mediation portion.
The most shocking part came when I removed the headset and discovered that I had forgotten I was surrounded by hundreds of people at the packed and noisy conference! Despite the fact that Guided Meditation VR is not clinically validated and is marketed for casual enjoyment and relaxation, it still has the ability to have significant positive impact on people’s lives.
In one example, Josh and his team attended a military conference where they shared their work with active duty officers who generally struggle with a very high rate of suicide caused by mental trauma and stress. A veteran of the Vietnam War and another soldier who had been deployed in Iraq both broke down crying while trying the demo, stating they hadn’t felt that relaxed in years. They were extremely excited at the notion that experiences like these could help others, especially those on active duty.
In another example, a young man who was wheelchair-bound because of a serious neurological condition tried the experience on the Oculus Rift. He reacted by moving around a bit. Unsure of what this meant, Josh asked the mother, who said, “He wants to give you a hug.”
The Guided Meditation VR team is now working to improve the experiences to be as accessible as possible for those with limited mobility. As VR and apps like this become mainstream, we likely will uncover additional groups of people who can feel profoundly better through experiencing something as simple as a virtual Zen garden.
Bringing light to mental darkness
The market for improving mental health through the use of VR has been well established based on decades of scientific research. However, this market is still in some ways in its infancy as the technology to date has not been advanced enough to allow massive patient access across the world.
Still, the majority of companies working in this space are focusing on developing clinical tools used by professional therapists to help them treat patients in person. Will the technology become good enough to enable safe, effective treatment in the absence of a professional therapist or clinician?Will we see increased diagnosis and treatment of patients, resulting in societal health and economic benefits?
In a few years’ time there should be a lot more data available from clinical studies to properly evaluate these new treatment modalities in different psychiatric conditions. Until then, we are bound to see an explosion of apps making all sorts of different claims — some supported by data and some yet to be validated.