Depression is a leading cause of disability and a major contributor to the burden of disease, globally. It is a complex mood disorder in which an individual experiences persistent sadness and a lack of interest in previously enjoyable or rewarding activities. Its impact is observed in all aspects of the individual’s life such as sleep, appetite, energy levels, attention, relationships and self-care, diminishing their quality of life. Individuals may also suffer from feelings of worthlessness, hopelessness, and even ideations of self-harm.
While depression can be treated or managed by different approaches including medication, counselling/talk therapy, exercise, meditation as well as surgical approaches (vagal nerve stimulation, or deep brain stimulation), less than 50% of individuals with depressive symptoms ever seek treatment for it. This is partly influenced by the paucity of mental health practitioners and the high cost of mental healthcare. The use of digital technology such as virtual reality in managing mental health has thus emerged from a need to make it more accessible to the larger population.
HOW CAN VR BE USED AS A TOOL TO MANAGE DEPRESSION?
Virtual reality can be used as an educational tool (psychoeducation) to help the individual understand the condition or symptoms they are experiencing. Whether it is understanding how different triggers may provoke the symptoms, how different treatment options work, or how a scenario can play out when certain strategies are employed, VR allows the individual to experience the information and learn from the experience.
Individuals with depression often withdraw from activities that are otherwise rewarding – such as socialization, physical activities, and self-care. Forcing these activities in the real world may provoke anxiety and make depression symptoms worse. To help with socialization, the individual can participate in a VR scenario (with or without a therapist guidance) and learn/practice correctly interpreting verbal and non-verbal cues, build conversational skills, and slowly be exposed to larger crowds as a type of exposure therapy.
VR can also be used to remediate the lack of motivation to engage in physical activity which is commonly experienced in depressive states. The use of VR to promote physical activity is based on behavioural activation and is compatible with a large variety of sports and exercise routines. The release of endorphins and striatal dopamine, mood elevation, improved sense of self, and sense of achievement associated with sport and physical activity have made it a popular treatment for mild to moderate depression.
Another valuable potential for the use of VR in managing depression is its use in cognitive restructuring. Individuals are asked to imagine stress-provoking situations and are encouraged to find alternative ways to actively reduce the intensity of stress. They are subsequently asked to imagine the new, less stressful scenario playing out - a technique known as imagery rescripting. Such techniques rely greatly on the vividness of the mental imagery and may therefore have variable effects depending on the abilities and interest of the individual. VR can provide a realistic display of the imagery within which the individual feels present and immersed – evoking psychophysiological responses (fear, anxiety, withdrawal) that are otherwise not replicable in the physical world. Within the VR environment, individuals can be guided to practice the various coping strategies and management techniques.
In a VR environment, an individual can embody themselves or another individual, or view actions in the third-person perspective. This unique feature is used to deliver “avatar-therapy” where an individual, who for example may be highly self-critical, may be asked to show compassion to an avatar experiencing depressive symptoms. Subsequently the individual embodies the avatar and then receives the exact motion and audio-captured acts of compassion, making them aware of the self-critical lens through which they viewed themselves. Through repeated practice, individuals will be able to identify self-critical behaviour and demonstrate self-compassion with the aim of blocking a downward spiral of emotions.
WHY IS IT A SUITABLE TOOL?
Exposure therapy necessitates the recreation of the stressful scenario, which a VR environment can do with high reality and fidelity. In VR the therapist can observe the evoked distressing emotion while protecting the individual from negative consequences. Since the dangers are not real, individuals appear to be more willing to expose themselves to their stressors in a VR world than in a real world.
The scenarios can be used repeatedly, modified as required, and can be designed to be used with or without the presence of a therapist. Within the VR, the user can be coached on appropriate responses or coping strategies and apply it immediately for greater learning and retention. Importantly, in comparison to mental imagery, VR allows for a higher level of self-reflection, analyses, and practice, critical components of behaviour change.
When used as a tool for “gamification” or entertainment, VR can provide motivation or temporary suspension from reality which can help alleviate depressive symptoms.
Finally, VR is no longer a scientific tool available in research centres or gaming centres. With VR kits, headsets and goggles becoming available to the regular user, individuals can experience complete immersion at home, work or in the therapist’s office.
HOW EFFECTIVE IS IT?
There is strong evidence to support the use of VR to manage symptoms of depression. Systematic reviews and meta-analyses reported significant improvements in severity of depression and anxiety symptoms subsequent to participation in VR exposure therapy. A systematic review of six studies reported that VR was effective in reducing the severity of depression. Other studies reported that in addition to decrease in depression, individuals reported improved quality of life, social functioning, and physical activity in a VR environment compared to in-person group based activities.
VR has a wide scope for applicability in the field of mental health. VR has been successfully used to manage fear, paranoia, delusions, post-traumatic stress disorders, anxiety, phantom sensations, schizophrenia, pain, and is also compatible as an adjunct to pharmacotherapeutics.
COVID-19 pandemic has shed light on the surging mental health crises our population faces. With the advantages, flexibility, and cost-effectiveness it offers, VR can be a feasible and scalable way to make mental healthcare more accessible.
- Gayatri Aravind is Dark Slope’s Science Director and Advisor on Learning Science. Contact us to learn more about how your organization can use XR technologies to improve mental health management.