This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
A new therapy which uses virtual reality helped many people with psychosis manage anxiety that is so excessive they are unable to leave their homes (agoraphobia). Research found that the virtual reality therapy required less therapist time than usual care, and could be delivered by staff with no experience of delivering talking therapies.
People with psychosis have lost some contact with reality. They may see or hear things that other people do not (hallucinations), or believe things that are not true (delusions). Almost 2 in 3 people with psychosis also struggle with agoraphobia. They can be helped by talking therapies but there is a shortage of trained therapists. This study assessed whether virtual reality could be used to deliver effective therapy.
The researchers worked with people with lived experience of psychosis to develop the virtual reality therapy. Those receiving the treatment wore a virtual reality headset, and explored an electronic version of an everyday situation they found distressing (getting on a bus or visiting the doctor, for instance).
All participants in this study received usual care (prescribed medications, regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist). Half received virtual reality therapy in addition. The study found that the virtual reality therapy generally had a positive impact. People in the group who received it were less likely to avoid situations they found uncomfortable, and were less distressed. Those with severe agoraphobia described lasting benefits.
Further testing is needed of this virtual reality therapy. It is not available on the NHS but is being evaluated by the UK National Institute for Health and Care Excellence (NICE).
More information about psychosis can be found on the NHS website.
UPDATE (27/12/2023): The virtual therapy tested in this study, gameChange, has been approved by the National Institute for Health and Care Excellence (NICE) for use in the NHS to treat severe agoraphobia in people with psychosis.
The issue: many people with psychosis avoid everyday situations
People with psychosis may become distressed when visiting shops, or getting on a bus. If their anxiety is so extreme that they avoid everyday situations, it is known as agoraphobia. Almost 2 in 3 people with psychosis also have agoraphobia.
The number of therapists who can deliver therapy to people with psychosis is limited. In addition, therapy for people with both psychosis and agoraphobia is intensive and takes time to have an effect.
The virtual reality therapy was designed to reduce the avoidance and distress of agoraphobia in a shorter time than traditional approaches. The therapy is automated and a virtual character within the programme provides psychological advice and guides people as they explore simulated environments.
The simulations programmed into the virtual reality headset were recommended by people who had experienced psychosis. They included leaving home, being in a café, shop, doctor’s surgery or pub, and getting on a bus.
Researchers compared the new therapy plus usual care (usually prescribed medications, regular visits from a community mental health worker and occasional outpatient appointments with a psychiatrist) with usual care alone.
What’s new?
The study included 346 people aged 16 and over; all had psychosis and symptoms of agoraphobia. They were recruited from 9 NHS Trusts in England. 174 received the virtual reality therapy plus usual care; 172 received usual care alone.
The virtual reality therapy was delivered in one 30-minute session per week over 6 weeks. The staff who delivered the therapy did not all have previous experience of cognitive therapy. Staff members encouraged participants to apply learnings from the therapy in the real world by setting homework tasks.
Participants filled out an agoraphobia questionnaire before, and 6 weeks after, therapy had started. They rated their avoidance of, and distress in, everyday situations. For instance, travelling on a bus for several stops or sitting on their own in a café for 10 minutes.
After 6 weeks, the study found:
- people who received virtual reality therapy had greater reductions in the avoidance and distress of agoraphobia than those who received usual care alone
- the benefits were greatest for those with the most severe problems, such as those who could not leave home unaccompanied.
In a separate study, the researchers asked 20 of the participants what difference the virtual reality therapy had made to them. It had made a big difference to only 4 people, but these people said it had enabled them to do things they had not imagined possible; “It’s very different now, I can open my curtains and look out my window, I can go out to local shops and places, I can meet up with friends and family, I can do such a lot more.”
A further 9 people had been able to experiment with new approaches and ways of coping, and found situations less stressful, even if they were not yet comfortable; “I still suffer from some of the things I did, well, all of the things I did before, but it’s definitely, definitely helped it in some way”. And 5 people had noticed small changes; “Now because my mood is quite good, I’m thinking, ‘Yeah, actually. I did take away stuff.’ But when I’m really anxious,… and then I’m like, I haven’t learnt anything.”
For most of the group therefore, the virtual reality therapy brought meaningful benefits. Only 2 people described little personal benefit as they struggled with symptoms of psychosis and anxiety: “It has not really made a magical difference for me, unfortunately, but I can see how it can be very helpful. I think I’m just too entrenched in my avoidance little bubble, that it wasn’t strong enough to pull me out of it. It’s just the same.”
Why is this important?
The study found that virtual reality therapy helped people with psychosis who also have agoraphobia.
The researchers believe this is the first randomised controlled trial of an automated virtual reality therapy (meaning that advice and guidance is provided by a virtual character within the programme) for people with psychosis.
It was delivered by staff after half a day’s training and did not require fully qualified therapists. This could reduce the length of time people wait for therapy. The researchers say that in future, it could be possible for people to keep a device at home and use it whenever they need to.
The study was small and most of those in the trial were white (85%); the virtual reality therapy might work differently for people from ethnic minority groups. The study took place during the pandemic. It is not possible to tell whether public health messages about reducing social contact had an impact on the treatment effects.
What’s next?
The therapy is likely to be most suitable for people with severe avoidance or distress in everyday situations. The researchers say it will need further clinical testing, and they are setting up pilot NHS sites to explore the best ways of implementing the innovation. NICE is assessing the therapy to see if it should be recommended on the NHS.
Therapies using virtual reality are being developed by other groups in a range of mental health conditions. The technology is becoming cheaper and more widely available. Other virtual reality applications are already in use for mental wellness (reducing anxiety) and clinical mental health (including post-traumatic stress disorder and phobias).
Virtual reality therapy has other potential uses, including pain management and people with disabilities, for example. New wheelchair users could use it to navigate a virtual environment before going out into the real world.
You may be interested to read
This Alert is based on: Freeman D, and others. Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses. Lancet Psychiatry 2022;9:375-388.
A study by the same team on people's experiences of using the virtual reality intervention: Bond J, and others. A safe place to learn: peer research qualitative investigation of gameChange virtual reality therapy. Journal of Medical Internet Research Serious Games 2023;11:e38065.
An animation produced by the researchers describing the virtual reality intervention used in this trial.
Further analysis of the trial by the same team: Freeman D, and others. Agoraphobic avoidance in patients with psychosis: severity and response to automated VR therapy in a secondary analysis of a randomised controlled clinical trial. Schizophrenia Research 2022;250:50-59.
Funding: This study was funded by NIHR Invention for Innovation (i4i) programme and NIHR Oxford Health Biomedical Research Centre.
Conflicts of Interest: Daniel Freeman is a founder and director of Oxford VR, which will commercialise the virtual reality intervention tested in this trial. Full disclosures can be found in the original research paper.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
