@Article{info:doi/10.2196/67755,
author="Li, Xiaoli
and Liu, Xiaoyu
and Yin, Cheng
and Collins, Sandra
and Alanazi, Eman",
title="Impact of a Virtual Reality Video (``A Walk-Through Dementia'') on YouTube Users: Topic Modeling Analysis",
journal="JMIR Form Res",
year="2025",
month="Apr",
day="16",
volume="9",
pages="e67755",
keywords="Alzheimer disease",
keywords="Alzheimer disease and related dementias",
keywords="ADRD",
keywords="dementia",
keywords="public awareness",
keywords="text mining",
keywords="older adult",
keywords="health care student",
keywords="training",
keywords="health care professional",
keywords="simulation",
keywords="digital world",
keywords="virtual environment",
keywords="virtual tour",
keywords="walk-through dementia",
keywords="virtual reality",
keywords="VR",
keywords="VR video",
keywords="VR application",
keywords="topic modeling",
keywords="YouTube",
keywords="Bidirectional Encoder Representations from Transformers",
keywords="BERT",
keywords="social media comments",
keywords="experiential learning tool",
abstract="Background: Emerging research has highlighted the potential of virtual reality (VR) as a tool for training health care students and professionals in care skills for individuals with Alzheimer disease and related dementias (ADRD). However, there is limited research on the use of VR to engage the general public in raising awareness about ADRD. Objective: This research aimed to examine the impact of the VR video ``A Walk-Through Dementia'' on YouTube users by analyzing their posts. Methods: We collected 12,754 comments from the VR video series ``A Walk-Through Dementia,'' which simulates the everyday challenges faced by individuals with ADRD, providing viewers with an immersive experience of the condition. Topic modeling was conducted to gauge viewer opinions and reactions to the videos. A pretrained Bidirectional Encoder Representations from Transformers (BERT) model was used to transform the YouTube comments into high-dimensional vector embeddings, allowing for systematic identification and detailed analysis of the principal topics and their thematic structures within the dataset. Results: We identified the top 300 most frequent words in the dataset and categorized them into nouns, verbs, and adjectives or adverbs using a part-of-speech tagging model, fine-tuned for accurate tagging tasks. The topic modeling process identified eight8 initial topics based on the most frequent words. After manually reviewing the 8 topics and the content of the comments, we synthesized them into 5 themes. The predominant theme, represented in 2917 comments, centered on users' personal experiences with the impact of ADRD on patients and caregivers. The remaining themes were categorized into 4 main areas: positive reactions to the VR videos, challenges faced by individuals with ADRD, the role of caregivers, and learning from the VR videos. Conclusions: Using topic modeling, this study demonstrated that VR applications serve as engaging and experiential learning tools, offering the public a deeper understanding of life with ADRD. Future research should explore additional VR applications on social media, as they hold the potential to reach wider audiences and effectively disseminate knowledge about ADRD. ",
doi="10.2196/67755",
url="https://formative.jmir.org/2025/1/e67755"
}


@Article{info:doi/10.2196/65770,
author="Schuler, R. Kaitlyn
and Ong, Triton
and Welch, M. Brandon
and Craggs, G. Jason
and Bunnell, E. Brian",
title="Examining a Telemedicine-Based Virtual Reality Clinic in Treating Adults With Specific Phobia: Protocol for a Feasibility Randomized Controlled Efficacy Trial",
journal="JMIR Res Protoc",
year="2025",
month="Apr",
day="10",
volume="14",
pages="e65770",
keywords="virtual reality",
keywords="exposure therapy",
keywords="phobias",
keywords="telemedicine",
keywords="telemental health",
keywords="tele-VR",
keywords="immersive simulations",
abstract="Background: Virtual reality (VR) has strong potential to enhance the effectiveness of telemental health care (TMH) by providing accessible, personalized treatment from home. While there is ample research supporting VR for in-person treatment, there is only preliminary data on the efficacy of telemedicine-based VR. Furthermore, the majority of VR apps used in therapy are not designed for mental health care. VR has the potential to enhance TMH through innovative technology solutions designed specifically for the enhancement of remotely delivered evidence-based practices. This feasibility randomized controlled efficacy trial aims to fill both of these gaps by piloting a novel telemedicine-based VR app (Doxy.me VR) equipped with animal phobia exposure stimuli. Objective: This is a feasibility randomized controlled efficacy trial comparing exposure therapy via a telemedicine-based VR clinic versus standard TMH with adults with an intense fear of dogs, snakes, or spiders. The primary objective is to assess the feasibility of a fully powered trial. The secondary objective is to conduct a preliminary examination of clinical outcomes (eg, specific phobia symptoms). Methods: This single-site trial will enroll a minimum of 30 and a maximum of 60 adults with self-reported fear of dogs, snakes, or spiders. Potential participants will be recruited through clinical trial and research recruitment websites and posting flyers. All self-report assessments and homework will be partially automated using REDCap (Research Electronic Data Capture; Vanderbilt University) forms and surveys, but the baseline assessment of phobia symptoms and exposure intervention will be administered by the study therapist. Results: The feasibility of the proposed trial methodology will be assessed using enrollment, retention, assessment completion, and treatment protocol fidelity benchmarks. Between-group differences in specific phobia, anxiety, and depression symptoms while covarying for pretreatment scores, will be conducted using repeated measures ANOVA along with differences in therapeutic alliance and presence. Data obtained from these analyses will inform power analyses for a fully powered efficacy trial. In total, 54 participants were randomized between October 25, 2023, and July 26, 2024 (Doxy.me VR n=28 and TMH n=26). Data analysis will be completed and submitted by the end of the second quarter of 2025. Conclusions: This feasibility randomized controlled trial comparing Doxy.me VR versus TMH aims to enhance the delivery of evidence-based treatments via telemedicine and reduce barriers to remotely delivered exposure therapy. This feasibility trial will be followed by a fully powered efficacy trial on telemedicine-based VR for animal phobias. Trial Registration: ClinicalTrials.gov NCT06302868; https://clinicaltrials.gov/study/NCT06302868 International Registered Report Identifier (IRRID): DERR1-10.2196/65770 ",
doi="10.2196/65770",
url="https://www.researchprotocols.org/2025/1/e65770"
}


@Article{info:doi/10.2196/59083,
author="Huang, Kuo-Ting
and Ma, Zexin
and Yao, Lan",
title="Media-Induced and Psychological Factors That Foster Empathy Through Virtual Reality in Nursing Education: 2{\texttimes}2 Between-Subjects Experimental Study",
journal="JMIR Med Educ",
year="2025",
month="Mar",
day="31",
volume="11",
pages="e59083",
keywords="nursing education",
keywords="narrative transportation",
keywords="presence",
keywords="virtual reality",
keywords="game-based learning",
keywords="affective empathy",
abstract="Background: Virtual reality (VR) has emerged as a promising tool in medical education, particularly for fostering critical skills such as empathy. However, how VR, combined with perspective-taking, influences affective empathy in nursing education remains underexplored. Objective: This study investigates the influence of VR and perspective-taking on affective empathy in nursing education, focusing on 4 psychological factors: perceived self-location, narrative transportation, emotional engagement, and affective empathy. Methods: A 2{\texttimes}2 between-subjects design was used, involving 69 nursing undergraduates from two Midwest universities. The participants engaged with a narrative-focused video game, That Dragon, Cancer, in either VR or non-VR conditions and from the perspective of either parents or clinicians. Results: VR significantly enhanced perceived self-location (P=.01), while adopting a clinician's perspective amplified emotional engagement (P=.03). However, VR did not significantly influence narrative transportation (P=.35). An interaction effect was found between the platform and player's perspective on narrative transportation (P=.04). Several indirect effects of media elements on affective empathy were observed via other psychological factors, though the direct effect of VR on affective empathy was not significant (P=.84). Conclusions: These findings underscore the potential of VR in medical education, suggesting that perspective-taking should be carefully considered when designing immersive learning experiences. The study advocates for broader integration of VR technologies into medical curricula to enhance instruction quality and patient-centered care. ",
doi="10.2196/59083",
url="https://mededu.jmir.org/2025/1/e59083"
}


@Article{info:doi/10.2196/50326,
author="Pallavicini, Federica
and Orena, Eleonora
and Arnoldi, Lisa
and Achille, Federica
and Stefanini, Stefano
and Cassa, Maddalena
and Pepe, Alessandro
and Veronese, Guido
and Bernardelli, Luca
and Sforza, Francesca
and Fascendini, Sara
and Defanti, Alberto Carlo
and Gemma, Marco
and Clerici, Massimo
and Riva, Giuseppe
and Mantovani, Fabrizia",
title="Effects and Acceptability of a 1-Week Home-Based Virtual Reality Training for Supporting the Management of Stress and Anxiety: Randomized Pilot Trial",
journal="JMIR Serious Games",
year="2025",
month="Mar",
day="6",
volume="13",
pages="e50326",
keywords="virtual reality",
keywords="relaxation",
keywords="anxiety",
keywords="depression",
keywords="emotions",
keywords="health care professionals",
keywords="health care workers",
keywords="hospital",
keywords="randomized clinicial trial",
keywords="hospitals",
abstract="Background: Virtual reality (VR) is helpful for the management of stress and anxiety. However, current interventions have limitations related to location (ie, therapist's office or hospitals) and content (ie, virtual experiences only for relaxation). Objective: This randomized pilot trial aims to investigate the efficacy and acceptability of a brief remote VR-based training for supporting stress and anxiety management in a sample of Italian health care workers. Methods: A total of 29 doctors and nurses (n=21; 72\% female; mean age 35.6, SD 10.3 years) were recruited and randomized to a VR intervention group or a control group in a passive control condition. Participants assigned to the VR intervention group received remote VR-based training consisting of 3 sessions at home delivered in 1 week using the VR psychoeducational experience ``MIND-VR'' and the 360{\textdegree} relaxing video ``The Secret Garden.'' The primary outcome measures were stress, anxiety, depression, and the knowledge of stress and anxiety assessed at baseline and posttreatment. We also evaluated the immediate effect of the remote VR-based training sessions on the perceived state of anxiety and negative and positive emotions. The secondary outcome measure was the usability at home of the VR system and content. Results: The VR intervention significantly reduced stress levels as assessed by the Perceived Stress Scale (6.46, 95\% CI 2.77 to 10.5; P=.046) and increased the knowledge of stress and anxiety, as evaluated by the ad hoc questionnaire adopted (--2.09, 95\% CI --3.86 to --0.529; P=.046). However, the home-based VR training did not yield similar reductions in stress, anxiety, and depression levels as assessed by the Depression, Anxiety, and Stress Scale-21 items or in trait anxiety as evaluated through the State-Trait Anxiety Inventory Form Y-1. After the home training sessions with VR, there was a significant decrease in anxiety, anger, and sadness and an increase in happiness levels. Analyses of the questionnaires on usability indicated that the health care workers found using the VR system at home easy and without adverse effects related to cybersickness. Of 33 participants, 29 (88\%) adhered to the protocol. Conclusions: The results of this randomized pilot study suggest that a week-long home VR intervention, created with content created specifically for this purpose and available free of charge, can help individuals manage stress and anxiety, encouraging further research investigating the potential of remote VR interventions to support mental health. Trial Registration: ClinicalTrials.gov NCT04611399; https://tinyurl.com/scxunprd ",
doi="10.2196/50326",
url="https://games.jmir.org/2025/1/e50326",
url="http://www.ncbi.nlm.nih.gov/pubmed/40053782"
}


@Article{info:doi/10.2196/64492,
author="Khundrakpam, Budhachandra
and Segado, Melanie
and Pazdera, Jesse
and Gagnon Shaigetz, Vincent
and Granek, A. Joshua
and Choudhury, Nusrat",
title="An Integrated Platform Combining Immersive Virtual Reality and Physiological Sensors for Systematic and Individualized Assessment of Stress Response (bWell): Design and Implementation Study",
journal="JMIR Form Res",
year="2025",
month="Mar",
day="4",
volume="9",
pages="e64492",
keywords="virtual reality",
keywords="stress",
keywords="physiological response",
keywords="NASA-Task Load Index",
keywords="cognitive demand",
keywords="physical demand",
keywords="vagal tone",
keywords="heart rate variability",
abstract="Background: Stress is a pervasive issue in modern society, manifesting in various forms such as emotional, physical, and work-related stress, each with distinct impacts on individuals and society. Traditional stress studies often rely on psychological, performance, or social tests; however, recently, immersive virtual reality (VR), which provides a sense of presence and natural interaction, offers the opportunity to simulate real-world tasks and stressors in controlled environments. Despite its potential, the use of VR to investigate the multifaceted manifestations of stress has not been thoroughly explored. Objective: This study aimed to explore the feasibility of using a VR-based platform, bWell, to elicit multifaceted stress responses and measure the resulting behavioral and physiological changes. Specifically, we aimed to design various VR stress exercises based on neurocardiac models to systematically test cardiac functioning within specific contexts of self-regulation (executive functioning, physical efforts, and emotional regulation). Methods: The development process adhered to guidelines for VR clinical trials and complex health interventions, encompassing 3 phases: preparation, development, and verification. The preparation phase involved a comprehensive literature review to establish links between stress, the heart, and the brain, leading to the formulation of a conceptual model based on the Neurovisceral Integration Model (NVIM) and Vagal Tank Theory (VTT). The development phase involved designing VR exercises targeting specific stressors and integrating physiological sensors such as photoplethysmography (PPG) and electromyography (EMG) to capture heart rate variability (HRV) and facial expressions. The verification phase, conducted with a small number of trials, aimed to design a study and implement a workflow for testing the feasibility, acceptability, and tolerability of the VR exercises. In addition, the potential for capturing physiological measures along with subjective ratings of stress for specific dimensions was assessed. Results: Verification trials demonstrated that the VR exercises were well tolerated, with negligible cybersickness and high user engagement. The different VR exercises successfully elicited the intended stress demands, along with the physiological responses. Conclusions: The study presents a novel VR-based experimental setup that allows a systematic and individualized assessment of stress responses, paving the way for future research to identify features that confer stress resilience and help individuals manage stress effectively. While our conceptual model highlights the role of HRV in providing valuable insights into stress responses, future research will involve multivariate and machine learning analyses to predict individual stress responses based on comprehensive sensor data, including EMG and the VR-based behavioral data, ultimately guiding personalized stress management interventions. ",
doi="10.2196/64492",
url="https://formative.jmir.org/2025/1/e64492",
url="http://www.ncbi.nlm.nih.gov/pubmed/40053709"
}


@Article{info:doi/10.2196/63235,
author="Mills, Jodie
and Duffy, Orla",
title="Speech and Language Therapists' Perspectives of Virtual Reality as a Clinical Tool for Autism: Cross-Sectional Survey",
journal="JMIR Rehabil Assist Technol",
year="2025",
month="Feb",
day="27",
volume="12",
pages="e63235",
keywords="virtual reality",
keywords="VR",
keywords="autistic",
keywords="ASD",
keywords="speech",
keywords="language",
keywords="autism",
keywords="speech and language therapy",
keywords="speech-language pathology",
keywords="SLT",
keywords="immersive",
keywords="voice",
keywords="vocal",
keywords="cross sectional",
keywords="surveys",
keywords="questionnaires",
keywords="experiences",
keywords="attitudes",
keywords="opinions",
keywords="perceptions",
keywords="perspectives",
keywords="autism spectrum disorder",
abstract="Background: Persistent difficulties with social skills form part of the diagnostic criteria for autism and in the past have required speech and language therapy (SLT) management. However, many speech and language therapists are moving toward neuro-affirmative practices, meaning that social skills approaches are now becoming redundant. Research demonstrates that virtual reality (VR) interventions have shown promise in overcoming challenges and promoting skill generalization for autistic children; however, the majority of these focus on social skills interventions. While VR is emerging as an SLT intervention, its application for autism remains unexamined in clinical practice. Objective: This research aimed to examine speech and language therapists' knowledge and attitudes toward immersive VR as a clinical tool for autistic children and explore the reasons for its limited integration into clinical practice. Methods: A web-based cross-sectional survey was available from April 3, 2023 to June 30, 2023. The survey, consisting of 23 questions, focused on VR knowledge, attitudes, and the support required by speech and language therapists to incorporate VR into clinical practice. Dissemination occurred through the Royal College of Speech and Language Therapists Clinical Excellence Networks to recruit speech therapists specializing in autism. Results: Analysis included a total of 53 responses from the cross-sectional survey. Approximately 92\% (n=49) of speech and language therapists were aware of VR but had not used it, and 1.82\% (n=1) had used VR with autistic children. Three key themes that emerged were (1) mixed general knowledge of VR, which was poor in relation to applications for autism; (2) positive and negative attitudes toward VR, with uncertainty about autism specific considerations for VR; and (3) barriers to adoption were noted and speech and language therapists required an improved neuro-affirming evidence base, guidelines, and training to adopt VR into clinical practice. Conclusions: While some speech and language therapists perceive VR as a promising intervention tool for autistic children, various barriers must be addressed before its full integration into the clinical toolkit. This study establishes a foundation for future co-design, development, and implementation of VR applications as clinical tools for autistic children. This study is the first to explore clinical implementation factors for the use of VR in SLT field, specifically with autistic children. Poor autism-specific VR knowledge, and mixed attitudes toward VR, highlight that specific barriers must be addressed before the technology can successfully integrate into the SLT clinical toolkit. Speech and language therapists require support from employers, funding, a robust neuro-affirming evidence base, and education and training to adopt VR into practice. Recommendations for a SLT VR education and training program for use with autistic children, are provided. ",
doi="10.2196/63235",
url="https://rehab.jmir.org/2025/1/e63235"
}


@Article{info:doi/10.2196/54452,
author="Maheta, Bhagvat
and Kraft, Alexandra
and Interrante, Nickolas
and Fereydooni, Soraya
and Bailenson, Jeremy
and Beams, Brian
and Keny, $\null$$\null$Christina
and Osborne, Thomas
and Giannitrapani, Karleen
and Lorenz, Karl",
title="Using Virtual Reality to Improve Outcomes Related to Quality of Life Among Older Adults With Serious Illnesses: Systematic Review of Randomized Controlled Trials",
journal="J Med Internet Res",
year="2025",
month="Feb",
day="26",
volume="27",
pages="e54452",
keywords="virtual reality",
keywords="serious illness",
keywords="pain",
keywords="anxiety",
keywords="older adults",
keywords="patient outcomes",
keywords="systematic review",
keywords="palliative care",
keywords="hospice",
abstract="Background: Virtual reality (VR) has promise as an innovative nonpharmacologic treatment for improving a patient's quality of life. VR can be used as an adjunct or treatment for many acute and chronic conditions, including serious illnesses. Objective: This systematic review aims to assess the current state of the literature of randomized controlled trials that use VR in patients with serious illnesses. Two secondary aims include assessing intervention components associated with improved quality of life and functional outcomes among older adults, as well as evaluating how well the randomized controlled trials adhere to consensus standards for VR research. Methods: We searched PubMed, Embase, and CINAHL for randomized controlled studies published at any time. We screened and accepted studies that reported outcomes related to patients' quality of life, provided an immersive VR intervention, and included patients with serious illness. We narratively summarized key attributes of publications that shed light on study efficacy, generalizability, replicability, and clinical utility. All studies were assessed for study quality with the Cochrane Risk of Bias tool and for concordance with 8 recent consensus standards for VR research. Results: From the 12,621 articles searched in May 2024, a total of 24 (0.19\%) studies met the inclusion criteria, and of these, 88\% (21/24) reported an improvement in at least 1 patient quality of life outcome and 67\% (16/24) had a high risk of bias. In 7 (n=24, 29\%) studies, VR was used to provide distraction therapy to reduce pain. In total, 5 (n=24, 21\%) studies included training, supervision, and assistance in VR use, which demonstrated improvements in patient quality of life--related outcomes. Of 24 studies, 9 (38\%) included patients with stroke, 9 (38\%) included patients with cancer, 4 (17\%) included patients with cardiovascular disease, 1 (4\%) included patients with chronic obstructive pulmonary disease, and 1 (4\%) included patients who reported pain in hospital. In all 9 studies that included patients with stroke, the main purpose of VR was to improve mobility and strength; these studies had higher frequency and longer durations of VR use, ranging from 2 to 9 weeks, as compared to a VR use duration of <2 weeks for studies aiming to reduce pain or anxiety. Regarding consensus standards for VR research, 29\% (7/24) of the studies adhered to all 8 criteria, and all studies (24/24, 100\%) adhered to ?5 criteria. Conclusions: Nascent evidence suggests VR's potential in mitigating pain, anxiety, and depression and improving mobility among persons with serious illnesses. Most studies did not provide detailed information about unassisted or assisted use, suggesting that VR for older adults is currently most appropriate for observed settings with assistance available. Trial Registration: PROSPERO CRD42022346178; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=346178 ",
doi="10.2196/54452",
url="https://www.jmir.org/2025/1/e54452"
}


@Article{info:doi/10.2196/67338,
author="Fang, Hao
and Fang, Changqing
and Che, Yan
and Peng, Xinyuan
and Zhang, Xiaofan
and Lin, Di",
title="Reward Feedback Mechanism in Virtual Reality Serious Games in Interventions for Children With Attention Deficits: Pre- and Posttest Experimental Control Group Study",
journal="JMIR Serious Games",
year="2025",
month="Feb",
day="24",
volume="13",
pages="e67338",
keywords="serious games",
keywords="virtual reality",
keywords="attention deficit",
keywords="inhibitory control ability",
keywords="reward feedback",
abstract="Background: Virtual reality (VR) serious games, due to their high level of freedom and realism, influence the rehabilitation training of inhibitory control abilities in children with attention-deficit/hyperactivity disorder (ADHD). Although reward feedback has a motivating effect on improving inhibitory control, the effectiveness and differences between various forms of rewards lack empirical research. Objective: This study aimed to investigate the effectiveness of different forms of reward feedback on the inhibitory control abilities of children with attention deficits in a VR serious game environment. Methods: This study focuses on children who meet the diagnostic criteria for ADHD tendencies, using a 2 (material rewards: coin reward and token reward) {\texttimes} 2 (psychological rewards: verbal encouragement and badge reward) factorial between-subject design (N=84), with a control group (n=15) for pre- and posttest experiments. The experimental group received VR feedback reinforcement training, while the control group underwent conventional VR training without feedback. The training period lasted 0.5 months, with each intervention session lasting 25 minutes, occurring twice daily with an interval of at least 5 hours for 28 sessions. Before and after training, the Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) Scale, stop signal task, inhibition conflict task, and Simon task were administered to assess the hyperactivity index and the 3 components of inhibitory control ability. The pretest included the SNAP-IV Scale and 3 task tests to obtain baseline data; the posttest involved repeating the above tests after completing all training. Data were entered and analyzed using SPSS (IBM) software. Independent sample t tests were performed on the experimental and control groups' pre- and posttest task results to determine whether significant differences existed between group means. Paired sample t tests were also conducted on the SNAP-IV Scale's pre- and posttest results to assess the intervention effect's significance. Results: Reward feedback was more effective than no reward feedback in improving behaviors related to attention deficits in children. Material rewards showed significant effects in the Stop-Signal Task (F1=13.04, P=.001), Inhibition Conflict Task (F1=7.34, P=.008), and SNAP-IV test (F1=69.23, P<.001); mental rewards showed significant effects in the Stop-Signal Task (F1=38.54, P<.001) and SNAP-IV test (F1=70.78, P<.001); the interaction between the 2 showed significant effects in the Stop-Signal Task (F1=4.47, P=.04) and SNAP-IV test (F1=23.85, P<.001). Conclusions: Combining material and psychological rewards within a VR platform can effectively improve attention-deficit behaviors in children with ADHD, enhancing their inhibitory control abilities. Among these, coin rewards are more effective than token rewards, and verbal encouragement outperforms badge rewards. The combined feedback of coin rewards and verbal encouragement yields the most significant improvement in inhibitory control abilities. ",
doi="10.2196/67338",
url="https://games.jmir.org/2025/1/e67338"
}


@Article{info:doi/10.2196/59922,
author="Ding, E. Michael
and Traiba, Hajar
and Perez, R. Hector",
title="Virtual Reality Interventions and Chronic Pain: Scoping Review",
journal="J Med Internet Res",
year="2025",
month="Feb",
day="18",
volume="27",
pages="e59922",
keywords="virtual reality",
keywords="chronic pain",
keywords="scoping review",
keywords="pain management",
keywords="efficacy",
keywords="anxiety disorders",
keywords="mood",
keywords="health condition",
keywords="health intervention",
keywords="adults",
keywords="aging",
keywords="therapeutic",
keywords="descriptive--analytical method",
keywords="monitoring",
keywords="US",
keywords="PRISMA",
abstract="Background: Virtual reality (VR) interventions have demonstrated efficacy for more than a decade for mood and anxiety disorders and emerging evidence suggests they can reduce pain symptoms in both acute and chronic pain. More recently, these interventions have abounded within the commercial and academic sectors, immersing participants within a virtual environment to confer health benefits to users. VR immersion can facilitate the delivery of health interventions by isolating participants from distractors and stressors in a therapeutic environment. While recent studies of VR interventions have exploded, they are not uniform in approach or device type, limiting generalizability. Recent scoping reviews on VR and chronic pain have focused on specific diseases or limited inquiries to specific interventions or study types. Objective: We conducted a scoping review to generate new knowledge about the sum total of VR studies on chronic pain with specific emphasis on the methods and results of each study, including (1) the type of interventions, (2) outcomes chosen, (3) samples studied, and (4) data generated. Methods: A scoping review was performed on the literature on VR and chronic pain to describe themes associated with the literature to date and identify important gaps and unanswered questions to guide future research. CINAHL [EBSCO] (Cumulative Index to Nursing and Allied Health Literature) and PubMed were queried for the terms ``virtual reality'' and ``pain,'' providing studies of chronic pain adult participants using VR delivered through headset displays. We included English-language manuscripts that had at least one VR intervention arm with adults with chronic pain. For this analysis, we only included VR interventions that were immersive (ie, using headsets). Non--study reports, studies with no specific chronic pain component, those not involving adults, and those using VR as part of a comprehensive rehabilitation program were excluded. A descriptive analytical method was used to extract data, compare studies, and contextualize the presented outcomes. Articles were categorized into several themes including the type of intervention, outcomes chosen, participant characteristics, degree to which immersion was achieved, and adverse effect monitoring and reporting. Results: A total of 36 articles were included in our analysis. We summarize the literature using 5 themes: (1) heterogeneity of chronic pain types, (2) highly variable intervention types, (3) highly variable secondary and exploratory outcomes, (4) immersion was highly variable between studies and not systemically explored in many articles, and (5) side effect monitoring was limited. Conclusions: The literature on VR in chronic pain is highly variable and lacks theoretical rigor. While there is emerging evidence that supports VR use in a wide variety of health conditions including chronic pain, future research should focus on producing theoretically rigorous work that focuses on mechanisms and that systematically assesses side effects to generate robust generalizable knowledge. ",
doi="10.2196/59922",
url="https://www.jmir.org/2025/1/e59922"
}


@Article{info:doi/10.2196/62663,
author="Verstegen, Amandine
and Van Daele, Tom
and Bonroy, Bert
and Debard, Glen
and Sels, Romy
and van Loo, Marlon
and Bernaerts, Sylvie",
title="Designing a Smartphone-Based Virtual Reality App for Relaxation: Qualitative Crossover Study",
journal="JMIR Form Res",
year="2025",
month="Feb",
day="13",
volume="9",
pages="e62663",
keywords="smartphone-based virtual reality",
keywords="virtual reality",
keywords="relaxation",
keywords="stress",
keywords="user experience",
keywords="mobile phone",
abstract="Background: Accumulating evidence supports the use of virtual reality (VR) in mental health care, with one potential application being its use to assist individuals with relaxation exercises. Despite studies finding support for the potential of VR to effectively aid in relaxation, its implementation remains limited outside of specialized clinics. Known barriers are insufficient knowledge regarding VR operation, lack of availability of VR relaxation apps tailored to local health care systems, and cost concerns. Unfortunately, many VR relaxation apps are designed exclusively for stand-alone headsets, limiting accessibility for a broad audience. Objective: We aimed to design an accessible, smartphone-based VR relaxation app based on user preferences. This paper describes the assessment of 2 stand-alone VR relaxation apps and the resulting smartphone-based VR relaxation app design. Methods: Overall, 30 participants (n=23, 77\% women; n=7, 23\% men) took part in 2 separate VR sessions, assessing 1 of the 2 VR relaxation apps (Flowborne and Calm Place) in each session. After each session, participants were presented with open-ended questions to assess their experiences via a web-based survey tool. These questions explored positive and negative features, shortcomings, and suggestions for improvements while also allowing space for additional remarks concerning the 2 VR relaxation apps. Three of the authors analyzed the responses using inductive thematic analysis, a process comprising 6 phases. Results: Across both the apps, 5 recurring themes and 13 recurring subthemes were identified in the participants' answers: audio (music and sounds, guidance), visuals (content, realism, variation and dynamics in the environment), features (language, options, feedback and instructions, duration, exercise), implementation (technical aspects, cybersickness, acceptability and usability), and experience. We analyzed the participants' findings and conducted a literature review, which served as the basis for developing the app. The resulting app is a Dutch-language, smartphone-based VR relaxation app, with customization options including 3 types of relaxation exercises, 2 guiding voices, and 3 different environments. Efforts have been made to ensure maximum variation and dynamism in the environments. Calming music and nature sounds accompany the exercises. The efficacy and effectiveness of the resulting app design were not assessed. Conclusions: This study provides insights into key features of VR relaxation apps, which were subsequently used for the development of a novel smartphone-based VR relaxation app. Further research concerning the effectiveness of this app, along with a broader evaluation of the efficacy and user feedback for smartphone-based VR relaxation apps, is needed. More generally, there is a clear need for more research on the impact of interactivity, biofeedback, and type of environment in VR relaxation. ",
doi="10.2196/62663",
url="https://formative.jmir.org/2025/1/e62663"
}


@Article{info:doi/10.2196/65206,
author="Klein Haneveld, Lisa
and Dekkers, Tessa
and Bouman, A. Yvonne H.
and Scholten, Hanneke
and Weerdmeester, Joanneke
and Kelders, M. Saskia
and Kip, Hanneke",
title="The Effect of the Virtual Reality--Based Biofeedback Intervention DEEP on Stress, Emotional Tension, and Anger in Forensic Psychiatric Inpatients: Mixed Methods Single-Case Experimental Design",
journal="JMIR Form Res",
year="2025",
month="Feb",
day="12",
volume="9",
pages="e65206",
keywords="virtual reality",
keywords="VR",
keywords="diaphragmatic breathing",
keywords="biofeedback",
keywords="DEEP",
keywords="forensic psychiatry",
keywords="mental health",
keywords="stress",
keywords="single-case experimental design",
keywords="experience sampling method",
abstract="Background: Decreasing aggression through stress reduction is an important part of forensic psychiatric treatment. DEEP is an experience-based virtual reality intervention that uses biofeedback to train diaphragmatic breathing and increase relaxation. Although DEEP has shown promising results in reducing stress and anxiety in students and adolescents in special education, it has not been examined in forensic psychiatric populations. Objective: This study aimed to evaluate DEEP's potential to reduce stress, emotional tension, and anger in forensic psychiatric inpatients. Methods: A mixed methods, alternating treatment, single-case experimental design was conducted with 6 Dutch forensic inpatients. For 20 days, participants engaged in 4 DEEP sessions. Experience sampling was used for continuous monitoring of stress, emotional tension, and anger twice daily. A repeated linear mixed model was used as a primary statistical approach for analyzing the experience sampling data as well as visual analyses. Finally, semistructured interviews were conducted with participants and health care professionals to compare quantitative with qualitative results. Results: Of the 6 participants, 3 (50\%) completed all 4 DEEP sessions, while the other 3 (50\%) missed one session due to technical difficulties or absence from the inpatient clinic. P1 showed a significant reduction of stress after session 2 ($\beta$=--.865; P=.005). No significant changes over time were found, although an experienced effect was reported during the interviews. P2 showed no significant results. They reported the sessions as being repetitive, with no experienced effect. P3 showed a momentary increase of emotional tension after the first session ($\beta$=--.053; P=.002), but no changes were observed over time. No experienced effects were reported in the interview. P4 did not show significant results over time, and was hesitant to report clear experienced effects. P5 showed a significant decline of emotional tension ($\beta$=--.012; P=.006), stress ($\beta$=--.014; P=.007), and anger ($\beta$=--.007; P=.02) over time. They also reported short-term experienced effects in the interview. P6 showed a significant decline of stress over time ($\beta$=--.029; P<.001) and reported experiencing substantial effects. Finally, health care professionals reported a relaxing effect of DEEP in their patients but did not expect many long-term effects because no clear behavioral changes were observed. Conclusions: DEEP shows promise in teaching deep breathing techniques to forensic psychiatric inpatients, potentially decreasing stress, emotional tension, and anger in some patients. However, DEEP is not a one-size-fits-all intervention that supports every patient because the effectiveness on the outcome measures varied among participants. To increase effectiveness, emphasis should be put on supporting patients to transfer deep breathing skills into their daily lives. This highlights the importance for the structural integration of DEEP into current treatment protocols. ",
doi="10.2196/65206",
url="https://formative.jmir.org/2025/1/e65206"
}


@Article{info:doi/10.2196/60845,
author="Yang, Xipeng
and Wu, Jinlong
and Ma, Yudan
and Yu, Jingxuan
and Cao, Hong
and Zeng, Aihua
and Fu, Rui
and Tang, Yucheng
and Ren, Zhanbing",
title="Effectiveness of Virtual Reality Technology Interventions in Improving the Social Skills of Children and Adolescents With Autism: Systematic Review",
journal="J Med Internet Res",
year="2025",
month="Feb",
day="5",
volume="27",
pages="e60845",
keywords="VR technology",
keywords="autism spectrum disorder",
keywords="children",
keywords="adolescents",
keywords="social skills",
keywords="virtual reality",
keywords="VR",
abstract="Background: Virtual reality (VR) technology has shown significant potential in improving the social skills of children and adolescents with autism spectrum disorder (ASD). Objective: This study aimed to systematically review the evidence supporting the effectiveness of VR technology in improving the social skills of children and adolescents with ASD. Methods: The search for eligible studies encompassed 4 databases: PubMed, Web of Science, IEEE, and Scopus. Two (XY and JW) researchers independently assessed the extracted studies according to predefined criteria for inclusion and exclusion. These researchers also independently extracted information regarding gathered data on the sources, samples, measurement methods, primary results, and data related to the main results of the studies that met the inclusion criteria. The quality of the studies was further evaluated using the Physiotherapy Evidence Database scale. Results: This review analyzed 14 studies on using VR technology interventions to improve social skills in children and adolescents with ASD. Our findings indicate that VR interventions have a positive effect on improving social skills in children and adolescents with ASD. Compared with individuals with low-functioning autism (LFA), those with high-functioning autism (HFA) benefited more from the intervention. The duration and frequency of the intervention may also influence its effectiveness. In addition, immersive VR is more suitable for training complex skills in individuals with HFA. At the same time, nonimmersive VR stands out in terms of lower cost and flexibility, making it more appropriate for basic skill interventions for people with LFA. Finally, while VR technology positively enhances social skills, some studies have reported potential adverse side effects. According to the quality assessment using the Physiotherapy Evidence Database scale, of the 14 studies, 6 (43\%) were classified as high quality, 4 (29\%) as moderate quality, and 4 (29\%) as low quality. Conclusions: This systematic review found that VR technology interventions positively impact social skills in children and adolescents with ASD, with particularly significant effects on the enhancement of complex social skills in individuals with HFA. For children and adolescents with LFA, progress was mainly observed in basic skills. Immersive VR interventions are more suitable for the development of complex skills. At the same time, nonimmersive VR, due to its lower cost and greater flexibility, also holds potential for application in specific contexts. However, the use of VR technology may lead to side effects such as dizziness, eye fatigue, and sensory overload, particularly in immersive settings. These potential issues should be carefully addressed in intervention designs to ensure user comfort and safety. Future research should focus on optimizing individualized interventions and further exploring the long-term effects of VR interventions. Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202420079U1; https://inplasy.com/inplasy-2024-2-0079/ ",
doi="10.2196/60845",
url="https://www.jmir.org/2025/1/e60845"
}


@Article{info:doi/10.2196/57297,
author="Sarai, Gurdeep
and Jayaraman, Prakash Prem
and Tirosh, Oren
and Wickramasinghe, Nilmini",
title="Exploring Virtual Reality and Exercise Simulator Interventions in Patients With Attention Deficit Hyperactivity Disorder: Comprehensive Literature Review",
journal="JMIR Serious Games",
year="2025",
month="Jan",
day="29",
volume="13",
pages="e57297",
keywords="exercise-based simulator",
keywords="exergame",
keywords="virtual reality",
keywords="physical activity",
keywords="attention-deficit/hyperactivity disorder",
abstract="Background: This review explores virtual reality (VR) and exercise simulator--based interventions for individuals with attention-deficit/hyperactivity disorder (ADHD). Past research indicates that both VR and simulator-based interventions enhance cognitive functions, such as executive function and memory, though their impacts on attention vary. Objective: This study aimed to contribute to the ongoing scientific discourse on integrating technology-driven interventions into the management and evaluation of ADHD. It specifically seeks to consolidate findings on how VR and exercise simulators may support individuals with ADHD, acknowledging associated challenges and implications inherent in both technological approaches. Methods: This research looks at existing literature to examine the potential efficacy of VR and exercise simulator--based interventions for individuals with ADHD. It evaluates the capacity of these interventions to address specific challenges along with an emphasis on the adjustments for accommodating unique user behaviors. Additionally, it underscores the limited exploration of user perceptions of exercise simulator--based interventions and the undervalued role of motor function in both ADHD assessment and symptom management. Results: The findings of this scoping review reveal that, while these interventions enhance user motivation and enjoyment, certain challenges resist modification through technology. Furthermore, this study explores the intricate complexities involved in customizing these technologies to accommodate the diverse aspects of user behavior and highlights the potential limitations in the use of VR. Conclusions: This scoping review contributes to the ongoing research on enhancing interventions to support individuals with ADHD. It advocates for participant-centric approaches that aim to optimize both cognitive and motor outcomes while prioritizing the enhancement of user experiences. This study emphasizes the need for a comprehensive approach to interventions, recognizing the relationship between cognitive and motor abilities, and calls for improving technological interventions to address the varied needs of individuals with ADHD. ",
doi="10.2196/57297",
url="https://games.jmir.org/2025/1/e57297",
url="http://www.ncbi.nlm.nih.gov/pubmed/39879092"
}


@Article{info:doi/10.2196/66925,
author="Tay, Ling Jing
and Qu, Yuanrong
and Lim, Lucas
and Puthran, Rohan
and Tan, Robert Chye Lee
and Rajendran, Rajkirren
and Wei, Chiah Ker
and Xie, Huiting
and Sim, Kang",
title="Impact of a Virtual Reality Intervention on Stigma, Empathy, and Attitudes Toward Patients With Psychotic Disorders Among Mental Health Care Professionals: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2025",
month="Jan",
day="21",
volume="12",
pages="e66925",
keywords="virtual reality",
keywords="social distance",
keywords="stigma",
keywords="empathy",
keywords="mental health",
keywords="schizophrenia",
keywords="psychosis",
keywords="psychotic disorder",
keywords="mental disorder",
keywords="healthcare professional",
keywords="VR",
keywords="randomized controlled trial",
keywords="RCT",
keywords="user satisfaction",
abstract="Background: Previous studies have found that psychotic disorders are among the most stigmatized mental disorders. Of note, virtual reality (VR) interventions have been associated with improvements in attitudes and empathy and reduced stigma toward individuals with psychotic disorders, especially among undergraduates, but this has not been examined among mental health care professionals. Objective: We aimed to evaluate the effectiveness of a newly developed VR intervention for mental health care professionals to improve attitudes and empathy and reduce stigma toward people with psychotic disorders. Methods: We conducted a randomized controlled trial and recruited eligible mental health care professionals from a tertiary mental health care institution. Both arms (VR intervention and VR control groups) were evaluated at baseline, postintervention, and 1-month follow up. The evaluation included outcomes related to attitudes (modified attitudes toward people with schizophrenia scale), stigma (social distance scale, personal stigma scale), and empathy (empathetic concern subscale of the Interpersonal Reactivity Index). The experience with the VR intervention was assessed using a user satisfaction questionnaire, and qualitative feedback was gathered. Results: Overall, 180 mental health care professionals participated and completed the study. Both groups showed improvements in attitude, social distance, and stigma scores but not the empathy score following the intervention. The VR intervention group had better user satisfaction than the VR control group. In addition, certain outcome measures were positively associated with specific factors including female gender, higher education level, certain job roles, years of work, and presence of loved ones with a mental disorder. Conclusions: Both the intervention and control VR groups of mental health care professionals showed improvements in attitudes, stigma, and social distance toward people with psychotic disorders. Future longitudinal studies may want to evaluate the impact of VR on caregivers and the public on these same and other outcome measures to reduce stigma and improve empathy toward individuals with psychotic disorders. Trial Registration: clinicaltrials.gov NCT05982548; https://clinicaltrials.gov/study/NCT05982548 ",
doi="10.2196/66925",
url="https://mental.jmir.org/2025/1/e66925"
}


@Article{info:doi/10.2196/59195,
author="Yang, Qin
and Zhang, Liuxin
and Chang, Fangyuan
and Yang, Hongyi
and Chen, Bin
and Liu, Zhao",
title="Virtual Reality Interventions for Older Adults With Mild Cognitive Impairment: Systematic Review and Meta-Analysis of Randomized Controlled Trials",
journal="J Med Internet Res",
year="2025",
month="Jan",
day="10",
volume="27",
pages="e59195",
keywords="Alzheimer disease",
keywords="virtual reality",
keywords="VR",
keywords="mild cognitive impairment",
keywords="meta-analysis",
keywords="health care",
keywords="cognitive function",
keywords="memory",
keywords="attention",
keywords="executive function",
keywords="older adults",
abstract="Background: Alzheimer disease is incurable, but it is possible to intervene and slow down the progression of dementia during periods of mild cognitive impairment (MCI) through virtual reality (VR) technology. Objective: This study aimed to analyze the effects of VR interventions on older adults with MCI. The examined outcomes include cognitive abilities, mood, quality of life, and physical fitness, including general cognitive function, memory performance, attention and information processing speed, executive function, language proficiency, visuospatial abilities, depression, daily mobility of individuals, muscle performance, and gait and balance. Methods: A total of 4 web-based databases (Web of Science, PubMed, Embase, and Ovid) were searched up to December 30, 2023, for randomized controlled trials assessing the self-reported outcomes of VR-based technology on cognition, mood, quality of life, and physical fitness in older adults (aged ?55 years) with MCI. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk-of-bias sensitivity analysis, and subgroup analysis were performed where appropriate to explore potential moderators. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence. Results: This review analyzed 18 studies involving 722 older adults with MCI. VR was delivered through different immersion levels with VR cognitive training, VR physical training, or VR cognitive-motor dual-task training. VR interventions showed significant improvements in memory (standardized mean difference [SMD] 0.2, 95\% CI 0.02-0.38), attention and information processing speed (SMD 0.25, 95\% CI 0.06-0.45), and executive function (SMD 0.22, 95\% CI 0.02-0.42). VR without therapist involvement improved memory as well as attention and information processing speed. VR cognitive training also resulted in significant improvements in attention and information processing speed in older adults with MCI (SMD 0.31, 95\% CI 0.05-0.58). In addition, immersive VR had a significant impact on improving attention and information processing speed (SMD 0.25; 95\% CI 0.01-0.50) and executive function (SMD 0.25; 95\% CI 0.00-0.50). However, the effects of the intervention were very small in terms of general cognitive function, language proficiency, visuospatial abilities, depression, daily living ability, muscle performance, and gait and balance. Quality of evidence varied, with moderate ratings for certain cognitive functions and low ratings for others, based on the GRADE approach. Conclusions: VR interventions can improve memory, attention and information processing speed, and executive function in older adults with MCI. The quality of evidence is moderate to low, and further research is needed to confirm these findings and explore additional health-related outcomes. ",
doi="10.2196/59195",
url="https://www.jmir.org/2025/1/e59195"
}


@Article{info:doi/10.2196/58086,
author="Arthur, Tom
and Melendez-Torres, GJ
and Harris, David
and Robinson, Sophie
and Wilson, Mark
and Vine, Sam",
title="Extended Reality Interventions for Health and Procedural Anxiety: Panoramic Meta-Analysis Based on Overviews of Reviews",
journal="J Med Internet Res",
year="2025",
month="Jan",
day="8",
volume="27",
pages="e58086",
keywords="virtual reality",
keywords="exposure therapy",
keywords="distraction techniques",
keywords="patient education",
keywords="fear",
keywords="phobia",
keywords="immersive",
keywords="anxiety",
keywords="meta-analysis",
keywords="extended reality",
keywords="intervention",
keywords="procedural anxiety",
keywords="patient anxiety",
keywords="exposure",
keywords="distraction",
abstract="Background: Extended reality (XR) technologies are increasingly being used to reduce health and procedural anxieties. The global effectiveness of these interventions is uncertain, and there is a lack of understanding of how patient outcomes might vary between different contexts and modalities. Objective: This research used panoramic meta-analysis to synthesize evidence across the diverse clinical contexts in which XR is used to address common outcomes of health and procedural anxiety. Methods: Review-level evidence was obtained from 4 databases (MEDLINE, Embase, APA PsycINFO, and Epistemonikos) from the beginning of 2013 until May 30, 2023. Reviews that performed meta-analysis of randomized controlled trials relating to patient-directed XR interventions for health and procedural anxiety were included. Studies that analyzed physiological measures, or focused on technologies that did not include meaningful immersive components, were excluded. Furthermore, data were only included from studies that compared intervention outcomes against no-treatment or treatment-as-usual controls. Analyses followed a preregistered, publicly available protocol. Trial effect sizes were extracted from reviews and expressed as standardized mean differences, which were entered into a 3-level generalized linear model. Here, outcomes were estimated for patients (level 1), studies (level 2), and anxiety indications (level 3), while meta-regressions explored possible influences of age, immersion, and different mechanisms of action. Where relevant, the quality of reviews was appraised using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews, Revised Instrument) tool. Results: Data from 83 individual trials were extracted from 18 eligible meta-analyses. Most studies involved pediatric patient groups and focused on procedural, as opposed to general, health anxieties (eg, relating to needle insertion, dental operations, and acute surgery contexts). Interventions targeted distraction-, education-, and exposure-based mechanisms, and were provided via a range of immersive and nonimmersive systems. These interventions proved broadly effective in reducing patient anxiety, with models revealing significant but heterogeneous effects for both procedural (d=--0.75, 95\% CI --0.95 to --0.54) and general health (d=--0.82, 95\% CI --1.20 to --0.45) indications (when compared with nontreatment or usual-care control conditions). For procedural anxieties, effects may be influenced by publication bias and appear more pronounced for children (vs adults) and nonimmersive (vs immersive) technology interventions, but they were not different by indication. Conclusions: Results demonstrate that XR interventions have successfully reduced patient anxiety across diverse clinical contexts. However, significant uncertainty remains about the generalizability of effects within various unexplored indications, and existing evidence is limited in methodological quality. Although current research is broadly positive in this area, it is premature to assert that XR interventions are effective for any given health or procedural anxiety indication. ",
doi="10.2196/58086",
url="https://www.jmir.org/2025/1/e58086"
}


@Article{info:doi/10.2196/58384,
author="Kang, Xin
and Zhang, Yiping
and Sun, Chaonan
and Zhang, Jiaxin
and Che, Zhe
and Zang, Jinhui
and Zhang, Rongzhi",
title="Effectiveness of Virtual Reality Training in Improving Outcomes for Dialysis Patients: Systematic Review and Meta-Analysis",
journal="J Med Internet Res",
year="2025",
month="Jan",
day="8",
volume="27",
pages="e58384",
keywords="virtual reality",
keywords="VR",
keywords="training",
keywords="dialysis",
keywords="hemodialysis",
keywords="peritoneal dialysis",
keywords="chronic kidney disease",
keywords="rehabilitation",
keywords="quality of life",
keywords="meta-analysis",
abstract="Background: Virtual reality (VR) training uses computer-generated simulations that enable users to engage with immersive virtual environments, simulating real-world activities or therapeutic exercises. This technology is increasingly recognized as a promising intervention to address the physical and psychological challenges faced by dialysis patients, who frequently experience diminished physical function, social isolation, and emotional distress associated with prolonged treatment regimens. Given the increasing prevalence of dialysis patients and the limitations of conventional rehabilitation approaches, VR presents a novel, interactive method that has the potential to enhance patient well-being and improve quality of life. Objective: This meta-analysis aimed to evaluate the effectiveness of VR training interventions for dialysis patients, with a focus on assessing their impact on motor abilities, psychological symptoms (specifically anxiety and depression), social functioning, and self-efficacy. This analysis also explores whether VR can offer comprehensive benefits to support both the physical and mental health of dialysis patients. Methods: The meta-analysis was conducted following Cochrane guidelines. Comprehensive searches were performed across major databases, including China National Knowledge Infrastructure, Wanfang database, China Science and Technology Journal Database, China Biomedical Literature database, Cochrane library, Web of Science, PubMed, and Embase, encompassing all studies up to December 2023. Inclusion criteria targeted studies assessing VR's impact on motor performance, psychological well-being, social functioning, and self-efficacy in dialysis patients. Two reviewers independently extracted data and assessed methodological quality using Cochrane's risk of bias criteria, ensuring data synthesis reliability. Results: A total of 12 studies, involving 625 dialysis patients in total, met the inclusion criteria. The meta-analysis demonstrated that VR training led to significant improvements across multiple domains. VR interventions were associated with improved physical capacity, evidenced by higher scores in the 6-minute walk test (standardized mean difference [SD]=29.36, 95\% CI 14.32-44.4, P<.001, I2=46\%). VR training was associated with significant reductions in depression (SD=--6.30, 95\% CI --7.14 to --5.47, P<.001, I2=96\%) and anxiety (SD=--8.91, 95\% CI --9.69 to --8.14, P<.001, I2=95\%). In addition, VR interventions enhanced social functioning (SD=16.20, 95\% CI 14.49-17.9, P<.001, I2=72\%), and improved self-efficacy (SD=20.47, 95\% CI 18.55-22.39, P<.001, I2=99\%). However, VR training did not yield significant differences in gait speed, balance, or functional tests (Ten Sit-to-Stand Test, Five Sit-to-Stand Test, Sixty Sit-to-Stand Test, Timed Up and Go Test, and fatigue) compared with control groups. Conclusions: The findings suggest that VR training is a promising intervention for dialysis patients, providing benefits in physical endurance, social engagement, and psychological well-being. Despite these advantages, VR remains underused among peritoneal dialysis patients compared with hemodialysis patients. Further studies with larger sample sizes and more refined experimental designs are recommended to validate these results and support VR as a complementary tool in the holistic care of dialysis patients. ",
doi="10.2196/58384",
url="https://www.jmir.org/2025/1/e58384"
}


@Article{info:doi/10.2196/45640,
author="Blackmore, Rebecca
and Giles, Claudia
and Tremain, Hailey
and Kelly, Ryan
and Foley, Fiona
and Fletcher, Kathryn
and Nedeljkovic, Maja
and Wadley, Greg
and Seabrook, Elizabeth
and Thomas, Neil",
title="Examining the Use of Virtual Reality to Support Mindfulness Skills Practice in Mood and Anxiety Disorders: Mixed Methods Study",
journal="J Med Internet Res",
year="2024",
month="Dec",
day="6",
volume="26",
pages="e45640",
keywords="virtual reality",
keywords="mindfulness",
keywords="mood disorders",
keywords="anxiety disorders",
keywords="depression",
keywords="bipolar disorder",
abstract="Background: Virtual reality (VR) has been proposed as a technology to support mindfulness practice through promoting increased engagement and presence. The proposed benefits of this technology have been largely unexamined with clinical populations. Further research is required to understand its clinical potential and utility in improving and managing mental health symptoms. Objective: This study aims to investigate the proximal impacts of a single, brief, VR-supported mindfulness practice for individuals with a mood or anxiety disorder and to understand user experiences, which may affect the acceptability and efficacy of VR mindfulness for this population. Methods: This mixed methods study recruited 28 participants with a primary diagnosis of major depressive disorder, bipolar disorder, or anxiety disorder. Participants completed a mindfulness practice wearing a VR headset that was presenting an omnidirectional video of a forest scene, which was overlaid with a guided audio voiceover. Before and after the practice, measures were completed assessing state mindfulness (Toronto Mindfulness Scale), affect (Positive and Negative Affect Schedule), and anxiety (State-Trait Anxiety Inventory Y-1; n=27). Semistructured interviews were then held inquiring about the user experience and were analyzed using thematic analysis (n=24). Results: After completing the VR-supported mindfulness practice, both measures of state mindfulness on the Toronto Mindfulness Scale, mean curiosity and decentering, increased significantly (Cohen d=1.3 and 1.51, respectively; P<.001). Negative affect on the Positive and Negative Affect Schedule (Cohen d=0.62; P=.003) and State-Trait Anxiety Inventory Y-1 state anxiety (Cohen d=0.84; P<.001) significantly reduced. There was no significant change in positive affect (Cohen d=0.29; P=.08). Qualitative analysis of interviews identified 14 themes across 5 primary theme categories. The results suggested that being mindful during the use of the app was experienced as relatively effortless because of the visual and immersive elements. It was also experienced as convenient and safe, including when compared with prior traditional experiences of mindfulness. Participants also identified the uses for VR-supported mindfulness in managing emotions and symptoms of mental illness. Conclusions: The results provide preliminary evidence that VR-supported mindfulness can improve emotional states and manage mental health symptoms for those with mood or anxiety disorders. It offers some potential clinical applications for those with mood or anxiety disorders for exploration within future research. ",
doi="10.2196/45640",
url="https://www.jmir.org/2024/1/e45640",
url="http://www.ncbi.nlm.nih.gov/pubmed/39641990"
}


@Article{info:doi/10.2196/52294,
author="Pe{\~n}a, Jorge
and Koebner, Ian
and Weisman, William",
title="Using Digital Art and Attachment Priming in a Web-Based Serious Game to Reduce Pain and Social Disconnection in Individuals With Chronic Pain and Loneliness: Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2024",
month="Nov",
day="27",
volume="12",
pages="e52294",
keywords="pain",
keywords="social disconnection",
keywords="loneliness",
keywords="randomized controlled trial",
keywords="art",
keywords="museums",
keywords="virtual reality",
keywords="serious games",
keywords="virtual art",
keywords="chronic pain and loneliness",
keywords="attachment",
keywords="priming",
keywords="mediation",
keywords="intervention",
keywords="cyberpsychology",
keywords="mental health",
abstract="Background: Arts engagement using virtual reality and serious games represent promising nonpharmacological self-management treatment approaches to chronic pain. This study is the first randomized controlled trial to explore the impact of a web-based serious game that simulated a visit to an art museum on pain and social disconnection among individuals living with chronic pain and loneliness. Objective: This study aimed to test the joint and separate effects of exposure to digital art and attachment figure priming on pain and social disconnection among individuals living with chronic pain and loneliness. Methods: This randomized controlled trial used a 2 (digital artwork present and absent) {\texttimes} 2 (secure attachment and avoidant attachment prime) repeated measures factorial web-based experimental design with a hanging control condition. Mediation and moderation analyses examined how feelings about the social world triggered by the artwork and frequency of museum visits impacted the effects of the interventions on pain and social disconnection. Results: The results are based on 308 participants. Mean age of the participants was 42.78 (SD 13.11; range 18-76) years, and 60.2\% (n=186) were women. Posttest pain was lower than pretest pain for the artwork present (P=.001) and absent (P=.001) conditions. Similarly, posttest pain was lower than pretest pain for the secure (P=.001) and avoidant (P=.001) attachment priming conditions. Relative to the control group, artwork present (P=.001) and absent (P=.01) conditions had decreased posttest pain. The secure (P=.001) and avoidant (P=.001) attachment priming conditions also had lower posttest pain scores relative to the control group. Moreover, social disconnection decreased from pre- to posttest for both the artwork present (P=.04) and the secure attachment priming (P=.002) conditions. Relative to the control group, posttest social disconnection was lower for the artwork present (P=.02) and secure attachment priming condition (P=.03). The artwork-secure attachment (P=.001) and artwork-avoidant attachment (P=.006) conditions had lower posttest pain scores compared with the control group. Social disconnection decreased from pre- to posttest for the artwork-secure attachment (P=.01) and no artwork-secure attachment (P=.05) conditions. Posttest social disconnection was lower for the artwork-secure attachment condition compared with the control group (P=.04). Positive feelings about the social world triggered by artwork exposure and frequency of museum visits in the last year played a mediating and moderating role in these effects. Positive feelings about the social world were associated with decreased pain (B=?.53) and social disconnection (B=?.25), and these effects operated on individuals exposed to digital artwork at low, medium, and high frequency of physical museum visits. Conclusions: Relative to a control group, visiting a web-based art museum reliably decreased pain and social disconnection among individuals living with chronic pain and loneliness. Engaging with digital artwork that triggers positive feelings about the social world may mitigate the burden of chronic pain. Trial Registration: ClinicalTrials.gov NCT05310747; https://clinicaltrials.gov/study/NCT05310747 ",
doi="10.2196/52294",
url="https://games.jmir.org/2024/1/e52294"
}


@Article{info:doi/10.2196/57225,
author="Kona{\c{c}}, Asli
and Bini, Maristella
and Fusco, Naomi
and Bourdin-Kreitz, Pierre",
title="Enhancing Executive Function Skills in Children With Attention-Deficit/Hyperactivity Disorder via Immersive Virtual Reality Interventions: Scoping Review",
journal="JMIR XR Spatial Comput",
year="2024",
month="Nov",
day="22",
volume="1",
pages="e57225",
keywords="immersive virtual reality",
keywords="ADHD",
keywords="neurofeedback",
keywords="executive functions",
keywords="systematic review",
keywords="adolescent",
keywords="attention-deficit/hyperactivity disorder",
keywords="behavioral therapy",
keywords="digital health tools",
keywords="neurodiversity",
keywords="virtual reality",
keywords="digital mental health",
abstract="Background: This scoping review investigated immersive virtual reality (IVR) interventions for improving executive function skills of children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Objective: This study aimed to identify and closely inspect the characteristics of these interventions and provide a summary of key findings to guide researchers in their future investigations. Methods: A search across Web of Science, Scopus, PubMed, and APA PsycInfo databases was carried out with restrictions of publication date (2000?2023) and language (English). The inclusion criteria were (1) research articles, excluding protocols, book chapters, reviews, and meta-analyses; (2) usage of IVR, excluding computer-based VR or augmented reality technologies; (3) aim of targeting executive function skills; (4) sample of children and adolescents diagnosed with ADHD (with or without learning disorder comorbidity); and (5) intervention studies (quasi-experimental clinical trials and randomized controlled trials, excluding assessments). Finally, the characteristics of the studies were summarized and inspected. Results: The search yielded 2484 potential records. After a rigorous screening process, 6 articles (5 randomized controlled trials and 1 pilot study) were included. A certain heterogeneity in duration, designs of IVR interventions, and outcome measures were observed. All studies reported overall improvements in the attentional performances of children; however, only a few reported improvements in executive functions. In addition, a tendency toward integration of neurofeedback systems with IVR technologies was observed. Conclusions: Because of the specific objectives and related inclusion and exclusion criteria of this review, only a few interventions could be included and analyzed. Even though there seem to be promising applications of IVR for children and adolescents with ADHD, heterogeneity in intervention characteristics accompanied by observed overall high or serious risk of bias prevented the authors from making generalized conclusions. ",
doi="10.2196/57225",
url="https://xr.jmir.org/2024/1/e57225"
}


@Article{info:doi/10.2196/53348,
author="Mao, Qian
and Zhao, Zhen
and Yu, Lisha
and Zhao, Yang
and Wang, Hailiang",
title="The Effects of Virtual Reality--Based Reminiscence Therapies for Older Adults With Cognitive Impairment: Systematic Review",
journal="J Med Internet Res",
year="2024",
month="Nov",
day="12",
volume="26",
pages="e53348",
keywords="virtual reality",
keywords="reminiscence therapy",
keywords="cognitive impairment",
keywords="older adults",
keywords="mobile phone",
abstract="Background: Reminiscence therapy (RT) is a commonly used nonpharmaceutical treatment for cognitive impairment. Artifacts or conversations are used in RT to recall individuals' memories and past experiences. Virtual reality (VR) has increasingly been used as an assistive technology during RT. However, the effects of VR-based RT (VR-RT) methods remain unclear, and insights into the related benefits and challenges are urgently needed. Objective: The study aims to systematically review the effects of VR-RTs for older adults with cognitive impairment. Methods: Seven databases (MEDLINE, Academic Search Premier, CINAHL, Web of Science, PubMed, the Cochrane Central Register of Controlled Trials, and ScienceDirect) were searched to identify relevant articles published from inception to August 10, 2023. Peer-reviewed publications that assessed the effect of VR-RTs (ie, using virtual clues to evoke participants' memories or past experiences) on cognitive-related outcomes were included. Two independent researchers conducted the literature search, review, and data extraction processes. A narrative synthesis approach was used to analyze the extracted data. Results: Of the 537 identified articles, 22 were ultimately included in the data analysis. The results revealed that VR-RTs could maintain cognitive status (4/4, 100\%) and reduce anxiety (2/2, 100\%) in older adults with cognitive impairment. Nevertheless, one study found a cognitive improvement after VR-RTs, whereas cognitive degradation was observed at a 3- to 6-month follow-up measure. Around 88\% (7/8) of the included studies indicated that VR-RTs improved memory; however, the evidence regarding the beneficial effects of VR-RTs was limited in improving quality of life (1/4, 25\%) and reducing apathy (0/2, 0\%) and depression (1/3, 33\%). The results indicated that VR-RTs are safe, engaging, acceptable, and satisfying for older adults with cognitive impairment. In VR scenarios, personalized stimulus materials related to the users' youth experiences were more effective for treating cognitive impairment than other stimulus materials. Conclusions: The results of this systematic review demonstrate the potential benefits of VR-RT for older adults with cognitive impairment, especially in improving emotion and memory and maintaining cognitive status. VR-RT is also safe and enjoyable for older adults. However, due to the trial heterogeneity of included studies, we can only provide qualitative results instead of performing meta-analysis to quantify the effect size of VR-RTs. Thus, more randomized controlled trials are required to examine the designs and effects of VR-RTs for groups of older adults with specific needs. ",
doi="10.2196/53348",
url="https://www.jmir.org/2024/1/e53348"
}


@Article{info:doi/10.2196/60441,
author="Fajnerova, Iveta
and Hejtm{\'a}nek, Luk{\'a}{\vs}
and Sedl{\'a}k, Michal
and Jablonsk{\'a}, Mark{\'e}ta
and Francov{\'a}, Anna
and Stopkov{\'a}, Pavla",
title="The Journey From Nonimmersive to Immersive Multiuser Applications in Mental Health Care: Systematic Review",
journal="J Med Internet Res",
year="2024",
month="Nov",
day="7",
volume="26",
pages="e60441",
keywords="digital health",
keywords="mental health care",
keywords="clinical interventions",
keywords="multiuser",
keywords="immersive",
keywords="virtual reality",
keywords="VR",
keywords="app",
keywords="mental health",
keywords="online tools",
keywords="synthesis",
keywords="mobile phone",
keywords="PRISMA",
abstract="Background: Over the past 25 years, the development of multiuser applications has seen considerable advancements and challenges. The technological development in this field has emerged from simple chat rooms through videoconferencing tools to the creation of complex, interactive, and often multisensory virtual worlds. These multiuser technologies have gradually found their way into mental health care, where they are used in both dyadic counseling and group interventions. However, some limitations in hardware capabilities, user experience designs, and scalability may have hindered the effectiveness of these applications. Objective: This systematic review aims at summarizing the progress made and the potential future directions in this field while evaluating various factors and perspectives relevant to remote multiuser interventions. Methods: The systematic review was performed based on a Web of Science and PubMed database search covering articles in English, published from January 1999 to March 2024, related to multiuser mental health interventions. Several inclusion and exclusion criteria were determined before and during the records screening process, which was performed in several steps. Results: We identified 49 records exploring multiuser applications in mental health care, ranging from text-based interventions to interventions set in fully immersive environments. The number of publications exploring this topic has been growing since 2015, with a large increase during the COVID-19 pandemic. Most digital interventions were delivered in the form of videoconferencing, with only a few implementing immersive environments. The studies used professional or peer-supported group interventions or a combination of both approaches. The research studies targeted diverse groups and topics, from nursing mothers to psychiatric disorders or various minority groups. Most group sessions occurred weekly, or in the case of the peer-support groups, often with a flexible schedule. Conclusions: We identified many benefits to multiuser digital interventions for mental health care. These approaches provide distributed, always available, and affordable peer support that can be used to deliver necessary help to people living outside of areas where in-person interventions are easily available. While immersive virtual environments have become a common tool in many areas of psychiatric care, such as exposure therapy, our results suggest that this technology in multiuser settings is still in its early stages. Most identified studies investigated mainstream technologies, such as videoconferencing or text-based support, substituting the immersive experience for convenience and ease of use. While many studies discuss useful features of virtual environments in group interventions, such as anonymity or stronger engagement with the group, we discuss persisting issues with these technologies, which currently prevent their full adoption. ",
doi="10.2196/60441",
url="https://www.jmir.org/2024/1/e60441"
}


@Article{info:doi/10.2196/56235,
author="Beele, Gesa
and Liesong, Paula
and Bojanowski, Sabine
and Hildebrand, Kristian
and Weingart, Malte
and Asbrand, Julia
and Correll, U. Christoph
and Morina, Nexhmedin
and Uhlhaas, J. Peter",
title="Virtual Reality Exposure Therapy for Reducing School Anxiety in Adolescents: Pilot Study",
journal="JMIR Ment Health",
year="2024",
month="Nov",
day="5",
volume="11",
pages="e56235",
keywords="virtual reality exposure therapy",
keywords="VRET",
keywords="school anxiety",
keywords="social anxiety",
keywords="adolescents",
keywords="virtual reality",
keywords="VR",
keywords="autonomic arousal",
keywords="exposure therapy",
keywords="posttreatment",
keywords="digital health",
keywords="simulation",
abstract="Background: Virtual reality exposure therapy (VRET) is a promising treatment approach for anxiety disorders. However, while its efficacy has been demonstrated in adults, research on the efficacy of VRET in the treatment of adolescents with anxiety disorders is largely lacking. Objective: A pilot study was carried out to test whether exposure to a virtual reality (VR) school environment elicits state anxiety and autonomic arousal in adolescents with school anxiety (diagnoses covering social anxiety disorder or specific phobia involving school contexts). In addition, we examined whether repeated VR exposure led to a reduction in this fear response, trait school anxiety, and social anxiety symptoms. Moreover, the relationship of presence, the subjective sense of ``being there,'' during VR exposure with anxiety measures and treatment response was examined. Methods: In a pilot study, 10 adolescents with school anxiety (age range 14 to 17 years) participated in five VRET sessions. Self-reported state anxiety, heart rate, and presence during exposure, as well as trait school anxiety and social anxiety before and after treatment, were measured. Results: The VR scenario induced state anxiety and autonomic arousal. After VRET, a significant reduction in state anxiety ($\eta$2=0.74) and social anxiety symptoms (d=0.82) as well as a trend toward a decrease in trait school anxiety were observed, while autonomic arousal did not change. In addition, presence during VR exposure was associated with state anxiety and treatment response. Conclusions: Our findings indicate the feasibility and potential effectiveness of VRET as a treatment method for symptoms of school and social anxiety in adolescents. ",
doi="10.2196/56235",
url="https://mental.jmir.org/2024/1/e56235"
}


@Article{info:doi/10.2196/64494,
author="Bouguettaya, Ayoub
and Aboujaoude, Elias",
title="Using Extended Reality to Enhance Effectiveness and Group Identification in Remote Group Therapy for Anxiety Disorders: A Critical Analysis",
journal="JMIR Form Res",
year="2024",
month="Nov",
day="4",
volume="8",
pages="e64494",
keywords="group therapy",
keywords="psychotherapy",
keywords="telepsychiatry",
keywords="mental health",
keywords="extended reality",
keywords="augmented reality",
keywords="virtual reality therapy",
keywords="anxiety",
keywords="cognitive behavioral therapy",
doi="10.2196/64494",
url="https://formative.jmir.org/2024/1/e64494"
}


@Article{info:doi/10.2196/52866,
author="Gee, Brioney
and Teague, Bonnie
and Laphan, Andrew
and Clarke, Tim
and Coote, Georgianna
and Garner, Jessica
and Wilson, Jon",
title="Outcomes of Providing Children Aged 7-12 Years With Access to Evidence-Based Anxiety Treatment Via a Standalone Digital Intervention Using Immersive Gaming Technology: Real-World Evaluation",
journal="JMIR Ment Health",
year="2024",
month="Oct",
day="22",
volume="11",
pages="e52866",
keywords="anxiety",
keywords="children",
keywords="young people",
keywords="exposure therapy",
keywords="graded exposures",
keywords="cognitive behavioural therapy",
keywords="digital intervention",
keywords="mobile app",
keywords="gaming",
keywords="real-world evaluation",
keywords="gaming technology",
keywords="real-world implementation",
abstract="Background: Anxiety disorders are among the most common mental health conditions in childhood, but most children with anxiety disorders do not access evidence-based interventions. The delivery of therapeutic interventions via digital technologies has been proposed to significantly increase timely access to evidence-based treatment. Lumi Nova (BfB Labs Limited) is a digital therapeutic intervention designed to deliver evidence-based anxiety treatment for those aged 7?12 years through a mobile app incorporating immersive gaming technology. Objective: We aimed to evaluate the real-world impact of providing access to Lumi Nova through UK National Health Service--funded mental health services. Methods: We analyzed precollected anonymized data routinely captured through the implementation of Lumi Nova from children aged 7?12 years, who lived in the United Kingdom and had the opportunity to use the intervention for at least 1 week over an 18-month period. Engagement indices included whether the game key was activated, number of unique sessions, time spent engaging, and number of ``challenges'' completed. Clinical outcomes were assessed using the Goal-Based Outcomes measure and Child Outcome Rating Scale. Demographic data were analyzed to assess the health equality implications of Lumi Nova. Results: Of 1029 eligible families invited to use Lumi Nova, 644 (62.5\%) activated their game key, of whom 374 (58.1\%) completed at least one in-game graded exposure challenge. The median number of unique sessions was 6 (IQR 3?12) and the median time spent engaging with the intervention was 42 (IQR 15?79) minutes. For the subset of young people with paired outcomes, there were statistically significant small to medium improvements in goal-based outcome scores (n=224; t223=5.78, P<.001; d=0.37, 95\% CI 0.25?0.52) and Child Outcome Rating Scale scores (n=123; t122=5.10, P<.001; d=0.46, 95\% CI 0.27?0.65) between the first and last data points. Two in 5 young people's scores reflected a change that would be considered reliable. Analysis of demographic characteristics tentatively suggested that children from ethnic minority backgrounds and those living in the most deprived neighbourhoods may be less likely to access Lumi Nova, but children from socioeconomically deprived areas were more likely to successfully complete a challenge once they accessed the intervention (P=.02). However, the level of missing data and small number of children in some demographic groups limited meaningful statistical comparisons. Conclusions: This study provides initial evidence that Lumi Nova may be associated with improved outcomes for those aged 7?12 years seeking anxiety treatment in real-world settings. However, the lack of a control comparator group and information about concurrent treatments accessed by the young people, in addition to substantial attrition, limited the analysis that could be conducted and confidence in the conclusions drawn. ",
doi="10.2196/52866",
url="https://mental.jmir.org/2024/1/e52866"
}


@Article{info:doi/10.2196/55679,
author="Ernst, Mathias
and Bouchard, St{\'e}phane
and Andersen, Tonny
and Orskov, Trads Per
and Tarp, Kristine
and Lichtenstein, Beck Mia",
title="Virtual Reality--Based Exposure With 360{\textdegree} Environments for Social Anxiety Disorder: Usability and Feasibility Study",
journal="JMIR Form Res",
year="2024",
month="Oct",
day="21",
volume="8",
pages="e55679",
keywords="anxiety",
keywords="exposure therapy",
keywords="social anxiety disorder",
keywords="virtual reality",
keywords="360{\textdegree}",
keywords="mixed methods",
keywords="interactive",
abstract="Background: Social anxiety disorder (SAD) is a long-term and overwhelming fear of social situations that can affect work, school, and other daily activities. Although cognitive behavioral therapy is effective, few seek treatment, and many who do start often drop out. This may be due to the component of exposure inherent to cognitive behavioral therapy, where the patient confronts feared stimuli outside the therapist's office, which they otherwise try to avoid. As an alternative, research has explored the effectiveness of virtual reality (VR)--based exposure therapy with promising results. However, few studies have investigated the feasibility of VR tools using mixed methodologies before assessing their efficacy. Objective: This study aims to assess the usability, feasibility, and presence of four 360{\textdegree} virtual environments and whether these were able to evoke anxiety in patients with SAD. Methods: A total of 10 adult participants with SAD and 10 healthy controls were recruited for 1 experimental session (age range 21-32 y; 12/20, 60\% male participants). Questionnaire and interview data were collected and analyzed. A mixed methods triangulation design was applied to analyze and compare the data. Results: Participants with SAD experienced increased anxiety when exposed to VR, and environments were considered relevant and useful as an exposure tool. Participants with SAD reported significantly higher average anxiety levels (P=.01) and peak anxiety levels (P=.01) compared with controls during exposure; however, significant differences in anxiety when accounting for baseline anxiety levels were only found in 2 of 4 environments (P=.01, P=.01, P=.07, and P=.06). While presence scores were acceptable in both groups, participants with SAD scored significantly lower than controls. Qualitative analyses highlight this finding within the SAD group, where some participants experienced presence reduction due to being observed while in VR and in situations with reduced interaction in VR. Conclusions: VR exposure with 360{\textdegree} videos seems to be useful as a first step of exposure therapy for patients with SAD. Future exploration in the clinical application of VR-based exposure for SAD, as well as means of increasing presence within the virtual environments, may be useful. ",
doi="10.2196/55679",
url="https://formative.jmir.org/2024/1/e55679",
url="http://www.ncbi.nlm.nih.gov/pubmed/39432344"
}


@Article{info:doi/10.2196/58462,
author="Benda, Natalie
and Desai, Pooja
and Reza, Zayan
and Zheng, Anna
and Kumar, Shiveen
and Harkins, Sarah
and Hermann, Alison
and Zhang, Yiye
and Joly, Rochelle
and Kim, Jessica
and Pathak, Jyotishman
and Reading Turchioe, Meghan",
title="Patient Perspectives on AI for Mental Health Care: Cross-Sectional Survey Study",
journal="JMIR Ment Health",
year="2024",
month="Sep",
day="18",
volume="11",
pages="e58462",
keywords="artificial intelligence",
keywords="AI",
keywords="mental health",
keywords="patient perspectives",
keywords="patients",
keywords="public survey",
keywords="application",
keywords="applications",
keywords="health care",
keywords="health professionals",
keywords="somatic issues",
keywords="radiology",
keywords="perinatal health",
keywords="Black",
keywords="professional relationship",
keywords="patient-health",
keywords="autonomy",
keywords="risk",
keywords="confidentiality",
keywords="machine learning",
keywords="digital mental health",
keywords="computing",
keywords="coding",
keywords="mobile phone",
abstract="Background: The application of artificial intelligence (AI) to health and health care is rapidly increasing. Several studies have assessed the attitudes of health professionals, but far fewer studies have explored the perspectives of patients or the general public. Studies investigating patient perspectives have focused on somatic issues, including those related to radiology, perinatal health, and general applications. Patient feedback has been elicited in the development of specific mental health care solutions, but broader perspectives toward AI for mental health care have been underexplored. Objective: This study aims to understand public perceptions regarding potential benefits of AI, concerns about AI, comfort with AI accomplishing various tasks, and values related to AI, all pertaining to mental health care. Methods: We conducted a 1-time cross-sectional survey with a nationally representative sample of 500 US-based adults. Participants provided structured responses on their perceived benefits, concerns, comfort, and values regarding AI for mental health care. They could also add free-text responses to elaborate on their concerns and values. Results: A plurality of participants (245/497, 49.3\%) believed AI may be beneficial for mental health care, but this perspective differed based on sociodemographic variables (all P<.05). Specifically, Black participants (odds ratio [OR] 1.76, 95\% CI 1.03-3.05) and those with lower health literacy (OR 2.16, 95\% CI 1.29-3.78) perceived AI to be more beneficial, and women (OR 0.68, 95\% CI 0.46-0.99) perceived AI to be less beneficial. Participants endorsed concerns about accuracy, possible unintended consequences such as misdiagnosis, the confidentiality of their information, and the loss of connection with their health professional when AI is used for mental health care. A majority of participants (80.4\%, 402/500) valued being able to understand individual factors driving their risk, confidentiality, and autonomy as it pertained to the use of AI for their mental health. When asked who was responsible for the misdiagnosis of mental health conditions using AI, 81.6\% (408/500) of participants found the health professional to be responsible. Qualitative results revealed similar concerns related to the accuracy of AI and how its use may impact the confidentiality of patients' information. Conclusions: Future work involving the use of AI for mental health care should investigate strategies for conveying the level of AI's accuracy, factors that drive patients' mental health risks, and how data are used confidentially so that patients can determine with their health professionals when AI may be beneficial. It will also be important in a mental health care context to ensure the patient--health professional relationship is preserved when AI is used. ",
doi="10.2196/58462",
url="https://mental.jmir.org/2024/1/e58462"
}


@Article{info:doi/10.2196/57093,
author="Maddalon, Luna
and Minissi, Eleonora Maria
and Parsons, Thomas
and Hervas, Amaia
and Alcaniz, Mariano",
title="Exploring Adaptive Virtual Reality Systems Used in Interventions for Children With Autism Spectrum Disorder: Systematic Review",
journal="J Med Internet Res",
year="2024",
month="Sep",
day="18",
volume="26",
pages="e57093",
keywords="adaptive system",
keywords="virtual reality",
keywords="autism spectrum disorder",
keywords="intervention",
keywords="training",
keywords="children",
keywords="machine learning",
keywords="biosignal",
abstract="Background: Adaptive systems serve to personalize interventions or training based on the user's needs and performance. The adaptation techniques rely on an underlying engine responsible for processing incoming data and generating tailored responses. Adaptive virtual reality (VR) systems have proven to be efficient in data monitoring and manipulation, as well as in their ability to transfer learning outcomes to the real world. In recent years, there has been significant interest in applying these systems to improve deficits associated with autism spectrum disorder (ASD). This is driven by the heterogeneity of symptoms among the population affected, highlighting the need for early customized interventions that target each individual's specific symptom configuration. Objective: Recognizing these technology-driven therapeutic tools as efficient solutions, this systematic review aims to explore the application of adaptive VR systems in interventions for young individuals with ASD. Methods: An extensive search was conducted across 3 different databases---PubMed Central, Scopus, and Web of Science---to identify relevant studies from approximately the past decade. Each author independently screened the included studies to assess the risk of bias. Studies satisfying the following inclusion criteria were selected: (1) the experimental tasks were delivered via a VR system, (2) system adaptation was automated, (3) the VR system was designed for intervention or training of ASD symptoms, (4) participants' ages ranged from 6 to 19 years, (5) the sample included at least 1 group with ASD, and (6) the adaptation strategy was thoroughly explained. Relevant information extracted from the studies included the sample size and mean age, the study's objectives, the skill trained, the implemented device, the adaptive strategy used, the engine techniques, and the signal used to adapt the systems. Results: Overall, a total of 10 articles were included, involving 129 participants, 76\% of whom had ASD. The studies included level switching (7/10, 70\%), adaptive feedback strategies (9/10, 90\%), and weighing the choice between a machine learning (ML) adaptive engine (3/10, 30\%) and a non-ML adaptive engine (8/10, 80\%). Adaptation signals ranged from explicit behavioral indicators (6/10, 60\%), such as task performance, to implicit biosignals, such as motor movements, eye gaze, speech, and peripheral physiological responses (7/10, 70\%). Conclusions: The findings reveal promising trends in the field, suggesting that automated VR systems leveraging real-time progression level switching and verbal feedback driven by non-ML techniques using explicit or, better yet, implicit signal processing have the potential to enhance interventions for young individuals with ASD. The limitations discussed mainly stem from the fact that no technological or automated tools were used to handle data, potentially introducing bias due to human error. ",
doi="10.2196/57093",
url="https://www.jmir.org/2024/1/e57093"
}


@Article{info:doi/10.2196/57809,
author="Kwan, Cho Rick Yiu
and Liu, Justina
and Sin, Kan Olive Suk
and Fong, K. Kenneth N.
and Qin, Jing
and Wong, Yin Joe Chi
and Lai, Claudia",
title="Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial",
journal="J Med Internet Res",
year="2024",
month="Sep",
day="11",
volume="26",
pages="e57809",
keywords="virtual reality",
keywords="motor-cognitive training",
keywords="cognitive frailty",
keywords="gamification",
abstract="Background: Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear. Objective: This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty. Methods: This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ?60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time {\texttimes} group) effects on the outcomes. Results: In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2\%), had completed primary education (152/293, 52.1\%), were married (167/293, 57.2\%), lived with friends (127/293, 43.3\%), and had no VR experience (232/293, 79.5\%). In the intervention group, 81.6\% (119/146) of participants attended >80\% (13/16, 81\%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7\% to 5/146, 3\%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes. Conclusions: VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living. Trial Registration: ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817 ",
doi="10.2196/57809",
url="https://www.jmir.org/2024/1/e57809"
}


@Article{info:doi/10.2196/51512,
author="Rosebrock, Laina
and Freeman, Jason
and Rovira, Aitor
and Miguel, Lages Andre
and Ward, Rupert
and Bousfield, Matthew
and Riffiod, Ludovic
and Kamvar, Roya
and Kabir, Thomas
and Waite, Felicity
and Freeman, Daniel",
title="Developing an Automated Virtual Reality Therapy for Improving Positive Self-Beliefs and Psychological Well-Being (Phoenix VR Self-Confidence Therapy): Tutorial",
journal="JMIR Serious Games",
year="2024",
month="Aug",
day="7",
volume="12",
pages="e51512",
keywords="virtual reality",
keywords="VR",
keywords="psychosis",
keywords="cognitive behavioural therapy",
keywords="psychological well-being",
keywords="design process",
keywords="self-beliefs",
keywords="psychological therapy",
keywords="real-world",
keywords="efficacy",
keywords="well-being",
keywords="mental health",
keywords="participant",
keywords="stakeholder",
keywords="user",
keywords="Phoenix VR Self-Confidence Therapy",
doi="10.2196/51512",
url="https://games.jmir.org/2024/1/e51512"
}


@Article{info:doi/10.2196/57101,
author="Imai, Ayu
and Matsuoka, Teruyuki
and Nakayama, Chikara
and Hashimoto, Nana
and Sano, Mutsuo
and Narumoto, Jin",
title="Effectiveness of a Virtual Reality Open-Air Bath Program in Reducing Loneliness and Improving Brain Function for Dementia Prevention in Older Adults: Protocol for a Prospective Randomized Crossover Study",
journal="JMIR Res Protoc",
year="2024",
month="Aug",
day="1",
volume="13",
pages="e57101",
keywords="loneliness",
keywords="virtual reality",
keywords="VR",
keywords="Alzheimer disease",
keywords="predementia",
keywords="intervention",
keywords="subjective cognitive decline",
keywords="mild cognitive impairment",
keywords="dementia",
keywords="older adult",
keywords="geriatric",
keywords="depression",
keywords="cognitive impairments",
abstract="Background: Older adults often face loneliness due to chronic illness or loss of close ones, a situation worsened by the COVID-19 pandemic. Increased loneliness heightens the risk of diseases, especially dementia, necessitating urgent action. Objective: This study aims to assess the impact of a virtual reality (VR)--based open-air bath program on depression and loneliness in older individuals with subjective cognitive decline/mild cognitive impairment attending the Dementia Medical Center in Kyoto, Japan. We further aim to evaluate the feasibility of the program (participant recruitment and adherence) and to measure program enjoyment and satisfaction. Methods: The study design is a crossover trial with a 1:1 ratio, wherein 12 participants will be randomly assigned to groups 1 and 2, with group 2 serving as a waitlist control and group 1 receiving the VR program from the onset for 6 months; the VR program will be conducted 6 times (monthly). Program completion for group 1 will be followed by an observation period from months 7 to 12. Group 2 will participate in the VR program from months 7 to 12, with an observation period from months 1 to 6. Cognitive tests, psychiatric assessments, and the University of California, Los Angeles Loneliness Scale will be conducted before the study, at 6 months, and at 12 months. Results will be analyzed using repeated-measures ANOVA. Head magnetic resonance imaging and single-photon emission computed tomography scans will be performed before and after the VR program to evaluate changes and effects on brain regions. Results: Recruitment began in September 2023 and data collection is expected to be completed by March 2025. Complete study results will be published by September 2025. Conclusions: This study examines the preliminary effects of VR on loneliness in older adults with predementia through open-air bath simulations. VR experiences could benefit this population, particularly those with limited outdoor activities. Quantifying VR's impact will aid in determining the size for a larger clinical trial. Qualitative results will inform participation mechanisms and guide the implementation and design of future trials. Trial Registration: University hospital Medical Information Network UMIN000052667; https://tinyurl.com/3yaccay5 International Registered Report Identifier (IRRID): DERR1-10.2196/57101 ",
doi="10.2196/57101",
url="https://www.researchprotocols.org/2024/1/e57101",
url="http://www.ncbi.nlm.nih.gov/pubmed/39088243"
}


@Article{info:doi/10.2196/38413,
author="Omisore, Mumini Olatunji
and Odenigbo, Ifeanyi
and Orji, Joseph
and Beltran, Hernandez Amelia Itzel
and Meier, Sandra
and Baghaei, Nilufar
and Orji, Rita",
title="Extended Reality for Mental Health Evaluation: Scoping Review",
journal="JMIR Serious Games",
year="2024",
month="Jul",
day="24",
volume="12",
pages="e38413",
keywords="extended reality",
keywords="mental disorder",
keywords="depression",
keywords="anxiety",
keywords="exposure therapy",
abstract="Background: Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, ``extended reality'' (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care. Objective: We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus. Methods: In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review. Results: We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47\%) and Germany (n=12, 14.12\%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59\%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47\%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35\%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82\%) rather than by using analytical and modeling approaches (n=8, 9.41\%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches. Conclusions: In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures. ",
doi="10.2196/38413",
url="https://games.jmir.org/2024/1/e38413"
}


@Article{info:doi/10.2196/54817,
author="Jackson, Walton Riley
and Cao-Nasalga, Ann
and Chieng, Amy
and Pirkl, Amy
and Jagielo, D. Annemarie
and Xu, Cindy
and Goldenhersch, Emilio
and Rosencovich, Nicolas
and Waitman, Cristian
and Prochaska, J. Judith",
title="Adding Virtual Reality Mindful Exposure Therapy to a Cancer Center's Tobacco Treatment Offerings: Feasibility and Acceptability Single-Group Pilot Study",
journal="JMIR Form Res",
year="2024",
month="Jul",
day="23",
volume="8",
pages="e54817",
keywords="tobacco cessation",
keywords="virtual reality",
keywords="exposure therapy",
keywords="cancer care",
keywords="mobile phone",
abstract="Background: Smoking contributes to 1 in 3 cancer deaths. At the Stanford Cancer Center, tobacco cessation medication management and counseling are provided as a covered benefit. Patients charted as using tobacco are contacted by a tobacco treatment specialist and offered cessation services. As a novel addition, this study examined the acceptability of a virtual reality (VR) mindful exposure therapy app for quitting smoking called MindCotine. Objective: The objective of this study was to determine the feasibility and acceptability of offering 6 weeks of MindCotine treatment as a part of Stanford's Tobacco Treatment Services for patients seen for cancer care. Methods: As part of a single-group pilot study, the MindCotine VR program was offered to English- or Spanish-speaking patients interested in quitting smoking. Given the visual interface, epilepsy was a medical exclusion. Viewed from a smartphone with an attachable VR headset, MindCotine provides a digital environment with audiovisual content guiding mindfulness exercises (eg, breathing techniques, body awareness, and thought recognition), text-based coaching, and cognitive behavioral therapy-based self-reflections for quitting smoking. Interested patients providing informed consent were mailed a MindCotine headset and asked to use the app for 10+ minutes a day. At the end of 6 weeks, participants completed a feedback survey. Results: Of the 357 patients reached by the tobacco treatment specialist, 62 (17.3\%) were ineligible, 190 (53.2\%) were not interested in tobacco treatment services, and 78 (21.8\%) preferred other tobacco treatment services. Among the 105 eligible and interested in assistance with quitting, 27 (25.7\%) were interested in MindCotine, of whom 20 completed the informed consent, 9 used the program, and 8 completed their end-of-treatment survey. Participants using MindCotine completed, on average, 13 (SD 20.2) program activities, 19 (SD 26) journal records, and 11 (SD 12.3) coaching engagements. Of the 9 participants who used MindCotine, 4 (44\%) reported some dizziness with app use that resolved and 7 (78\%) would recommend MindCotine to a friend. In total, 2 participants quit tobacco (22.2\% reporting, 10\% overall), 2 others reduced their smoking by 50\% or more, and 2 quit for 24 hours and then relapsed. Conclusions: In a feasibility and acceptability pilot study of a novel VR tobacco treatment app offered to patients at a cancer center, 4 of 9 (44\%) reporting and 4 of 20 (20\%) overall substantially reduced or quit using tobacco after 6 weeks and most would recommend the app to others. Further testing on a larger sample is warranted. Trial Registration: ClinicalTrials.gov NCT05220254; https://clinicaltrials.gov/study/NCT05220254 ",
doi="10.2196/54817",
url="https://formative.jmir.org/2024/1/e54817"
}


@Article{info:doi/10.2196/53261,
author="Szczepocka, Ewa
and Mokros, ?ukasz
and Kazmierski, Jakub
and Nowakowska, Karina
and ?ucka, Anna
and Antoszczyk, Anna
and Oltra-Cucarella, Javier
and Werzowa, Walter
and Hellevik, Moum Martin
and Skouras, Stavros
and Bagger, Karsten",
title="The Effectiveness of Virtual Reality--Based Training on Cognitive, Social, and Physical Functioning in High-Functioning Older Adults (CoSoPhy FX): 2-Arm, Parallel-Group Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2024",
month="Jun",
day="5",
volume="13",
pages="e53261",
keywords="cognitive functions",
keywords="head-mounted-display",
keywords="healthy seniors",
keywords="virtual reality",
keywords="well-being",
keywords="mobile phone",
abstract="Background: Virtual reality (VR) has emerged as a promising technology for enhancing the health care of older individuals, particularly in the domains of cognition, physical activity, and social engagement. However, existing VR products and services have limited availability and affordability; hence, there is a need for a scientifically validated and personalized VR service to be used by older adults in their homes, which can improve their overall physical, cognitive, and social well-being. Objective: The main purpose of the CoSoPhy FX (Cognitive, Social, and Physical Effects) study was to analyze the effects of a VR-based digital therapeutics app on the cognitive, social, and physical performance abilities of healthy (high-functioning) older adults. This paper presents the study protocol and the results from the recruitment phase. Methods: A group of 188 healthy older adults aged 65-85 years, recruited at the Medical University of Lodz, Poland, were randomly allocated to the experimental group (VR dual-task training program) or to the control group (using a VR headset app showing nature videos). A total of 3 cognitive exercises were performed in various 360{\textdegree} nature environments delivered via a VR head-mounted display; the participants listened to their preferred music genre. Each patient received 3 sessions of 12 minutes per week for 12 weeks, totaling a minimum of 36 sessions per participant. Attention and working memory (Central Nervous System Vital Signs computerized cognitive battery) were used as primary outcomes, while other cognitive domains in the Central Nervous System Vital Signs battery, quality of life (World Health Organization--5 Well-Being Index), health-related quality of life (EQ-5D-5L), and anxiety (General Anxiety Disorder 7-item questionnaire) were the secondary outcomes. The group-by-time interaction was determined using linear mixed models with participants' individual slopes. Results: In total, 122 (39\%) of the initial 310 participants failed to meet the inclusion criteria, resulting in a recruitment rate of 61\% (188/310). Among the participants, 68 successfully completed the intervention and 62 completed the control treatment. The data are currently being analyzed, and we plan to publish the results by the end of September 2024. Conclusions: VR interventions have significant potential among healthy older individuals. VR can address various aspects of well-being by stimulating cognitive functions, promoting physical activity, and facilitating social interaction. However, challenges such as physical discomfort, technology acceptance, safety concerns, and cost must be considered when implementing them for older adults. Further research is needed to determine the long-term effects of VR-based interventions, optimal intervention designs, and the specific populations that would benefit most. Trial Registration: ClinicalTrials.gov NCT05369897; https://clinicaltrials.gov/study/NCT05369897 International Registered Report Identifier (IRRID): DERR1-10.2196/53261 ",
doi="10.2196/53261",
url="https://www.researchprotocols.org/2024/1/e53261",
url="http://www.ncbi.nlm.nih.gov/pubmed/38837194"
}


@Article{info:doi/10.2196/53999,
author="Craig, V. Tabitha
and Rhodes, E. Ryan
and Sui, Wuyou",
title="Examining and Comparing the Energy Expenditure of Two Modes of a Virtual Reality Fitness Game (Supernatural): Indirect Calorimetry Study",
journal="JMIR Serious Games",
year="2024",
month="Jun",
day="4",
volume="12",
pages="e53999",
keywords="energy expenditure",
keywords="exergaming",
keywords="indirect calorimetry",
keywords="virtual reality",
keywords="VR",
keywords="VR fitness",
keywords="VR gaming",
abstract="Background: The effectiveness of virtual reality (VR) fitness games as a form of moderate to vigorous physical activity has yet to be thoroughly quantified through gold standard energy expenditure measures. Objective: The purpose of this study was to examine the energy expenditure of 2 medium-intensity modes (``Flow and ``Boxing'') of a VR fitness game, Supernatural, using indirect calorimetry. Methods: Indirect calorimetry was used to examine relative and objective maximal oxygen consumption (VO2 max), metabolic equivalents of task (METs), and calories burned during medium-intensity bouts of both Flow and Boxing gameplay modes in young (mean age 25.42, SD 3.25 years), active individuals (n=12 female and n=11 male). METs and calories were also compared using a triaxial waist-worn accelerometer, an Apple smartwatch, and a VR headset. Mood states were assessed pre- and postbout using the shortened Profile of Mood States Questionnaire. Paired 2-tailed t tests were used to examine differences in game modes, between sexes, and pre-post exercise sessions. Results: Objective and relative VO2 max averaged 1.93 (SD 0.44) L/min and 27.61 (SD 5.60) mL/kg/min, respectively, between modes. Flow (mean 8.2, SD 1.54 METs) and Boxing (mean 7.6, SD 1.66 METs) are both classified as high energy expenditure, vigorous activities. Calorie expenditure data of the accelerometer and VR headset differed significantly from the metabolic cart. Mood changes pre- to post exercise were consistent with expected values for moderate- to vigorous-intensity physical activity, with participants reporting that they felt more ``active,'' ``full of pep,'' ``vigorous,'' and ``lively'' (P<.05) following bouts. Male individuals reported higher objective oxygen consumption (VO2) for both Flow and Boxing modes; no other sex-specific differences were observed. Conclusions: Both Flow and Boxing gameplay modes of Supernatural classify as vigorous physical activity and demonstrate the potential to promote mental and physical health benefits. Supernatural may be an effective exercise modality in a VO2 training program. ",
doi="10.2196/53999",
url="https://games.jmir.org/2024/1/e53999",
url="http://www.ncbi.nlm.nih.gov/pubmed/38833285"
}


@Article{info:doi/10.2196/55692,
author="El-Gabalawy, Ren{\'e}e
and Sommer, L. Jordana
and Hebbard, Pamela
and Reynolds, Kristin
and Logan, S. Gabrielle
and Smith, D. Michael S.
and Mutter, C. Thomas
and Mutch, Alan W.
and Mota, Natalie
and Proulx, Catherine
and Gagnon Shaigetz, Vincent
and Maples-Keller, L. Jessica
and Arora, C. Rakesh
and Perrin, David
and Benedictson, Jada
and Jacobsohn, Eric",
title="An Immersive Virtual Reality Intervention for Preoperative Anxiety and Distress Among Adults Undergoing Oncological Surgery: Protocol for a 3-Phase Development and Feasibility Trial",
journal="JMIR Res Protoc",
year="2024",
month="May",
day="14",
volume="13",
pages="e55692",
keywords="virtual reality",
keywords="preoperative anxiety and distress",
keywords="perioperative mental health",
keywords="breast cancer",
keywords="oncological surgery",
abstract="Background: Preoperative state anxiety (PSA) is distress and anxiety directly associated with perioperative events. PSA is associated with negative postoperative outcomes such as longer hospital length of stay, increased pain and opioid use, and higher rates of rehospitalization. Psychological prehabilitation, such as education, exposure to hospital environments, and relaxation strategies, has been shown to mitigate PSA; however, there are limited skilled personnel to deliver such interventions in clinical practice. Immersive virtual reality (VR) has the potential for greater accessibility and enhanced integration into an immersive and interactive experience. VR is rarely used in the preoperative setting, but similar forms of stress inoculation training involving exposure to stressful events have improved psychological preparation in contexts such as military deployment. Objective: This study seeks to develop and investigate a targeted PSA intervention in patients undergoing oncological surgery using a single preoperative VR exposure. The primary objectives are to (1) develop a novel VR program for patients undergoing oncological surgery with general anesthesia; (2) assess the feasibility, including acceptability, of a single exposure to this intervention; (3) assess the feasibility, including acceptability, of outcome measures of PSA; and (4) use these results to refine the VR content and outcome measures for a larger trial. A secondary objective is to preliminarily assess the clinical utility of the intervention for PSA. Methods: This study comprises 3 phases. Phase 1 (completed) involved the development of a VR prototype targeting PSA, using multidisciplinary iterative input. Phase 2 (data collection completed) involves examining the feasibility aspects of the VR intervention. This randomized feasibility trial involves assessing the novel VR preoperative intervention compared to a VR control (ie, nature trek) condition and a treatment-as-usual group among patients undergoing breast cancer surgery. Phase 3 will involve refining the prototype based on feasibility findings and input from people with lived experience for a future clinical trial, using focus groups with participants from phase 2. Results: This study was funded in March 2019. Phase 1 was completed in April 2020. Phase 2 data collection was completed in January 2024 and data analysis is ongoing. Focus groups were completed in February 2024. Both the feasibility study and focus groups will contribute to further refinement of the initial VR prototype (phase 3), with the final simulation to be completed by mid-2024. Conclusions: The findings from this work will contribute to the limited body of research examining feasible and broadly accessible interventions for PSA. Knowledge gained from this research will contribute to the final development of a novel VR intervention to be tested in a large population of patients with cancer before surgery in a randomized clinical trial. Trial Registration: ClinicalTrials.gov NCT04544618; https://www.clinicaltrials.gov/study/NCT04544618 International Registered Report Identifier (IRRID): DERR1-10.2196/55692 ",
doi="10.2196/55692",
url="https://www.researchprotocols.org/2024/1/e55692",
url="http://www.ncbi.nlm.nih.gov/pubmed/38743939"
}


@Article{info:doi/10.2196/47382,
author="Bould, Helen
and Kennedy, Mari-Rose
and Penton-Voak, Ian
and Thomas, May Lisa
and Bird, Jon
and Biddle, Lucy",
title="Exploring How Virtual Reality Could Be Used to Treat Eating Disorders: Qualitative Study of People With Eating Disorders and Clinicians Who Treat Them",
journal="JMIR XR Spatial Comput",
year="2024",
month="May",
day="14",
volume="1",
pages="e47382",
keywords="eating disorders",
keywords="virtual reality",
keywords="anorexia nervosa",
keywords="bulimia nervosa",
keywords="EDNOS",
keywords="treatment",
keywords="immersive",
keywords="clinicians",
keywords="qualitative data",
keywords="psychoeducation",
keywords="therapeutic",
keywords="limitations",
abstract="Background: Immersive virtual reality (VR) interventions are being developed and trialed for use in the treatment of eating disorders. However, little work has explored the opinions of people with eating disorders, or the clinicians who treat them, on the possible use of VR in this context. Objective: This study aims to use qualitative methodology to explore the views of people with eating disorders, and clinicians who treat them, on the possible use of VR in the treatment of eating disorders. Methods: We conducted a series of focus groups and interviews with people with lived experience of eating disorders and clinicians on their views about VR and how it could potentially be used in the treatment of eating disorders. People with lived experience of eating disorders were recruited between October and December 2020, with focus groups held online between November 2020 and February 2021; clinicians were recruited in September 2021 and interviewed between September and October 2021. We took a thematic approach to analyzing the resulting qualitative data. Results: We conducted 3 focus groups with 10 individuals with a current or previous eating disorder, 2 focus groups with 4 participants, and 1 with 2 participants. We held individual interviews with 4 clinicians experienced in treating people with eating disorders. Clinicians were all interviewed one-to-one because of difficulties in scheduling mutually convenient groups. We describe themes around representing the body in VR, potential therapeutic uses for VR, the strengths and limitations of VR in this context, and the practicalities of delivering VR therapy. Suggested therapeutic uses were to practice challenging situations around food-related and weight/appearance-related scenarios and interactions, to retrain attention, the representation of the body, to represent the eating disorder, for psychoeducation, and to enable therapeutic conversations with oneself. There was a substantial agreement between the groups on these themes. Conclusions: People with lived experience of eating disorders and clinicians with experience in treating eating disorders generated many ideas as to how VR could be used as a part of eating disorders treatment. They were also aware of potential limitations and expressed the need for caution around how bodies are represented in a VR setting. ",
doi="10.2196/47382",
url="https://xr.jmir.org/2024/1/e47382"
}


@Article{info:doi/10.2196/54180,
author="Martin, Josh
and Rueda, Alice
and Lee, Hee Gyu
and Tassone, K. Vanessa
and Park, Haley
and Ivanov, Martin
and Darnell, C. Benjamin
and Beavers, Lindsay
and Campbell, M. Douglas
and Nguyen, Binh
and Torres, Andrei
and Jung, Hyejung
and Lou, Wendy
and Nazarov, Anthony
and Ashbaugh, Andrea
and Kapralos, Bill
and Litz, Brett
and Jetly, Rakesh
and Dubrowski, Adam
and Strudwick, Gillian
and Krishnan, Sridhar
and Bhat, Venkat",
title="Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study",
journal="JMIR Res Protoc",
year="2024",
month="May",
day="6",
volume="13",
pages="e54180",
keywords="web-based platform",
keywords="stress",
keywords="distress",
keywords="moral distress",
keywords="wearable",
keywords="oura ring",
keywords="virtual reality",
keywords="VR",
keywords="COVID-19",
keywords="nursing",
keywords="digital health implementation",
abstract="Background: Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited. Objective: This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level. Methods: This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants' experiences. Results: The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing. Conclusions: It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel. Trial Registration: ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398 International Registered Report Identifier (IRRID): DERR1-10.2196/54180 ",
doi="10.2196/54180",
url="https://www.researchprotocols.org/2024/1/e54180",
url="http://www.ncbi.nlm.nih.gov/pubmed/38709554"
}


@Article{info:doi/10.2196/56056,
author="Reategui-Rivera, Mahony C.
and Villarreal-Zegarra, David
and De La Cruz-Torralva, Kelly
and D{\'i}az-S{\'a}nchez, Paquita
and Finkelstein, Joseph",
title="Immersive Technologies for Depression Care: Scoping Review",
journal="JMIR Ment Health",
year="2024",
month="Apr",
day="25",
volume="11",
pages="e56056",
keywords="depression",
keywords="immersive technologies",
keywords="virtual reality",
keywords="augmented reality",
keywords="mobile phone",
abstract="Background: Depression significantly impacts quality of life, affecting approximately 280 million people worldwide. However, only 16.5\% of those affected receive treatment, indicating a substantial treatment gap. Immersive technologies (IMTs) such as virtual reality (VR) and augmented reality offer new avenues for treating depression by creating immersive environments for therapeutic interventions. Despite their potential, significant gaps exist in the current evidence regarding the design, implementation, and use of IMTs for depression care. Objective: We aim to map the available evidence on IMT interventions targeting depression treatment. Methods: This scoping review followed a methodological framework, and we systematically searched databases for studies on IMTs and depression. The focus was on randomized clinical trials involving adults and using IMTs. The selection and charting process involved multiple reviewers to minimize bias. Results: The search identified 16 peer-reviewed articles, predominantly from Europe (n=10, 63\%), with a notable emphasis on Poland (n=9, 56\%), which contributed to more than half of the articles. Most of the studies (9/16, 56\%) were conducted between 2020 and 2021. Regarding participant demographics, of the 16 articles, 5 (31\%) exclusively involved female participants, and 7 (44\%) featured participants whose mean or median age was >60 years. Regarding technical aspects, all studies focused on VR, with most using stand-alone VR headsets (14/16, 88\%), and interventions typically ranging from 2 to 8 weeks, predominantly in hospital settings (11/16, 69\%). Only 2 (13\%) of the 16 studies mentioned using a specific VR design framework in planning their interventions. The most frequently used therapeutic approach was Ericksonian psychotherapy, used in 56\% (9/16) of the studies. Notably, none of the articles reported using an implementation framework or identified barriers and enablers to implementation. Conclusions: This scoping review highlights the growing interest in using IMTs, particularly VR, for depression treatment but emphasizes the need for more inclusive and comprehensive research. Future studies should explore varied therapeutic approaches and cost-effectiveness as well as the inclusion of augmented reality to fully realize the potential of IMTs in mental health care. ",
doi="10.2196/56056",
url="https://mental.jmir.org/2024/1/e56056",
url="http://www.ncbi.nlm.nih.gov/pubmed/38663004"
}


@Article{info:doi/10.2196/49171,
author="Bj{\"o}rling, A. Elin
and Sonney, Jennifer
and Zade, Himanshu
and Rodriguez, Sofia
and Pullmann, D. Michael
and Moon, Hyun Soo",
title="Using Virtual Reality to Reduce Stress in Adolescents: Mixed Methods Usability Study",
journal="JMIR XR Spatial Comput",
year="2024",
month="Apr",
day="22",
volume="1",
pages="e49171",
keywords="virtual reality",
keywords="adolescents",
keywords="perceived stress",
keywords="participatory design",
keywords="depression",
abstract="Background: Adolescent mental health is a national mental health emergency amid surging rates of anxiety and depression. Given the scarcity and lack of scalable mental health services, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. Objective: The goal of this study was 2-fold: (1) to determine the feasibility, usability, and engagement of a participatory designed, nature-based virtual reality (VR) environment and (2) to determine the preliminary outcomes of our self-administered VR environment on depression, mindfulness, perceived stress, and momentary stress and mood. Methods: We conducted a within-person, 3-week, in-home study with a community-based sample of 44 adolescents. Participants completed surveys of perceived stress, depression, cognitive fusion, and mindfulness at intake, postintervention, and a 3-week follow-up. Participants were invited to use a nature-based, VR environment that included 6 evidence-based activities 3 to 5 times per week. They completed momentary stress and mood surveys 5 times each day and before and after each VR session. Postintervention, participants completed surveys on system and intervention usability and their experiences with using the VR system. Quantitative data were analyzed using descriptive statistics and mixed effects modeling to explore the effect of the VR environment on stress. Qualitative data were analyzed using collaborative thematic analysis. Results: Participants' use of the VR environment ranged from 1 session to 24 sessions (mean 6.27 sessions) at home over a 3-week period. The 44 participants completed all study protocols, indicating our protocol was feasible and the VR environment was engaging for most. Both the use of the VR system and novel VR intervention received strong usability ratings (mean 74.87 on the System Usability Scale). Most teens indicated that they found the tool to be easily administered, relaxing, and helpful with stress. For some, it offered space to process difficult emotions. The themes calm, regulating, and forget about everything resulted from open-ended exit interview data. Although the Relaxation Environment for Stress in Teens (RESeT) did not significantly affect repeated survey measurements of depression, mindfulness, nor cognitive fusion, it did positively affect momentary mood (pre-intervention: 10.8, post-intervention: 12.0, P=.001) and decrease momentary stress (pre-intervention: 37.9, post-intervention: 20.6, P=.001). We found a significant reduction in within-day momentary stress that strengthened with increased VR use over time during the study period (P=.03). Conclusions: These preliminary data inform our own VR environment design but also provide evidence of the potential for self-administered VR as a promising tool to support adolescent mental health. Self-administered VR for mental health may be an effective intervention for reducing adolescent stress. However, understanding barriers (including disengagement) to using VR, as well as further encouraging participatory design with teens, may be imperative to the success of future mental health interventions. ",
doi="10.2196/49171",
url="https://xr.jmir.org/2024/1/e49171"
}


@Article{info:doi/10.2196/52326,
author="Paul, Margot
and Bullock, Kim
and Bailenson, Jeremy
and Burns, David",
title="Examining the Efficacy of Extended Reality--Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2024",
month="Apr",
day="15",
volume="11",
pages="e52326",
keywords="virtual reality",
keywords="extended reality",
keywords="major depressive disorder",
keywords="behavioral activation",
keywords="depression",
keywords="Meta Quest 2",
abstract="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 ",
doi="10.2196/52326",
url="https://mental.jmir.org/2024/1/e52326",
url="http://www.ncbi.nlm.nih.gov/pubmed/38437873"
}


@Article{info:doi/10.2196/52186,
author="Xu, Joy
and Khanotia, Areej
and Juni, Shmuel
and Ku, Josephine
and Sami, Hana
and Lin, Vallen
and Walterson, Roberta
and Payne, Evelyn
and Jo, Helen
and Rahimpoor-Marnani, Parmin",
title="Effectiveness of Virtual Reality--Based Well-Being Interventions for Stress Reduction in Young Adults: Systematic Review",
journal="JMIR Ment Health",
year="2024",
month="Mar",
day="29",
volume="11",
pages="e52186",
keywords="well-being",
keywords="virtual reality",
keywords="VR",
keywords="stress, nature",
keywords="academic",
keywords="student",
keywords="intervention",
keywords="young adults",
keywords="teens",
keywords="adolescent",
keywords="stressors",
keywords="stress management",
keywords="systematic review",
keywords="accessible",
keywords="accessibility",
keywords="students",
keywords="affordable",
abstract="Background: Adolescents can be especially vulnerable to various stressors as they are still in their formative years and transitioning into adulthood. Hence, it is important for them to have effective stress management strategies. Objective: This systematic review investigates current well-being interventions that are aimed at reducing stress among young adults. In particular, interventions using the medium of virtual reality (VR) are explored. Methods: This mixed methods systematic review follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines, and papers were gathered from databases such as PsycINFO, PubMed, Science Direct, Web of Science, OpenGrey, and Edutopia. Predetermined criteria and specific keywords were used to search for the papers. Search results were screened and extracted with all article screening or extraction delegated among all authors. Any disagreements after reconciliation were settled by a third author. The quality and risk of bias of included studies were assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) Tool for Quantitative Studies. Studies were analyzed qualitatively. Results: In total, 20 studies were included, and qualitative analysis was performed to evaluate the effectiveness of VR-based interventions in 3 domains: nature, stress, and academics. Conclusions: Studies using VR interventions, overall, promoted a reduction in stress and an increase in well-being. The findings suggest that VR may serve as an accessible and affordable medium of stress reduction for students and young adults. Larger sample sizes, and a greater number of included studies, may be required in future directions. ",
doi="10.2196/52186",
url="https://mental.jmir.org/2024/1/e52186",
url="http://www.ncbi.nlm.nih.gov/pubmed/38551625"
}


@Article{info:doi/10.2196/50282,
author="Kirkham, Rebecca
and Kooijman, Lars
and Albertella, Lucy
and Myles, Dan
and Y{\"u}cel, Murat
and Rotaru, Kristian",
title="Immersive Virtual Reality--Based Methods for Assessing Executive Functioning: Systematic Review",
journal="JMIR Serious Games",
year="2024",
month="Feb",
day="26",
volume="12",
pages="e50282",
keywords="virtual reality",
keywords="executive functioning",
keywords="neuropsychological assessment",
keywords="systematic review",
keywords="psychometric properties",
keywords="cybersickness",
keywords="immersion",
keywords="cognition",
abstract="Background: Neuropsychological assessments traditionally include tests of executive functioning (EF) because of its critical role in daily activities and link to mental disorders. Established traditional EF assessments, although robust, lack ecological validity and are limited to single cognitive processes. These methods, which are suitable for clinical populations, are less informative regarding EF in healthy individuals. With these limitations in mind, immersive virtual reality (VR)--based assessments of EF have garnered interest because of their potential to increase test sensitivity, ecological validity, and neuropsychological assessment accessibility. Objective: This systematic review aims to explore the literature on immersive VR assessments of EF focusing on (1) EF components being assessed, (2) how these assessments are validated, and (3) strategies for monitoring potential adverse (cybersickness) and beneficial (immersion) effects. Methods: EBSCOhost, Scopus, and Web of Science were searched in July 2022 using keywords that reflected the main themes of VR, neuropsychological tests, and EF. Articles had to be peer-reviewed manuscripts written in English and published after 2013 that detailed empirical, clinical, or proof-of-concept studies in which a virtual environment using a head-mounted display was used to assess EF in an adult population. A tabular synthesis method was used in which validation details from each study, including comparative assessments and scores, were systematically organized in a table. The results were summed and qualitatively analyzed to provide a comprehensive overview of the findings. Results: The search retrieved 555 unique articles, of which 19 (3.4\%) met the inclusion criteria. The reviewed studies encompassed EF and associated higher-order cognitive functions such as inhibitory control, cognitive flexibility, working memory, planning, and attention. VR assessments commonly underwent validation against gold-standard traditional tasks. However, discrepancies were observed, with some studies lacking reported a priori planned correlations, omitting detailed descriptions of the EF constructs evaluated using the VR paradigms, and frequently reporting incomplete results. Notably, only 4 of the 19 (21\%) studies evaluated cybersickness, and 5 of the 19 (26\%) studies included user experience assessments. Conclusions: Although it acknowledges the potential of VR paradigms for assessing EF, the evidence has limitations. The methodological and psychometric properties of the included studies were inconsistently addressed, raising concerns about their validity and reliability. Infrequent monitoring of adverse effects such as cybersickness and considerable variability in sample sizes may limit interpretation and hinder psychometric evaluation. Several recommendations are proposed to improve the theory and practice of immersive VR assessments of EF. Future studies should explore the integration of biosensors with VR systems and the capabilities of VR in the context of spatial navigation assessments. Despite considerable promise, the systematic and validated implementation of VR assessments is essential for ensuring their practical utility in real-world applications. ",
doi="10.2196/50282",
url="https://games.jmir.org/2024/1/e50282",
url="http://www.ncbi.nlm.nih.gov/pubmed/38407958"
}


@Article{info:doi/10.2196/48916,
author="Shahid, Simon
and Kelson, Joshua
and Saliba, Anthony",
title="Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review",
journal="JMIR Ment Health",
year="2024",
month="Feb",
day="8",
volume="11",
pages="e48916",
keywords="social anxiety disorder",
keywords="social phobia",
keywords="virtual reality",
keywords="VR",
keywords="VR exposure therapy",
keywords="effectiveness",
keywords="user experience",
keywords="safety",
keywords="usability",
keywords="acceptability",
keywords="anxiety",
keywords="phobia",
keywords="exposure",
keywords="systematic",
keywords="review methods",
keywords="review methodology",
keywords="social",
keywords="psychiatric",
keywords="mental health",
keywords="mobile phone",
abstract="Background: Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD. Objective: The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD. Methods: The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items. Results: The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria. Conclusions: The findings showed that VR exposure therapy--based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36\%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues. Trial Registration: PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=353891 ",
doi="10.2196/48916",
url="https://mental.jmir.org/2024/1/e48916",
url="http://www.ncbi.nlm.nih.gov/pubmed/38329804"
}


@Article{info:doi/10.2196/51758,
author="Appel, Lora
and Appel, Eva
and Kisonas, Erika
and Lewis-Fung, Samantha
and Pardini, Susanna
and Rosenberg, Jarred
and Appel, Julian
and Smith, Christopher",
title="Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT)",
journal="J Med Internet Res",
year="2024",
month="Jan",
day="30",
volume="26",
pages="e51758",
keywords="digital therapies",
keywords="nonpharmacological",
keywords="cognitive impairment",
keywords="behavioral and psychological symptoms of dementia",
keywords="BPSDs",
keywords="randomized controlled trial",
keywords="virtual reality",
abstract="Background: Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings. Objective: The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention's feasibility in terms of acceptability, safety, and patient experience. Methods: A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ?65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51\%) or VR (n=34, 49\%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360{\textdegree} VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses' daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95\% significance level based on the intention-to-treat method. Results: VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy. Conclusions: Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments. Trial Registration: ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119 International Registered Report Identifier (IRRID): RR2-10.2196/22406 ",
doi="10.2196/51758",
url="https://www.jmir.org/2024/1/e51758",
url="http://www.ncbi.nlm.nih.gov/pubmed/38289666"
}


@Article{info:doi/10.2196/48649,
author="Pardini, Susanna
and Gabrielli, Silvia
and Olivetto, Silvia
and Fusina, Francesca
and Dianti, Marco
and Forti, Stefano
and Lancini, Cristina
and Novara, Caterina",
title="Personalized Virtual Reality Compared With Guided Imagery for Enhancing the Impact of Progressive Muscle Relaxation Training: Pilot Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2024",
month="Jan",
day="30",
volume="11",
pages="e48649",
keywords="digital health",
keywords="progressive muscular relaxation technique",
keywords="mental well-being",
keywords="virtual reality therapy",
keywords="anxiety",
keywords="relaxation",
keywords="e-therapy",
keywords="eHealth",
keywords="mobile phone",
abstract="Background: Empirical evidence has shown that virtual reality (VR) scenarios can increase the effects of relaxation techniques, reducing anxiety by enabling people to experience emotional conditions in more vivid settings. Objective: This pilot randomized controlled study aims to investigate whether the progressive muscle relaxation technique (PMRT) associated with a personalized scenario in VR promotes psychological well-being and facilitates the recall of relaxing images more than the standard complementary intervention that involves the integration of PMRT and guided imagery (GI). Methods: On the basis of a longitudinal, between-subject design, 72 university students were randomly exposed to one of two experimental conditions: (1) standard complementary procedure (PMRT and GI exposure) and (2) experimental procedure (PMRT and personalized VR exposure). Individuals were assessed by a therapist before and after 7 training sessions based on measures investigating anxiety, depression, quality of life, coping strategies, sense of presence, engagement, and side effects related to VR exposure. Heart rate data were also collected. Results: Differences in changes between the 2 groups after the in vivo PMRT session conducted by the psychotherapist (T1) were statistically significant for state anxiety (F1,67=30.56; P<.001) and heart rate (F1,67=4.87; P=.01). Individuals in the VR group obtained lower scores both before (t67=?2.63; P=.01; Cohen d=0.91) and after (t67=?7.23; P<.001; Cohen d=2.45) the relaxation session when it was self-administered by participants (T2). A significant reduction in perceived state anxiety at T1 and T2 was observed for both groups (P<.001). After the VR experience, individuals reported feeling higher engagement in the experience than what was mentioned by participants in the GI group (F1,67=2.85; P=.03; $\eta$p2=0.15), and they experienced the environment as more realistic (F1,67=4.38; P=.003; $\eta$p2=0.21). No differences between groups regarding sense of presence were found (F1,67=1.99; P=.11; $\eta$p2=0.11). Individuals exposed before to the VR scenario (T1) referred to perceiving the scenario recalled in-imagination at T2 as more realistic than what those in the GI group experienced (F1,67=3.21; P=.02; $\eta$p2=0.12). The VR group had lower trait anxiety levels than the GI group after the relaxation session during session 7 (T2; t67=?2.43; P=.02). Conclusions: Personalized relaxing VR scenarios can contribute to improving relaxation and decreasing anxiety when integrated with PMRT as a complementary relaxation method. Trial Registration: ClinicalTrials.gov NCT05478941; https://classic.clinicaltrials.gov/ct2/show/NCT05478941 International Registered Report Identifier (IRRID): RR2-10.2196/44183 ",
doi="10.2196/48649",
url="https://mental.jmir.org/2024/1/e48649",
url="http://www.ncbi.nlm.nih.gov/pubmed/38289673"
}


@Article{info:doi/10.2196/48537,
author="Gomez Bergin, D. Aislinn
and Allison, M. Aoife
and Hazell, M. Cassie",
title="Understanding Public Perceptions of Virtual Reality Psychological Therapy Using the Attitudes Towards Virtual Reality Therapy (AVRT) Scale: Mixed Methods Development Study",
journal="JMIR Ment Health",
year="2024",
month="Jan",
day="12",
volume="11",
pages="e48537",
keywords="psychological interventions",
keywords="digital",
keywords="virtual reality",
keywords="virtual agent",
keywords="mental health",
keywords="presence",
abstract="Background: Virtual reality (VR) psychological therapy has the potential to increase access to evidence-based mental health interventions by automating their delivery while maintaining outcomes. However, it is unclear whether these more automated therapies are acceptable to potential users of mental health services. Objective: The main aim of this study was to develop a new, validated questionnaire to measure public perceptions of VR therapy (VRT) guided by a virtual coach. We also aimed to explore these perceptions in depth and test how aspects such as familiarity with VR and mental health are associated with these perceptions, using both quantitative and qualitative approaches. Methods: We used a cross-sectional mixed methods design and conducted an exploratory factor analysis of a questionnaire that we developed, the Attitudes Towards Virtual Reality Therapy (AVRT) Scale, and a qualitative content analysis of the data collected through free-text responses during completion of the questionnaire. Results: We received 295 responses and identified 4 factors within the AVRT Scale, including attitudes toward VRT, expectation of presence, preference for VRT, and cost-effectiveness. We found that being more familiar with VR was correlated with more positive attitudes toward VRT (factor 1), a higher expectation of presence (factor 2), a preference for VRT over face-to-face therapy (factor 3), and a belief that VRT is cost-effective (factor 4). Qualitative data supported the factors we identified and indicated that VRT is acceptable when delivered at home and guided by a virtual coach. Conclusions: This study is the first to validate a scale to explore attitudes toward VRT guided by a virtual coach. Our findings indicate that people are willing to try VRT, particularly because it offers increased access and choice, and that as VR becomes ubiquitous, they will also have positive attitudes toward VRT. Future research should further validate the AVRT Scale. ",
doi="10.2196/48537",
url="https://mental.jmir.org/2024/1/e48537",
url="http://www.ncbi.nlm.nih.gov/pubmed/38214958"
}


@Article{info:doi/10.2196/51318,
author="Hasan, Safa
and Alhaj, Hamid
and Hassoulas, Athanasios",
title="The Efficacy and Therapeutic Alliance of Augmented Reality Exposure Therapy in Treating Adults With Phobic Disorders: Systematic Review",
journal="JMIR Ment Health",
year="2023",
month="Nov",
day="30",
volume="10",
pages="e51318",
keywords="augmented reality",
keywords="virtual reality",
keywords="anxiety disorders",
keywords="phobic disorders",
keywords="exposure therapy",
keywords="augmented reality exposure",
keywords="phobia",
keywords="excessive fear",
keywords="prevalence",
keywords="technology",
keywords="cost-effectiveness",
keywords="fear",
keywords="phobic",
abstract="Background: Phobic disorders are characterized by excessive fear of a stimulus that can affect the quality of a patient's life. The lifetime prevalence in adults is 7.7\% to 12.5\%. The current literature provides evidence-based inferences about the effectiveness of in-vivo exposure therapy (IVET) in treating phobia. However, this method can put the therapist and the client in danger, with high drop out and refusal rates. A newer approach for exposure therapy using augmented reality technology is under assessment. Objective: This systematic review investigated the novel technology's efficacy, cost-efficacy, and therapeutic alliance in treating adults with phobia. Methods: An extensive search was conducted using 4 major databases (MEDLINE, PsycINFO, Embase, and Scopus) using a comprehensive list of synonyms for augmented reality exposure therapy (ARET) and phobic disorders. The search targeted any randomized control trial testing ARET in adults with phobic disorders up to August 8, 2022. Results: A total of 6 studies were included, with 208 participants providing results. Studies investigating the efficacy of ARET compared to no intervention showed significant results (P<.05) in the ARET group improvement. Head-to-head comparative studies comparing ARET to IVET showed no significant difference (P>.05) in the effectiveness and therapeutic alliance between both therapies. Further, the results demonstrated that the ARET group had a better long-term effect than IVET, with the ability to put the patients in more situations to face the feared object. Conclusions: The current data suggest clinically significant efficacy and a promising therapeutic alliance of ARET. However, no data are available investigating the cost-effectiveness of ARET. Further research is warranted to ascertain ARET's cost-effectiveness and examine its efficacy in other populations and anxiety conditions. ",
doi="10.2196/51318",
url="https://mental.jmir.org/2023/1/e51318",
url="http://www.ncbi.nlm.nih.gov/pubmed/38032710"
}


@Article{info:doi/10.2196/46592,
author="Klein Schaarsberg, E. Ren{\'e}e
and Ribberink, Z. Amber
and Osinga, Babette
and van Dam, Levi
and Lindauer, L. Ram{\'o}n J.
and Popma, Arne",
title="Treatment Responsivity in Adolescents With Disruptive Behavior Problems: Co-Creation of a Virtual Reality--Based Add-On Intervention",
journal="JMIR Form Res",
year="2023",
month="Nov",
day="28",
volume="7",
pages="e46592",
keywords="virtual reality",
keywords="role-playing",
keywords="cognitive behavioral therapy",
keywords="co-creation",
keywords="disruptive behavior",
keywords="mentalization",
keywords="adolescence",
keywords="mental health",
keywords="child",
keywords="youth",
keywords="clinical practice",
keywords="intervention",
abstract="Background: We developed Street Temptations (ST) as an add-on intervention to increase the treatment responsivity of adolescents with disruptive behavior problems. ST's primary aim is to improve adolescents' mentalizing abilities in order to help them engage in and benefit from psychotherapy. Additionally, virtual reality (VR) is used to work in a more visual, less verbal, fashion. Objective: By recapping the lessons learned while developing ST so far, we aim to design the following study on ST. Furthermore, we aim to enhance the development and study of new health care interventions in clinical practice, together with adolescents as their end users. Methods: We followed an iterative co-creation process to develop a prototype of ST, in collaboration with adolescents and professionals from a secured residential facility in Amsterdam, the Netherlands. The prototype was tested during a pilot phase, involving 2 test runs, in which 4 adolescents and 4 professionals participated. Qualitative data were collected through interviews with the adolescents and by conducting a group interview with the professionals, in order to gain first insights into ST's usability, feasibility, and its added value to clinical practice. In between the first and second test runs, the prototype was enhanced. On the basis of the complete pilot phase, we reflected on the future development and implementation of ST to design a subsequent study. Results: Over the course of 6 months, ST's first prototype was developed during multiple creative sessions. Included was the development of a short 360{\textdegree} VR video, to serve as a base for the mentalization exercises. The final version of ST consisted of 7 individual therapy sessions, incorporating both the VR video and a VR StreetView app. On the basis of the qualitative data collected during the pilot phase, we found preliminary signs of ST's potential to support adolescents' perspective-taking abilities specifically. Additionally, using VR to focus on real-life situations that adolescents encounter in their daily lives possibly helps to facilitate communication. However, several challenges and requests concerning the VR hardware and software and the implementation of ST emerged, pointing toward further development of ST as an add-on intervention. These challenges currently limit large-scale implementation, resulting in specific requirements regarding a subsequent study. Conclusions: In order to gather more extensive information to shape further development and study treatment effects, a small-scale and individually oriented research design seems currently more suitable than a more standard between-subjects design. Using the reflection on the lessons learned described in this report, a research protocol for a forthcoming study on ST has been developed. By presenting our co-creation journey thus far, we hope to be of inspiration for a more co-creative mindset and in that way contribute to the mutual reinforcement of science and clinical practice. ",
doi="10.2196/46592",
url="https://formative.jmir.org/2023/1/e46592",
url="http://www.ncbi.nlm.nih.gov/pubmed/38015607"
}


@Article{info:doi/10.2196/46959,
author="Vaezipour, Atiyeh
and Aldridge, Danielle
and Koenig, Sebastian
and Burns, Clare
and Baghaei, Nilufar
and Theodoros, Deborah
and Russell, Trevor",
title="Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study",
journal="JMIR Rehabil Assist Technol",
year="2023",
month="Oct",
day="31",
volume="10",
pages="e46959",
keywords="communication disorders",
keywords="speech and language therapy",
keywords="rehabilitation",
keywords="virtual reality",
keywords="human-computer interaction",
keywords="technology acceptance",
keywords="acceptance",
keywords="communication",
keywords="therapy",
keywords="usefulness",
keywords="usability",
keywords="survey",
keywords="barrier",
keywords="mobile phone",
abstract="Background: Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders. Objective: This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders. Methods: Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes. Results: The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology. Conclusions: Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities. ",
doi="10.2196/46959",
url="https://rehab.jmir.org/2023/1/e46959",
url="http://www.ncbi.nlm.nih.gov/pubmed/37906228"
}


@Article{info:doi/10.2196/48912,
author="Kim, Du-Ri
and Moon, EunSoo
and Shin, Myung-Jun
and Yang, Yeong-Ae
and Park, Jong-Hwan",
title="Effect of Individual Virtual Reality Cognitive Training Programs on Cognitive Function and Depression in Middle-Aged Women: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2023",
month="Oct",
day="25",
volume="10",
pages="e48912",
keywords="cognitive function",
keywords="depression",
keywords="middle aged",
keywords="virtual reality",
keywords="women",
abstract="Background: Given the increasing incidence of early-onset Alzheimer disease, strategies for early diagnosis and swift treatment interventions are crucial for mitigating cognitive problems in women and middle-aged individuals who face a high risk of cognitive impairment. Objective: This study aimed to assess the effectiveness of individual cognitive training programs based on virtual reality (VR), a nonpharmacological intervention, on cognitive function and depression in middle-aged women at risk of cognitive impairment. It used VR technology, which has recently been recognized as a promising tool. Methods: We administered a VR-based cognitive training program for 30 minutes daily, twice a week, for 12 weeks (24 sessions). This study included middle-aged women residing in older adults' welfare facilities in G-gu, Busan, from May to August 2021. A total of 60 participants were randomly divided into the training (n=30) and control (n=30) groups. Cognitive and depressive functions were assessed using the Korean versions of the Montreal Cognitive Assessment (K-MoCA), Digit Span Test (DST), Korean-Color Word Stroop Test (K-CWST), and Short Form of the Geriatric Depression Scale (SGDS-K) before the intervention. The training group underwent a VR-based cognitive training program, whereas the control group was educated to maintain regular daily activities. The same assessments were performed 12 weeks after treatment. Results: A comparison of the mean scores before and after K-MoCA in the training group revealed a significant increase from 24.87 (SD 2.62) to 27.50 (SD 1.70; P<.01), indicating substantial cognitive improvement. Similarly, the mean DST forward scores increased significantly from 6.97 (SD 1.10) to 7.90 (SD 1.18; P<.01), suggesting enhanced short-term auditory memory and attention. The mean DST backward scores also showed a significant improvement from 4.10 (SD 0.71) to 4.77 (SD 1.2; P=.01). Notably, the mean SGDS-K scores decreased significantly from 3.97 (SD 2.51) to 2.13 (SD 1.87; P<.01), indicating a reduction in depression within the training group. Conclusions: The VR-based cognitive training programs significantly enhanced cognitive function and reduced depression in middle-aged women. Consequently, these programs are considered beneficial nonpharmacological cognitive training interventions for middle-aged women at high risk of cognitive impairment. Trial Registration: UMIN Clinical Trials Registry UMIN000049752; https://tinyurl.com/z5du989z ",
doi="10.2196/48912",
url="https://mental.jmir.org/2023/1/e48912",
url="http://www.ncbi.nlm.nih.gov/pubmed/37878378"
}


@Article{info:doi/10.2196/47443,
author="Levy, N. Amanda
and Nittas, Vasileios
and Wray, B. Tyler",
title="Patient Perceptions of In Vivo Versus Virtual Reality Exposures for the Treatment of Anxiety Disorders: Cross-Sectional Survey Study",
journal="JMIR Form Res",
year="2023",
month="Oct",
day="16",
volume="7",
pages="e47443",
keywords="counseling treatment",
keywords="phobias",
keywords="PTSD",
keywords="patient perspective",
keywords="in vivo exposures",
keywords="virtual reality",
keywords="exposure therapy",
keywords="anxiety",
keywords="psychotherapy",
keywords="effectiveness",
keywords="digital therapy",
keywords="affective disorders",
abstract="Background: Psychotherapy, and particularly exposure therapy, has been proven to be an effective treatment for many anxiety disorders, including social and specific phobias, as well as posttraumatic stress disorders. Currently, exposures are underused and mostly delivered in vivo. Virtual reality exposure therapy (VRET) offers a more flexible delivery mechanism that has the potential to address some of the implementation barriers of in vivo exposures while retaining effectiveness. Yet, there is little evidence on how patients perceive different exposure therapy methods. Objective: This study aims to explore the perceptions of individuals with anxiety disorders toward in vivo and VRET. Our findings can inform therapists about the degree of patient interest in both methods while exploring the demand for VRET as an alternative and novel treatment approach. Methods: Web-based survey assessing the (1) interest in, (2) willingness to use, (3) comfort with, (4) enthusiasm toward, and (5) perceived effectiveness of exposure therapy when delivered in vivo and through VR. Participants included individuals with specific phobia, social phobia, posttraumatic stress disorder, or acute stress disorder or reaction. Participants were presented with educational videos about in vivo and VRET and asked to provide their perceptions quantitatively and qualitatively through a rated scale and free-text responses. Results: In total, 184 surveys were completed and analyzed, in which 82\% (n=151) of participants reported being willing to receive in vivo exposures and 90.2\% (n=166) reported willingness to receive VRET. Participants reported higher interest in, comfort with, enthusiasm toward, and perceived effectiveness of VRET compared to in vivo. Most reported in vivo concerns were linked to (1) increased anxiety, (2) feelings of embarrassment or shame, and (3) exacerbation of current condition. Most reported VRET concerns were linked to (1) risk of side effects including increased anxiety, (2) efficacy uncertainty, and (3) health insurance coverage. The most frequently mentioned VRET benefits include (1) privacy, (2) safety, (3) the ability to control exposures, (4) comfort, (5) the absence of real-life consequences, (6) effectiveness, and (7) customizability to a wider variety of exposures. Conclusions: On average, our participants expressed positive perceptions toward exposure therapy, with slightly more positive perceptions of VRET over in vivo exposures. Despite valid personal concerns and some misconceptions, our findings emphasize that VRET provides an opportunity to get much-needed therapy to patients in ways that are more acceptable and less concerning. ",
doi="10.2196/47443",
url="https://formative.jmir.org/2023/1/e47443",
url="http://www.ncbi.nlm.nih.gov/pubmed/37843884"
}


@Article{info:doi/10.2196/47617,
author="Halim, Ilona
and Stemmet, Lehan
and Hach, Sylvia
and Porter, Richard
and Liang, Hai-Ning
and Vaezipour, Atiyeh
and Henry, D. Julie
and Baghaei, Nilufar",
title="Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study",
journal="JMIR Ment Health",
year="2023",
month="Oct",
day="2",
volume="10",
pages="e47617",
keywords="individualized virtual reality",
keywords="mental health",
keywords="self-compassion",
keywords="depression",
keywords="depressive symptoms",
keywords="mobile phone",
abstract="Background: Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited. Objective: The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality. Methods: A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants' perceptions about the perceived usability and system acceptability of the iVR approach. Results: Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36\% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64\% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable. Conclusions: Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future. ",
doi="10.2196/47617",
url="https://mental.jmir.org/2023/1/e47617",
url="http://www.ncbi.nlm.nih.gov/pubmed/37782537"
}


@Article{info:doi/10.2196/48208,
author="Wong, Po Ka
and Qin, Jing",
title="Effectiveness of Social Virtual Reality Training in Enhancing Social Interaction Skills in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Three-Arm Pilot Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2023",
month="Sep",
day="18",
volume="12",
pages="e48208",
keywords="attention-deficit/hyperactivity disorder",
keywords="social interaction skills",
keywords="executive functioning",
keywords="emotional control",
keywords="3-arm randomized controlled trial",
keywords="ADHD",
keywords="attention deficit",
keywords="hyperactive",
keywords="hyperactivity",
keywords="randomized",
keywords="RCT",
keywords="social interaction",
keywords="social interactions",
keywords="social skills",
keywords="child",
keywords="children",
keywords="youth",
keywords="pediatric",
keywords="pediatrics",
keywords="VR",
keywords="virtual reality",
keywords="childhood",
keywords="neurodevelopmental",
abstract="Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Children with ADHD have challenges in understanding social cues and behavioral problems when entering a social setting. Virtual reality (VR) has been applied to improve cognitive behaviors in children with ADHD. Previous studies have not adopted VR to improve social interaction competence and appropriateness in children with ADHD. VR offers a more effective alternative to therapeutic strategies for children with ADHD. Objective: This study aims to examine the feasibility and effectiveness of social VR training in enhancing social interaction skills compared to traditional social skills training in children with ADHD. We hypothesize that participants in the social VR training group are likely to perform better on social interaction skills than those in the traditional social skills training group. Methods: In this nonblinded, 3-arm randomized controlled trial (RCT), 90 participants with ADHD recruited from the community will be randomized 1:1:1 to the social VR intervention group, traditional social skills training group, or waitlist control group. The child psychiatrist will conduct assessments for each participant at baseline and after the intervention. The Social Skills Rating Scale--Parent will be used to assess the social interaction skills of the participants before and after the intervention. Participants in the social VR intervention group and traditional social skills training group will receive twelve 20-minute training sessions for 3 weeks. The participants in the waitlist control group will receive no training. The primary outcome measure is training acceptability and compliance. The secondary outcome measures are the child psychiatrist's assessment and the Social Skills Rating Scale--Parent before and after the intervention. Another outcome measure is the Behavior Rating Inventory of Executive Function and Attention. Differences in the scale scores will be examined using a t test and an F test. Results: This study is set to commence in the fourth quarter of 2023. It is anticipated that participants in the social VR intervention group will exhibit superior social interaction skills than those in the traditional social skills training group. Conclusions: To our knowledge, this RCT is the first study examining the feasibility and effectiveness of a social VR-based intervention for enhancing the social interaction skills of children with ADHD in Hong Kong. The VR-based social skills training is expected to provide a safer and more effective environment for children with ADHD to learn than the traditional approach. This study can lead to a full-scale RCT. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526  International Registered Report Identifier (IRRID): PRR1-10.2196/48208 ",
doi="10.2196/48208",
url="https://www.researchprotocols.org/2023/1/e48208",
url="http://www.ncbi.nlm.nih.gov/pubmed/37721790"
}


@Article{info:doi/10.2196/43985,
author="Afzal, Waqar M.
and Ahmad, Ashfaq
and Hanif, Bilal Hafiz Muhammad
and Chaudhary, Nauman
and Gilani, Amir Syed",
title="Effects of Virtual Reality Exercises on Chronic Low Back Pain: Quasi-Experimental Study",
journal="JMIR Rehabil Assist Technol",
year="2023",
month="Sep",
day="15",
volume="10",
pages="e43985",
keywords="low back pain, lumbar range of motion",
keywords="pain",
keywords="Oswestry disability index",
keywords="virtual reality",
keywords="exercise",
keywords="back pain",
keywords="lumbar",
keywords="range of motion",
keywords="VR",
keywords="rehabilitation",
keywords="gaming",
keywords="serious game",
abstract="Background: Low back pain is a common health problem globally. Based on the duration of pain, it is classified as acute, subacute, or chronic low back pain. Different treatment strategies are available to reduce chronic low back pain. Virtual reality (VR) is a novel approach in back pain rehabilitation. Objective: This study aimed to compare the effects of VR games on chronic low back pain. Methods: This quasi-experimental study was conducted among 40 patients with chronic low back pain. The data were collected using a nonprobability, convenient sampling technique. Patients visiting the Department of Physiotherapy, Government Services Hospital, Lahore, Pakistan, were recruited and equally divided into 4 groups. Group A received the Reflex Ridge game; group B received the Body Ball game; group C combined the 2 games without back-strengthening exercises; and group D combined the 2 games with back-strengthening exercises. The participants received 8 treatment sessions, with 3 sessions/wk. The outcomes were pre- and posttest measurements of pain intensity, low back disability, and lumbar range of motion. The repeated measurement ANOVA was used for inter- and intragroup comparison, with significance at P?.05. Results: The study comprised a sample of 40 patients with low back pain; 12 (40\%) were female and 28 (60\%) were male, with a mean age of 37.85 (SD 12.15) years. The pre- and posttest mean pain scores were 7.60 (SD 1.84) and 4.20 (SD 1.62) in group A, 6.60 (SD 1.776) and 5.90 (SD 1.73) in group B, 6.90 (SD 1.73) and 5.40 (SD 1.07) in group C, and 7.10 (SD 1.53) and 3.60 (SD 0.97) in group D, respectively. The mean pain score differences of group D (combining the Reflex Ridge and Body Ball games with back-strengthening exercises) compared to groups A, B, and C were --.60 (P=.76), --2.30 (P<.001), and --1.80 (P=.03), respectively. Regarding the range of motion, the forward lumbar flexion mean differences of group D compared to groups A, B, and C were 3.80 (P=.21), 4.80 (P=.07), and 7.40 (P<.001), respectively. Similarly, the right lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P=.04), 5.20 (P<.001), and 4.80 (P<.001), respectively. The left lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P<.001), 4.80 (P=.02), and 2.20 (P<.001). respectively, showing significant pre- and posttreatment effects. Conclusions: VR exercises had statistically significant effects on improving pain, low back disability, and range of motion in all groups, but the combination of Reflex Ridge and Body Ball games with back-strengthening exercises had dominant effects compared to the other groups. Trial Registration: Iranian Registry of Clinical Trial IRCT20200330046895N1; https://en.irct.ir/trial/46916 ",
doi="10.2196/43985",
url="https://rehab.jmir.org/2023/1/e43985",
url="http://www.ncbi.nlm.nih.gov/pubmed/37713252"
}


@Article{info:doi/10.2196/42067,
author="Kilcioglu, Seyma
and Schiltz, Beno{\^i}t
and Araneda, Rodrigo
and Bleyenheuft, Yannick",
title="Short- to Long-Term Effects of Virtual Reality on Motor Skill Learning in Children With Cerebral Palsy: Systematic Review and Meta-Analysis",
journal="JMIR Serious Games",
year="2023",
month="Sep",
day="12",
volume="11",
pages="e42067",
keywords="cerebral palsy",
keywords="virtual reality",
keywords="motor skill learning",
keywords="long-term effect",
keywords="daily life activities",
keywords="motor functions",
abstract="Background: Many studies have started integrating virtual reality (VR) into neurorehabilitation for children with cerebral palsy (CP). The results of the effects of VR on motor skill learning, including the short- to long-term results of relevant studies, must be pooled in a generic framework. Objective: This systematic review and meta-analysis aimed to investigate the short- to long-term effects of therapies including VR on motor skill learning in children with CP. Methods: Two examiners followed the inclusion and exclusion criteria of the ``Participant, Intervention, Control, and Outcome'' framework. Randomized controlled trials (RCTs) and non-RCTs were considered if they compared VR-included interventions with control groups on motor functions and daily life activities in children with CP. PubMed, ScienceDirect, Embase, and IEEE Xplore databases were searched. The modified Downs and Black assessment was used to assess the methodological quality of the included studies. Meta-analyses and subgroup analyses for RCTs were conducted whenever possible. Results: A total of 7 RCTs, 2 non-RCTs, and 258 children with CP were included. The priority focus of 78\% (7/9) of the studies was upper limb functions. There was a significant short-term effect of adding VR to conventional therapies on upper limb functions when compared with conventional therapies (P=.04; standardized mean difference [SMD]=0.39, 95\% CI 0.01-0.76). The overall medium- to long-term effects showed a trend toward favoring the VR group, although the difference was not statistically significant (P=.06; SMD=0.37, 95\% CI ?0.02 to 0.77). For balance (P=.06; SMD=1.04, 95\% CI ?0.04 to 2.12), gross motor functions (P=.30; SMD=2.85, 95\% CI ?2.57 to 8.28), and daily life activities outcomes (P=.21; SMD=0.29, 95\% CI ?0.16 to 0.74), the overall effect in the short term also showed a trend toward favoring the VR group, but these results were not statistically significant. Conclusions: VR seems to have additional benefits for motor skill learning in children with CP. Studies with follow-up outcomes of VR training focusing on balance and gross motor functions in patients with CP were quite limited. Future research on balance and gross motor function outcomes should target particularly long-term results of therapies including VR on motor skill learning. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227734; https://www.crd.york.ac.uk/prospero/display\_record.php?ID=CRD42021227734 ",
doi="10.2196/42067",
url="https://games.jmir.org/2023/1/e42067",
url="http://www.ncbi.nlm.nih.gov/pubmed/37698895"
}


@Article{info:doi/10.2196/34629,
author="Sharrad, Kelsey
and Martini, Caitlin
and Tai, Andrew
and Spurrier, Nicola
and Smith, Ross
and Esterman, Adrian
and Gwilt, Ian
and Sandford, Debra
and Carson-Chahhoud, Kristin",
title="Mixed Reality Technology to Deliver Psychological Interventions to Adolescents With Asthma: Qualitative Study Using the Theoretical Framework of Acceptability",
journal="JMIR Hum Factors",
year="2023",
month="Jul",
day="26",
volume="10",
pages="e34629",
keywords="asthma",
keywords="augmented reality",
keywords="virtual reality",
keywords="mixed reality",
keywords="psychological distress",
keywords="adolescent",
keywords="cognitive behavioral therapies",
keywords="mental health",
abstract="Background: Interactive, mixed reality technologies such as augmented reality, virtual reality, and holographic technology may provide a novel solution to fast-track the translation of evidence into practice. They may also help overcome barriers to both mental health and asthma management service uptake, such as cost, availability of appointments, fear of judgment, and quality of care. Objective: This study aimed to investigate if mixed reality technology is an acceptable mechanism for the delivery of a component of cognitive and behavioral therapies for the management of elevated psychological distress among young people with asthma. Methods: To explore the perceived acceptability of these technologies, mixed reality tools were evaluated via qualitative, 1-on-1 interviews with young people with asthma and symptoms of psychological distress, parents/caregivers of young people with asthma and symptoms of psychological distress, and relevant health professionals. The Theoretical Framework of Acceptability was used for the deductive coding of the recorded interview transcripts. Results: This study enrolled the following participants: (1) 3 adolescents with asthma and symptoms of psychological distress with a mean age of 14 (SD 1.7) years; (2) 4 parents/caregivers of adolescents with asthma with a mean age of 55 (SD 14.6) years; and (3) 6 health professionals with a mean age of 40.8 (SD 4.3) years. A total of 4 constructs---experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence---were coded in all participant transcripts. The most frequently coded constructs were experienced affective attitude and intervention coherence, which were reported a total of 96 times. The least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. Participants were mostly positive about the mixed reality resources. However, some concerns were raised regarding ethicality, particularly regarding privacy, accessibility, and messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and that some patients would respond to this type of delivery mechanism better than others. Conclusions: These results suggest that mixed reality technology to deliver psychological interventions may be an acceptable addition to current health care practices for young people with asthma and symptoms of psychological distress. Trial Registration: Australia and New Zealand Clinical Trials Registry ACTRN12620001109998; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380427 ",
doi="10.2196/34629",
url="https://humanfactors.jmir.org/2023/1/e34629",
url="http://www.ncbi.nlm.nih.gov/pubmed/37494096"
}


@Article{info:doi/10.2196/42377,
author="Ezawa, D. Iony
and Hollon, D. Steven
and Robinson, Noah",
title="Examining Predictors of Depression and Anxiety Symptom Change in Cognitive Behavioral Immersion: Observational Study",
journal="JMIR Ment Health",
year="2023",
month="Jul",
day="14",
volume="10",
pages="e42377",
keywords="Cognitive Behavioral Immersion",
keywords="virtual reality",
keywords="metaverse",
keywords="alliance",
keywords="social support",
keywords="cognitive behavioral",
keywords="depression",
keywords="anxiety",
keywords="mood",
keywords="mental health",
keywords="mobile phone",
abstract="Background: Depressive and anxiety disorders are the most common mental disorders, and there is a critical need for effective, affordable, and accessible interventions. Cognitive Behavioral Immersion (CBI) is a novel group-based cognitive behavioral skills training program delivered by lay coaches in the metaverse that can be accessed through various modalities including virtual reality (VR) head-mounted displays or flat-screen devices. Combining its ability to offer empirically supported therapy skills in a digital setting that can still facilitate interpersonal variables (eg, working alliance and sense of social support) with the aid of lay coaches, CBI has the potential to help fill this critical need. Objective: This study had 2 primary aims. First, we aimed to examine changes in depression and anxiety symptoms in a sample of individuals who participated in CBI. Second, we aimed to examine 2 interpersonal process variables (working alliance and web-based social support) as predictors of symptom changes. We predicted CBI participants would experience depression and anxiety symptom improvements and that such improvements would be associated with an increase in both interpersonal process variables. Methods: The study sample consists of 127 participants who endorsed clinical levels of depression or anxiety symptoms during their first CBI session and attended at least 2 sessions. Participants were asked to complete self-report measures of depression symptoms, anxiety symptoms, alliance, and web-based social support throughout their participation in CBI. Results: Repeated measures ANOVAs determined that depression and anxiety symptom scores differed significantly across sessions (Ps<.01). We also found participants' web-based social support predicted improvement in depression symptoms (P=.01), but neither the alliance nor web-based social support predicted change in anxiety symptoms (Ps>.05). We also observed a significant difference in anxiety symptoms between participants who used a VR head-mounted display to access CBI and those who did not, such that participants who used VR head-mounted displays endorsed lower anxiety symptoms than those who did not at nearly every session (P=.04). Conclusions: Participation in CBI is associated with both depression and anxiety symptom improvement. Web-based social support may play an important role in fostering changes in depression symptoms. Future studies are encouraged to continue examining the process of change in CBI with special attention paid to methods that can elucidate causal mechanisms of change. ",
doi="10.2196/42377",
url="https://mental.jmir.org/2023/1/e42377",
url="http://www.ncbi.nlm.nih.gov/pubmed/37450322"
}


@Article{info:doi/10.2196/44998,
author="Li Pira, Giorgio
and Aquilini, Beatrice
and Davoli, Alessandro
and Grandi, Silvana
and Ruini, Chiara",
title="The Use of Virtual Reality Interventions to Promote Positive Mental Health: Systematic Literature Review",
journal="JMIR Ment Health",
year="2023",
month="Jul",
day="6",
volume="10",
pages="e44998",
keywords="positive mental health",
keywords="well-being",
keywords="virtual reality",
keywords="interventions",
keywords="psychopathology",
keywords="mobile phone",
abstract="Background: A large body of research has documented the efficacy of psychological interventions integrated with virtual reality (VR) therapies in treating psychiatric disorders. However, the concept of positive mental health calls for a 2-fold approach in which both symptoms and positive functioning should be addressed by modern interventions. Objective: This review aimed to summarize studies that applied VR therapies by embracing the positive mental health perspective. Methods: A literature search was conducted by entering the following keywords---``virtual reality'' AND ``intervention'' OR ``treatment'' OR ``therapy'' AND ``mental health'' NOT ``systematic review or meta-analysis''---and limiting it to ``journal article'' and the English language. To be included in this review, articles had to present at least one quantitative measure of positive functioning and one quantitative measure of symptoms or distress and had to investigate adult populations, including populations with psychiatric disorders. Results: A total of 20 articles were included. They described various VR protocols that were applied for the treatment of anxiety disorders (5/20, 25\%), depression (2/20, 10\%), posttraumatic stress disorder (3/20, 15\%), psychosis (3/20, 15\%), and stress (7/20, 35\%). Most of the studies (13/20, 65\%) showed the beneficial effects of VR therapies in improving stress and negative symptoms. However, 35\% (7/20) of the studies showed no or a small effect on the various dimensions of positivity, particularly in clinical samples. Conclusions: VR interventions might be cost-effective and largely scalable, but further research is needed to develop existing VR software and treatments according to the modern positive mental health approach. ",
doi="10.2196/44998",
url="https://mental.jmir.org/2023/1/e44998",
url="http://www.ncbi.nlm.nih.gov/pubmed/37410520"
}


@Article{info:doi/10.2196/48927,
author="Xu, Ling
and Hagedorn, Aaron
and Chi, Iris",
title="Intergenerational Reminiscence Approach in Improving Emotional Well-Being of Older Asian Americans in Early-Stage Dementia Using Virtual Reality: Protocol for an Explanatory Sequential Mixed Methods Study",
journal="JMIR Res Protoc",
year="2023",
month="Jun",
day="26",
volume="12",
pages="e48927",
keywords="intergenerational reminiscence",
keywords="grandparent-grandchild",
keywords="dyad",
keywords="emotional",
keywords="well-being",
keywords="Asian American",
keywords="older adults",
keywords="dementia",
keywords="virtual reality",
keywords="VR",
abstract="Background: After a dementia diagnosis, Asian Americans experience anxiety, feelings of shame, and other negative effects. Emotional well-being is not only an important aspect of mental health, but also a quality of resilience that helps people bounce back faster from difficulties. However, few studies have addressed issues in developing, implementing, and testing intervention strategies to promote emotional well-being among older adults. Intergenerational solidarity between grandparents and grandchildren has been emphasized in Asian families and is beneficial for the health of persons with dementia. Reminiscence and life review have been identified as potentially effective intervention strategies for helping depression and emotional well-being for older adults. Objective: This proposed study aims to develop and implement an intergenerational reminiscence approach and evaluate its potential feasibility and effectiveness in improving the emotional well-being of older Asian American adults who have a recent dementia diagnosis. Methods: An explanatory sequential mixed methods design will be used in which quantitative data will first be collected and analyzed to identify subsamples of participants who report the greatest and least change in emotional well-being; then, these subsamples will be interviewed to further understand why or why not this intervention works for them. Older adults will receive 6 sessions of life review with grandchildren in virtual reality (VR; 1-1.5 hours each week for 6 weeks), aided by pictures and virtually traveling to important places in their life using Google Earth to look around at those places and remember important times. Quantitative survey data will be collected pre- and postintervention and at a 3-month follow-up. Qualitative interviews with selected participants will also be integrated into the study design. The quantitative data from the surveys will be entered into SPSS (IBM Corp) and analyzed using descriptive analyses, Pearson chi-square tests, nonparametric Friedman tests, or nonparametric Wilcox signed-rank tests (2-tailed). The qualitative data will be transcribed by research assistants, coded by the investigators independently, and analyzed with guidance from content analysis software (Atlas.ti; Atlas.ti Scientific Software Development GmbH). Results: The project was delayed due to the COVID-19 pandemic. Data collection started in late 2021, and 26 participants were recruited as of December 2022. While we are still cleaning and analyzing the quantitative data, the qualitative interviews showed promising results of this intergenerational reminiscence approach in improving emotional well-being among older Asian American adults who have cognitive impairment. Conclusions: Intergenerational reminiscence provided by grandchildren is promising in improving the emotional well-being of grandparents. VR technology is likely to be accepted by older adults. Future research may consider scaling up this pilot into a trackable, replicable model that includes more participants and develops a more rigorous study design with control groups to test the effectiveness of this intervention for older adults with dementia. International Registered Report Identifier (IRRID): DERR1-10.2196/48927 ",
doi="10.2196/48927",
url="https://www.researchprotocols.org/2023/1/e48927",
url="http://www.ncbi.nlm.nih.gov/pubmed/37358895"
}


@Article{info:doi/10.2196/40236,
author="Seon, Quinta
and Mady, Noor
and Yang, Michelle
and Karia, Maharshee
and Lashley, Myrna
and Sescu, Claudia
and Lalonde, Maud
and Puskas, Stephen
and Outerbridge, Joy
and Parent-Racine, Echo
and Pagiatakis, Catherine
and Gomez-Cardona, Liliana
and Jiang, Di
and Bouchard, St{\'e}phane
and Linnaranta, Outi",
title="A Virtual Reality--Assisted Cognitive Behavioral Therapy for and With Inuit in Qu{\'e}bec: Protocol for a Proof-of-Concept Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2023",
month="May",
day="24",
volume="12",
pages="e40236",
keywords="Inuit health",
keywords="randomized controlled trial",
keywords="emotion regulation",
keywords="virtual reality",
keywords="cognitive behavioral therapy",
keywords="co-design",
keywords="biofeedback",
keywords="cultural adaptation",
keywords="Indigenous",
abstract="Background: Emotion regulation is an ability related to psychological well-being; when dysregulated, individuals may have psychiatric symptoms and maladapted physiological responses. Virtual reality--assisted cognitive behavioral therapy (VR-CBT) is an effective psychotherapy to target and strengthen emotion regulation; however, it currently lacks cultural sensitivity and can be improved by adapting it to the cultural context of service users. During previous participatory research, we co-designed a culturally adapted cognitive behavioral therapy (CBT) manual and 2 virtual reality (VR) environments to function as a complement to therapy (VR-CBT) for Inuit who would like to access psychotherapy. Emotion regulation skill building will occur in virtual environments that have interactive components such as heart rate biofeedback. Objective: We describe a protocol for a proof-of-concept 2-arm randomized controlled trial (RCT) with Inuit (n=40) in Qu{\'e}bec. The primary aims of this research are to investigate the feasibility, benefits, and challenges of the culturally adapted VR-CBT intervention versus an established VR self-management that is available commercially. We will also investigate self-rated mental well-being and objective psychophysiological measures. Finally, we will use proof-of-concept data to identify suitable primary outcome measures, conduct power calculations in a larger trial for efficacy, and collect information about preferences for on-site or at-home treatment. Methods: Trial participants will be randomly assigned to an active condition or active control condition in a 1:1 ratio. Inuit aged 14 to 60 years will receive a culturally adapted and therapist-guided VR-CBT with biofeedback or a VR relaxation program with nonpersonalized guided components over a 10-week period. We will collect pre- and posttreatment measures of emotion regulation and biweekly assessments over the treatment and at 3-month follow-up. The primary outcome will be measured by the Difficulties in Emotion Regulation Scale (DERS-16) and a novel psychophysiological reactivity paradigm. Secondary measures include psychological symptoms and well-being via rating scales (eg, anxiety or depressive symptoms). Results: As this is the prospective registration of an RCT protocol, we do not yet report any results from the trial. Funding was confirmed in January 2020, and recruitment is expected to start in March 2023 and is set to finish in August 2025. The expected results are to be published in spring 2026. Conclusions: The proposed study responds to the community's desire for accessible and appropriate resources for psychological well-being, as it was developed in active collaboration with the Inuit community in Qu{\'e}bec. We will test feasibility and acceptance by comparing a culturally adapted, on-site psychotherapy with a commercial self-management program while incorporating novel technology and measurement in the area of Indigenous health. We also aim to fulfill the needs for RCT evidence of culturally adapted psychotherapies that are lacking in Canada. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 21831510; https://www.isrctn.com/ISRCTN21831510 International Registered Report Identifier (IRRID): PRR1-10.2196/40236 ",
doi="10.2196/40236",
url="https://www.researchprotocols.org/2023/1/e40236",
url="http://www.ncbi.nlm.nih.gov/pubmed/37223973"
}


@Article{info:doi/10.2196/44632,
author="Dechsling, Anders
and Cogo-Moreira, Hugo
and Gangestad, Spydevold Jonathan
and Johannessen, Nettum Sandra
and Nordahl-Hansen, Anders",
title="Evaluating the Feasibility of Emotion Expressions in Avatars Created From Real Person Photos: Pilot Web-Based Survey of Virtual Reality Software",
journal="JMIR Form Res",
year="2023",
month="May",
day="11",
volume="7",
pages="e44632",
keywords="avatar",
keywords="emotion recognition",
keywords="emotion",
keywords="face",
keywords="facial expression",
keywords="facial",
keywords="images",
keywords="real images",
keywords="software",
keywords="virtual reality",
abstract="Background: The availability and potential of virtual reality (VR) has led to an increase of its application. VR is suggested to be helpful in training elements of social competence but with an emphasis on interventions being tailored. Recognizing facial expressions is an important social skill and thus a target for training. Using VR in training these skills could have advantages over desktop alternatives. Children with autism, for instance, appear to prefer avatars over real images when assessing facial expressions. Available software provides the opportunity to transform profile pictures into avatars, thereby giving the possibility of tailoring according to an individual's own environment. However, the emotions provided by such software should be validated before application. Objective: Our aim was to investigate whether available software is a quick, easy, and viable way of providing emotion expressions in avatars transformed from real images. Methods: A total of 401 participants from a general population completed a survey on the web containing 27 different images of avatars transformed, using a software, from real images. We calculated the reliability of each image and their level of difficulty using a structural equation modeling approach. We used Bayesian confirmatory factor analysis testing under a multidimensional first-order correlated factor structure where faces showing the same emotions represented a latent variable. Results: Few emotions were correctly perceived and rated as higher than other emotions. The factor loadings indicating the discrimination of the image were around 0.7, which means 49\% shared variance with the latent factor that the face is linked with. The standardized thresholds indicating the difficulty level of the images are mostly around average, and the highest correlation is between faces showing happiness and anger. Conclusions: Only using a software to transform profile pictures to avatars is not sufficient to provide valid emotion expressions. Adjustments are needed to increase faces' discrimination (eg, increasing reliabilities). The faces showed average levels of difficulty, meaning that they are neither very difficult nor very easy to perceive, which fits a general population. Adjustments should be made for specific populations and when applying this technology in clinical practice. ",
doi="10.2196/44632",
url="https://formative.jmir.org/2023/1/e44632",
url="http://www.ncbi.nlm.nih.gov/pubmed/37166970"
}


@Article{info:doi/10.2196/43240,
author="Lundin, M. Robert
and Yeap, Yuhern
and Menkes, B. David",
title="Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review",
journal="JMIR Ment Health",
year="2023",
month="May",
day="5",
volume="10",
pages="e43240",
keywords="virtual reality",
keywords="augmented reality",
keywords="mental health",
keywords="side effects",
keywords="adverse events",
keywords="hardware",
keywords="VR",
keywords="software",
keywords="AR",
keywords="cybersickness",
keywords="reporting standards",
abstract="Background: Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies. Objective: Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects. Methods: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses. Results: Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported ``no adverse effects'' but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever. Conclusions: An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported. ",
doi="10.2196/43240",
url="https://mental.jmir.org/2023/1/e43240",
url="http://www.ncbi.nlm.nih.gov/pubmed/37145841"
}


@Article{info:doi/10.2196/42523,
author="Langener, Simon
and Kolkmeier, Jan
and VanDerNagel, Joanne
and Klaassen, Randy
and van Manen, Jeannette
and Heylen, Dirk",
title="Development of an Alcohol Refusal Training in Immersive Virtual Reality for Patients With Mild to Borderline Intellectual Disability and Alcohol Use Disorder: Cocreation With Experts in Addiction Care",
journal="JMIR Form Res",
year="2023",
month="Apr",
day="26",
volume="7",
pages="e42523",
keywords="virtual reality",
keywords="conversational agent",
keywords="embodied agent",
keywords="persuasion",
keywords="peer pressure",
keywords="addiction",
keywords="alcohol",
keywords="intellectual disability",
abstract="Background: People with mild to borderline intellectual disability (MBID; IQ=50-85) are at risk for developing an alcohol use disorder (AUD). One factor contributing to this risk is sensitivity to peer pressure. Hence, tailored trainings are needed to practice alcohol refusal in impacted patients. Immersive virtual reality (IVR) appears promising to engage patients in dialogs with virtual humans, allowing to practice alcohol refusal realistically. However, requirements for such an IVR have not been studied for MBID/AUD. Objective: This study aims to develop an IVR alcohol refusal training for patients with MBID and AUD. In this work, we cocreated our peer pressure simulation with experienced experts in addiction care. Methods: We followed the Persuasive System Design (PSD) model to develop our IVR alcohol refusal training. With 5 experts from a Dutch addiction clinic for patients with MBID, we held 3 focus groups to design the virtual environment, persuasive virtual human(s), and persuasive dialog. Subsequently, we developed our initial IVR prototype and conducted another focus group to evaluate IVR and procedures for clinical usage, resulting in our final peer pressure simulation. Results: Our experts described visiting a friend at home with multiple friends as the most relevant peer pressure situation in the clinical setting. Based on the identified requirements, we developed a social-housing apartment with multiple virtual friends present. Moreover, we embedded a virtual man with generic appearance to exert peer pressure using a persuasive dialog. Patients can respond to persuasive attempts by selecting (refusal) responses with varying degrees of risk for relapse in alcohol use. Our evaluation showed that experts value a realistic and interactable IVR. However, experts identified lacking persuasive design elements, such as paralanguage, for our virtual human. For clinical usage, a user-centered customization is needed to prevent adverse effects. Further, interventions should be therapist delivered to avoid try-and-error in patients with MBID. Lastly, we identified factors for immersion, as well as facilitators and barriers for IVR accessibility. Conclusions: Our work establishes an initial PSD for IVR for alcohol refusal trainings in patients with MBID and AUD. With this, scholars can create comparable simulations by performing an analogous cocreation, replicate findings, and identify active PSD elements. For peer pressure, conveying emotional information in a virtual human's voice (eg, paralanguage) seems vital. However, previous rapport building may be needed to ensure that virtual humans are perceived as cognitively capable entities. Future work should validate our PSD with patients and start developing IVR treatment protocols using interdisciplinary teams. ",
doi="10.2196/42523",
url="https://formative.jmir.org/2023/1/e42523",
url="http://www.ncbi.nlm.nih.gov/pubmed/37099362"
}


@Article{info:doi/10.2196/44183,
author="Pardini, Susanna
and Gabrielli, Silvia
and Olivetto, Silvia
and Fusina, Francesca
and Dianti, Marco
and Forti, Stefano
and Lancini, Cristina
and Novara, Caterina",
title="Personalized, Naturalistic Virtual Reality Scenarios Coupled With Web-Based Progressive Muscle Relaxation Training for the General Population: Protocol for a Proof-of-Principle Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2023",
month="Apr",
day="17",
volume="12",
pages="e44183",
keywords="digital health",
keywords="progressive muscular relaxation technique",
keywords="mental well-being",
keywords="virtual reality therapy",
keywords="anxiety",
keywords="relaxation",
keywords="e-therapy",
keywords="e-Health",
keywords="virtual reality",
keywords="tool",
keywords="symptoms",
keywords="depression",
keywords="quality of life",
keywords="coping",
abstract="Background: Virtual reality (VR) is an innovative tool that can facilitate exposure to either stressful or relaxing stimuli and enables individuals who have difficulties visualizing scenes to be involved in a more realistic sensorimotor experience. It also facilitates multisensory stimulation, a sense of presence, and achievement of relaxation. VR scenarios representing visual and auditory elements of natural relaxing environments can facilitate the learning of relaxation techniques such as the progressive muscle relaxation technique (PMRT). A complementary standardized technique deployed to reduce anxiety symptoms is the integration of PMRT and guided imagery (GI). Exposure to a pleasant imaginary environment helps the establishment of an association between a relaxing scenario and the relaxation technique, consequently promoting relaxation. Empirical evidence has shown that VR scenarios can increase the effects of relaxation techniques by enabling people to experience emotional conditions in more vivid settings. Objective: The main aim of this pilot study protocol is to investigate the impact on state anxiety of PMRT, associated with a personalized relaxing scenario in VR, and the role of VR scenarios in facilitating the recall of relaxing images and a sense of presence. A secondary aim is to understand if relaxing sessions administered via Zoom are more effective for managing anxiety and stress than a procedural setting based on audio-track guidance. Methods: Based on a longitudinal, between-subject design, 108 university students will be randomly exposed to one of three experimental conditions: (1) PMRT via Zoom and GI exposure, (2) PMRT via Zoom and personalized VR exposure, and (3) PMRT based on audio-track guidance and personalized VR exposure. Individuals are assessed before and after 7 training sessions based on self-report questionnaires investigating anxiety, depression, quality of life, coping strategies, sense of presence, engagement, and side effects related to VR exposure. Heart rate data are also detected by an Mi Band 2 sensor. Results: The experimental procedure is ongoing. In this paper, preliminary data from a sample of 40 participants will be illustrated. The experimental phase is expected to conclude in May 2023, and the final results of the research will be presented in June 2023. Conclusions: The results of this study will help shape the experimental design to apply it on a subsequent randomized controlled trial, also considering clinical samples. This work is expected to measure whether VR is a more engaging and helpful technique in promoting relaxation and decreasing anxiety levels than GI, by making the visualization process easier and by helping people to face more realistic sensory experiences. Assessing the efficacy of the PMRT in alternative delivery modes may extend its applications, especially in situations where the standard procedure is more challenging to be administered. To our knowledge, no equivalent study has been published so far on this matter. Trial Registration: ClinicalTrials.gov NCT05478941; https://clinicaltrials.gov/ct2/show/NCT05478941 International Registered Report Identifier (IRRID): DERR1-10.2196/44183 ",
doi="10.2196/44183",
url="https://www.researchprotocols.org/2023/1/e44183",
url="http://www.ncbi.nlm.nih.gov/pubmed/37067881"
}


@Article{info:doi/10.2196/43904,
author="Hernandez Hernandez, Elena Maria
and Michalak, Erin
and Choudhury, Nusrat
and Hewko, Mark
and Torres, Ivan
and Menon, Mahesh
and Lam, W. Raymond
and Chakrabarty, Trisha",
title="Co-design of a Virtual Reality Cognitive Remediation Program for Depression (bWell-D) With Patient End Users and Clinicians: Qualitative Interview Study Among Patients and Clinicians",
journal="JMIR Serious Games",
year="2023",
month="Apr",
day="7",
volume="11",
pages="e43904",
keywords="depression",
keywords="cognitive remediation",
keywords="cognitive dysfunction",
keywords="thematic analysis",
keywords="virtual reality",
keywords="VR",
keywords="qualitative study",
keywords="user-centered design",
keywords="immersive",
keywords="co-design",
keywords="depressive",
keywords="mental health",
keywords="mental illness",
abstract="Background: Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction---a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation. Objective: This study aimed to develop the first prototype VR cognitive remediation program for MDD (``bWell-D''). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings. Methods: Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants' perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis. Results: End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid (ie, home and clinic) treatment modality was preferred. Conclusions: Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes. ",
doi="10.2196/43904",
url="https://games.jmir.org/2023/1/e43904",
url="http://www.ncbi.nlm.nih.gov/pubmed/37027183"
}


@Article{info:doi/10.2196/38256,
author="Guo, Qifan
and Zhang, LIMing
and Gui, Chenfan
and Chen, Guanghui
and Chen, Yi
and Tan, Huixin
and Su, Wei
and Zhang, Ruishi
and Gao, Qiang",
title="Virtual Reality Intervention for Patients With Neck Pain: Systematic Review and Meta-analysis of Randomized Controlled Trials",
journal="J Med Internet Res",
year="2023",
month="Apr",
day="3",
volume="25",
pages="e38256",
keywords="meta-analysis",
keywords="virtual reality",
keywords="neck pain",
keywords="disability",
keywords="systematic review",
abstract="Background: Neck pain is a prevalent condition that causes an enormous health care burden due to the lack of efficient therapies. As a promising technology, virtual reality (VR) has shown advantages in orthopedic rehabilitation. However, there is no meta-analysis evaluating the effectiveness of VR in neck pain management. Objective: This study aims to review original randomized controlled trials (RCTs) evaluating the effectiveness of VR for neck pain and to provide evidence for the clinical application of a new alternative approach for pain management. Methods: A total of 9 electronic databases were systematically searched for relevant articles published from inception to October 2022. RCTs in English or Chinese that investigated VR therapy for participants with neck pain were included. The methodological quality and the evidence level were assessed using the Cochrane Back and Neck Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guideline, respectively. Results: A total of 8 studies with 382 participants were included for the final analysis. For the pain intensity, the overall pooled effect size was 0.51, with a standardized mean difference (SMD) of ?0.51 (95\% CI ?0.91 to ?0.11; GRADE: moderate), favoring VR therapy compared with controls. Subgroups analyses revealed that significant differences in pain intensity were found in the multimodal intervention (VR in combination with other therapies) than in other interventions (SMD ?0.45, 95\% CI ?0.78 to ?0.13; GRADE: moderate), and better analgesic effects were also observed in patients with chronic neck pain receiving VR intervention (SMD ?0.70, 95\% CI ?1.08 to ?0.32; GRADE: moderate) and patients treated in the clinic or research unit (SMD ?0.52, 95\% CI ?0.99 to ?0.05; GRADE: moderate) than controls. Regarding other health outcomes, the VR experienced less disability, lower kinesiophobia, and greater kinematic function (cervical range of motion, mean and peak velocity). Nevertheless, the follow-up effects of VR therapy on pain intensity and disability were not found. Conclusions: Existing moderate evidence support VR as a beneficial nonpharmacological approach to improve pain intensity in patients with neck pain, with advantages to multimodal intervention, people with chronic neck pain, and clinic or research unit--based VR therapy. However, the limited quantity and high heterogeneity of the articles limit our findings. Trial Registration: PROSPERO CRD42020188635; https://tinyurl.com/2839jh8w ",
doi="10.2196/38256",
url="https://www.jmir.org/2023/1/e38256",
url="http://www.ncbi.nlm.nih.gov/pubmed/37010891"
}


@Article{info:doi/10.2196/38619,
author="Le Du, Katell
and Septans, Anne-Lise
and Maloisel, Fr{\'e}d{\'e}ric
and Vanquaethem, H{\'e}l{\`e}ne
and Schmitt, Anna
and Le Goff, Marielle
and Clavert, Aline
and Zinger, Marie
and Bourgeois, Hugues
and Dupuis, Olivier
and Denis, Fabrice
and Bouchard, St{\'e}phane",
title="A New Option for Pain Prevention Using a Therapeutic Virtual Reality Solution for Bone Marrow Biopsy (REVEH Trial): Open-Label, Randomized, Multicenter, Phase 3 Study",
journal="J Med Internet Res",
year="2023",
month="Feb",
day="15",
volume="25",
pages="e38619",
keywords="virtual reality",
keywords="VR",
keywords="bone marrow",
keywords="biopsy",
keywords="pain",
keywords="digital therapeutics",
keywords="digital health",
keywords="eHealth",
keywords="RCT",
keywords="randomized controlled trial",
keywords="clinical trial",
keywords="distraction",
keywords="imagery",
keywords="imagination",
keywords="imaginary",
keywords="immersive environment",
keywords="interactive environment",
keywords="head-mounted display",
keywords="medical procedure",
keywords="satisfaction",
keywords="safety",
keywords="efficacy",
keywords="effectiveness",
abstract="Background: Evidence regarding the analgesic effect of distraction through immersion in virtual reality (VR) for care-induced pain has been documented in several phase 2 trials, but comparison with standard treatments in large, randomized studies is needed. Objective: In this open-label, multicenter, randomized, phase 3 trial, we evaluated the safety and efficacy of a novel VR therapy solution for distraction in the context of bone marrow biopsy. Methods: Bliss is a VR software with 4 imaginary interactive environments in 3 dimensions with binaural sound (head-mounted display). Efficacy regarding pain intensity was evaluated using a visual analog scale (VAS; score from 0 to 10) immediately after the biopsy. Secondary end points were anxiety and tolerance. Modified intention-to-treat analysis was performed. Results: Overall, 126 patients with previously documented untreated or suspected malignant hemopathy between September 6, 2018, and May 18, 2020, were randomly assigned in a 1:1 ratio to receive pain prevention with a mixture of nitrous oxide/oxygen (MEOPA; n=63) or VR (n=63) before and during the bone marrow biopsy. We excluded 8 patients from the final analysis (3 in the MEOPA group and 5 in the VR group). All patients received local anesthesia (lidocaine) before biopsy. Follow-up was limited to 1 month after the biopsy. Participants' median age was 65.5 (range 18-87) years, and 54.2\% (64/118) of patients were male. The average pain intensity was 3.5 (SD 2.6, 95\% CI --1.6 to 8.6) for the MEOPA group and 3.0 (SD 2.4, 95\% CI --1.7 to 7.7) for the VR group, without any significant differences in age, sex, center, and hemopathy (P=.26). Concerning anxiety, 67.5\% (79/117; fear of pain questionnaire) of the patients were afraid before the biopsy, and anxiety scores were moderate to very high in 26.3\% (30/114; revised Spielberger State-Trait Anxiety Inventory questionnaire) of the patients before the biopsy and 9.0\% (10/114) after the biopsy for all patients, without a significant difference between the 2 groups (P=.83). Immersion in VR was well tolerated by the majority (54/57, 95\%) of patients in the VR group. Conclusions: The intensity of pain did not significantly differ between both arms. VR was well tolerated, and the satisfaction of patients, nurses, and physicians was very high. VR could be an alternative treatment in case of contraindication or intolerance to MEOPA. Trial Registration: ClinicalTrials.gov NCT03483194; https://clinicaltrials.gov/ct2/show/NCT03483194 ",
doi="10.2196/38619",
url="https://www.jmir.org/2023/1/e38619",
url="http://www.ncbi.nlm.nih.gov/pubmed/36790852"
}


@Article{info:doi/10.2196/41523,
author="Gray, Gabrielle Hannah
and Tchao, Danielle
and Lewis-Fung, Samantha
and Pardini, Susanna
and Harris, R. Laurence
and Appel, Lora",
title="Virtual Reality Therapy for People With Epilepsy and Related Anxiety: Protocol for a 3-Phase Pilot Clinical Trial",
journal="JMIR Res Protoc",
year="2023",
month="Jan",
day="24",
volume="12",
pages="e41523",
keywords="epilepsy",
keywords="anxiety",
keywords="virtual reality",
keywords="exposure therapy",
keywords="eHealth",
keywords="digital health",
keywords="virtual reality exposure therapy",
keywords="cognitive behavioral therapy",
keywords="CBT",
keywords="nonpharmacological intervention",
keywords="biomedical technology",
abstract="Background: Anxiety is one of the most common psychiatric comorbidities in people with epilepsy and often involves fears specifically related to the condition, such as anxiety related to the fear of having another seizure. These epilepsy- or seizure-related fears have been reported as being more disabling than the seizures themselves and significantly impact quality of life. Although research has suggested that exposure therapy (ET) is helpful in decreasing anxiety in people with epilepsy, no research to our knowledge has been conducted on ET in people with epilepsy using virtual reality (VR). The use of novel technologies such as an immersive VR head-mounted display for ET in this population offers several benefits. Indeed, using VR can increase accessibility for people with epilepsy with transportation barriers (eg, those who live outside urban centers or who have a suspended driver's license owing to their condition), among other advantages. In the present research protocol, we describe the design of an innovative VR-ET program administered in the home that focuses on decreasing anxiety in people with epilepsy, specifically anxiety related to their epilepsy or seizures. Objective: Our primary objective is to examine the feasibility of the study protocol and proposed treatment as well as identify suggestions for improvement when designing subsequent larger clinical trials. Our secondary objective is to evaluate whether VR-ET is effective in decreasing anxiety in a pilot study. We hypothesize that levels of anxiety in people with epilepsy will decrease from using VR-ET. Methods: This mixed methods study comprises 3 phases. Phase 1 involves engaging with those with lived experience through a web-based questionnaire to validate assumptions about anxiety in people with epilepsy. Phase 2 involves filming videos using a 360{\textdegree} camera for the VR-ET intervention (likely consisting of 3 sets of scenes, each with 3 intensity levels) based on the epilepsy- and seizure-related fears most commonly reported in the phase 1 questionnaire. Finally, phase 3 involves evaluating the at-home VR-ET intervention and study methods using a series of validated scales, as well as semistructured interviews. Results: This pilot study was funded in November 2021. Data collection for phase 1 was completed as of August 7, 2022, and had a final sample of 18 participants. Conclusions: Our findings will add to the limited body of knowledge on anxiety in people with epilepsy and the use of VR in this population. We anticipate that the insights gained from this study will lay the foundation for a novel and accessible VR intervention for this underrecognized and undertreated comorbidity in people with epilepsy. Trial Registration: ClinicalTrials.gov NCT05296057; https://clinicaltrials.gov/ct2/show/NCT05296057 International Registered Report Identifier (IRRID): DERR1-10.2196/41523 ",
doi="10.2196/41523",
url="https://www.researchprotocols.org/2023/1/e41523",
url="http://www.ncbi.nlm.nih.gov/pubmed/36692939"
}


@Article{info:doi/10.2196/41080,
author="van Spaendonck, Zita
and Leeuwenburgh, Pieter Koen
and Dremmen, Marjolein
and van Schuppen, Joost
and Starreveld, Dani{\"e}lle
and Dierckx, Bram
and Legerstee, S. Jeroen",
title="Comparing Smartphone Virtual Reality Exposure Preparation to Care as Usual in Children Aged 6 to 14 Years Undergoing Magnetic Resonance Imaging: Protocol for a Multicenter, Observer-Blinded, Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2023",
month="Jan",
day="24",
volume="12",
pages="e41080",
keywords="virtual reality",
keywords="VR",
keywords="children",
keywords="anxiety",
keywords="magnetic resonance imaging",
keywords="MRI",
keywords="MRI scans",
keywords="imaging",
keywords="randomized controlled trial",
keywords="MRI preparation",
keywords="smartphone virtual reality",
keywords="smartphone intervention",
keywords="procedural anxiety",
keywords="psychosocial intervention",
abstract="Background: A magnetic resonance imaging (MRI) procedure can cause preprocedural and periprocedural anxiety in children. Psychosocial interventions are used to prepare children for the procedure to alleviate anxiety, but these interventions are time-consuming and costly, limiting their clinical use. Virtual reality (VR) is a promising way to overcome these limitations in the preparation of children before an MRI scan. Objective: The objective of this study is (1) to develop a VR smartphone intervention to prepare children at home for an MRI procedure; and (2) to examine the effect of the VR intervention in a randomized controlled trial, in which the VR intervention will be compared to care as usual (CAU). CAU involves an information letter about an MRI examination. The primary outcome is the child's procedural anxiety during the MRI procedure. Secondary outcomes include preprocedural anxiety and parental anxiety. We hypothesize that the VR preparation will result in a higher reduction of the periprocedural anxiety of both parents and children as compared to CAU. Methods: The VR intervention provides a highly realistic and child-friendly representation of an MRI environment. In this randomized controlled trial, 128 children (aged 6 to 14 years) undergoing an MRI scan will be randomly allocated to the VR intervention or CAU. Children in the VR intervention will receive a log-in code for the VR app and are sent cardboard VR glasses. Results: The VR smartphone preparation app was developed in 2020. The recruitment of participants is expected to be completed in December 2022. Data will be analyzed, and scientific papers will be submitted for publication in 2023. Conclusions: The VR smartphone app is expected to significantly reduce pre- and periprocedural anxiety in pediatric patients undergoing an MRI scan. The VR app offers a realistic and child-friendly experience that can contribute to modern care. A smartphone version of the VR app has the advantage that children, and potentially their parents, can get habituated to the VR environment and noises in their own home environment and can do this VR MRI preparation as often and as long as needed. Trial Registration: ISRCTN Registry ISRCTN20976625; https://www.isrctn.com/ISRCTN20976625 International Registered Report Identifier (IRRID): DERR1-10.2196/41080 ",
doi="10.2196/41080",
url="https://www.researchprotocols.org/2023/1/e41080",
url="http://www.ncbi.nlm.nih.gov/pubmed/36692931"
}


@Article{info:doi/10.2196/40582,
author="Shu, Sara
and Woo, P. Benjamin K.",
title="Pioneering the Metaverse: The Role of the Metaverse in an Aging Population",
journal="JMIR Aging",
year="2023",
month="Jan",
day="20",
volume="6",
pages="e40582",
keywords="metaverse",
keywords="older adult",
keywords="aging in place",
keywords="dementia",
keywords="gerontology",
keywords="geriatric",
keywords="digital health",
keywords="digital technology",
keywords="computer generated",
keywords="artificial intelligence",
keywords="virtual reality",
keywords="mixed reality",
keywords="augmented reality",
keywords="aging",
keywords="mental health",
doi="10.2196/40582",
url="https://aging.jmir.org/2023/1/e40582",
url="http://www.ncbi.nlm.nih.gov/pubmed/36662547"
}


@Article{info:doi/10.2196/38065,
author="Bond, Jessica
and Kenny, Alexandra
and Pinfold, Vanessa
and Couperthwaite, Lisa
and 
and Kabir, Thomas
and Larkin, Michael
and Beckley, Ariane
and Rosebrock, Laina
and Lambe, Sin{\'e}ad
and Freeman, Daniel
and Waite, Felicity
and Robotham, Dan",
title="A Safe Place to Learn: Peer Research Qualitative Investigation of gameChange Virtual Reality Therapy",
journal="JMIR Serious Games",
year="2023",
month="Jan",
day="16",
volume="11",
pages="e38065",
keywords="peer research",
keywords="lived experience",
keywords="qualitative methods",
keywords="interpretative phenomenological analysis",
keywords="IPA",
keywords="anxiety",
keywords="psychosis",
keywords="virtual reality",
keywords="VR",
keywords="cognitive therapy",
keywords="automated",
keywords="implementation",
abstract="Background: Automated virtual reality (VR) therapy has the potential to substantially increase access to evidence-based psychological treatments. The results of a multicenter randomized controlled trial showed that gameChange VR cognitive therapy reduces the agoraphobic avoidance of people diagnosed with psychosis, especially for those with severe avoidance. Objective: We set out to use a peer research approach to explore participants' experiences with gameChange VR therapy. This in-depth experiential exploration of user experience may inform the implementation in clinical services and future VR therapy development. Methods: Peer-led semistructured remote interviews were conducted with 20 people with a diagnosis of psychosis who had received gameChange as part of the clinical trial (ISRCTN17308399). Data were analyzed using interpretative phenomenological analysis and template analyses. A multiperspectival approach was taken to explore subgroups. Credibility checks were conducted with the study Lived Experience Advisory Panel. Results: Participants reported the substantial impact of anxious avoidance on their lives before the VR intervention, leaving some of them housebound and isolated. Those who were struggling the most with agoraphobic avoidance expressed the most appreciation for, and gains from, the gameChange therapy. The VR scenarios provided ``a place to practise.'' Immersion within the VR scenarios triggered anxiety, yet participants were able to observe this and respond in different ways than usual. The ``security of knowing the VR scenarios are not real'' created a safe place to learn about fears. The ``balance of safety and anxiety'' could be calibrated to the individual. The new learning made in VR was ``taken into the real world'' through practice and distilling key messages with support from the delivery staff member. Conclusions: Automated VR can provide a therapeutic simulation that allows people diagnosed with psychosis to learn and embed new ways of responding to the situations that challenge them. An important process in anxiety reduction is enabling the presentation of stimuli that induce the original anxious fears yet allow for learning of safety. In gameChange, the interaction of anxiety and safety could be calibrated to provide a safe place to learn about fears and build confidence. This navigation of therapeutic learning can be successfully managed by patients themselves in an automated therapy, with staff support, that provides users with personalized control. The clinical improvements for people with severe anxious avoidance, the positive experience of VR, and the maintenance of a sense of control are likely to facilitate implementation. ",
doi="10.2196/38065",
url="https://games.jmir.org/2023/1/e38065",
url="http://www.ncbi.nlm.nih.gov/pubmed/36645707"
}


@Article{info:doi/10.2196/43203,
author="Hsieh, Pei-Lun
and Wang, Yu-Rung
and Huang, Tien-Chi",
title="Exploring Key Factors Influencing Nursing Students' Cognitive Load and Willingness to Serve Older Adults: Cross-sectional Descriptive Correlational Study",
journal="JMIR Serious Games",
year="2023",
month="Jan",
day="4",
volume="11",
pages="e43203",
keywords="immersive virtual reality learning",
keywords="VR learning",
keywords="mental effort",
keywords="mental load",
keywords="service willingness",
keywords="older adult",
keywords="virtual reality",
keywords="nursing student",
keywords="professional education",
keywords="digital learning",
keywords="older adult population",
abstract="Background: Virtual learning environments (VLEs) use a virtual environment to support learning activities. VLEs are commonly used to overcome the temporal and spatial restrictions of learning activities held in conventional face-to-face classrooms. In VLEs, students can participate in learning activities using the internet, and teachers can provide assistive learning tools during the process. Objective: The purpose of this study was to investigate the relationships among nursing students' mental load, cognitive load, and affective learning outcomes in terms of their willingness to serve older adults in an interaction-based educational virtual reality (VR) learning environment. Methods: This study used a cross-sectional method. A total of 130 students participated in interaction-based VR learning and completed related questionnaires. Descriptive and inferential statistics and stepwise regression for data analysis were used. Results: The research results revealed that in the dimension of willingness to use VR learning materials, perceived usefulness received the highest score (mean 4.42, SD 0.45). In the dimension of nursing ability, students scored the highest in information management and application ability to care for case patients (mean 4.35, SD 0.54). Correlation analysis revealed that cognitive load during learning and willingness to serve older adults were negatively correlated, whereas willingness to use VR learning materials was positively correlated with nursing ability and willingness to serve older adults. Analyzing the regression coefficients of predictor variables revealed that willingness to use VR learning materials ($\beta$=.23; t2=2.89, P=.005) and cognitive load during learning ($\beta$=--.35; t2=--.4.30, P<.001) were predictive factors of nursing students' willingness to serve older adults. Conclusions: This study demonstrated that students' willingness to use VR learning materials and their cognitive load during learning affected their willingness to care for older adults. Therefore, the components of mental or cognitive load generate inconsistent predictive effects on affective variables and willingness to serve older adults. ",
doi="10.2196/43203",
url="https://games.jmir.org/2023/1/e43203",
url="http://www.ncbi.nlm.nih.gov/pubmed/36333104"
}


@Article{info:doi/10.2196/39966,
author="Langener, Simon
and Klaassen, Randy
and VanDerNagel, Joanne
and Heylen, Dirk",
title="Immersive Virtual Reality Avatars for Embodiment Illusions in People With Mild to Borderline Intellectual Disability: User-Centered Development and Feasibility Study",
journal="JMIR Serious Games",
year="2022",
month="Dec",
day="7",
volume="10",
number="4",
pages="e39966",
keywords="virtual reality",
keywords="VR",
keywords="embodiment",
keywords="avatar",
keywords="embodied learning",
keywords="body-centered",
keywords="intellectual disability",
keywords="addiction",
keywords="user-centered design",
abstract="Background: Immersive virtual reality (IVR) has been investigated as a tool for treating psychiatric conditions. In particular, the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID; IQ=50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (ie, avatar) appears promising for enhancing learning (eg, by changing perspectives) and usability (eg, natural interactions). However, design requirements, immersion procedures, and proof of concept of such embodiment illusion (ie, substituting the real body with a virtual one) have not been explored in this group. Objective: Our study aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored 3 factors to induce the illusion, by testing the avatar's appearance, locomotion using IVR controllers, and virtual object manipulation. Furthermore, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. Methods: We conducted a user-centered study with 29 end users in care facilities, to investigate the avatar's appearance, controller-based locomotion (ie, teleport, joystick, or hybrid), and object manipulation. Overall, 3 iterations were conducted using semistructured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the sense of embodiment (SoE) during 5 interaction tasks. Results: IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants' desire to replicate their own body image. Similarly, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notably, interactions that are implausible (eg, teleport and occlusions when grabbing) showed a negative influence on SoE. In contrast, implementing artificial interaction aids into the IVR avatar's hands (ie, for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (eg, motion sickness), possibly hindering uptake in practice. Conclusions: Balancing the embodiment immersion by focusing on interaction habituation (eg, controller-based locomotion) and lowering customization effort seems crucial to achieve both high SoE and usability for people with MBID. Hence, future studies should investigate the requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (eg, animations, physics-based collision, and touch) and other interaction techniques (eg, hand tracking and redirected walking). In addition, procedures and use for learning should be explored for tailored mental health therapies in people with MBID. ",
doi="10.2196/39966",
url="https://games.jmir.org/2022/4/e39966",
url="http://www.ncbi.nlm.nih.gov/pubmed/36476721"
}


@Article{info:doi/10.2196/40056,
author="Mayer, Gwendolyn
and Gronewold, Nadine
and Polte, Kirsten
and Hummel, Svenja
and Barniske, Joshua
and Korbel, J. Jakob
and Zarnekow, R{\"u}diger
and Schultz, Jobst-Hendrik",
title="Experiences of Patients and Therapists Testing a Virtual Reality Exposure App for Symptoms of Claustrophobia: Mixed Methods Study",
journal="JMIR Ment Health",
year="2022",
month="Dec",
day="5",
volume="9",
number="12",
pages="e40056",
keywords="virtual reality",
keywords="exposure therapy",
keywords="anxiety disorders",
keywords="claustrophobia",
keywords="think-aloud",
keywords="mixed methods",
keywords="virtual reality exposure therapy",
keywords="VR",
keywords="anxiety",
keywords="therapy",
keywords="mental health",
keywords="user experience",
keywords="perspective",
abstract="Background: The effectiveness of virtual reality exposure (VRE) in the treatment of anxiety disorders is well established. Several psychological mechanisms of VRE have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge of examples of implementation in the case of VRE for claustrophobia based on patients' experiences and the perspective of therapists. Objective: This study asks for key elements of a VRE app that are necessary for effective exposure for people with claustrophobic symptoms. Methods: A mixed methods design was applied in which patients (n=15) and therapeutic experts (n=15) tested a VRE intervention of an elevator ride at 5 intensity levels. Intensity was varied by elevator size, duration of the elevator ride, and presence of virtual humans. Quantitative measures examined self-reported presence with the Igroup Presence Questionnaire (IPQ) ranging from 0 to 6 and 15 Likert-scaled evaluation items that had been developed for the purpose of this study, ranging from 1 to 5. In both measures, higher scores indicate higher levels of presence or agreement. Think-aloud protocols of the patients and semistructured interviews posttreatment of all participants were conducted to gain in-depth perspectives on emotional processes. Results: The intervention induced a feeling of presence in patients and experts, posttreatment scores showed a high IPQ presence score (mean 3.84, SD 0.88), with its subscores IPQ spatial presence (mean 4.53, SD 1.06), IPQ involvement (mean 3.83, SD 1.22), and IPQ experienced realism (mean 2.75, SD 1.02). Patients preferred a setting in the presence of a therapist (mean 4.13, SD 0.83) more than the experts did (mean 3.33, SD 1.54). Think-aloud protocols of the patients revealed that presence and anxiety both were achieved. Qualitative interviews of patients and experts uncovered 8 topics: feelings and emotions, personal story, telepresence, potential therapeutic effects, barriers, conditions and requirements, future prospects, and realization. The intensity levels were felt to appropriately increase in challenge, with ambivalent results regarding the final level. Virtual humans contributed to feelings of fear. Conclusions: Key elements of a VRE app for claustrophobic symptoms should include variation of intensity by adding challenging cues in order to evoke presence and anxiety. Virtual humans are a suitable possibility to make the intervention realistic and to provide a sense of closeness; however, some of the fears might then be related to symptoms of social phobia or agoraphobia. Patients may need the physical presence of a therapist, though not all of them share this view. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety. ",
doi="10.2196/40056",
url="https://mental.jmir.org/2022/12/e40056",
url="http://www.ncbi.nlm.nih.gov/pubmed/36469413"
}


@Article{info:doi/10.2196/39248,
author="Altunkaya, James
and Craven, Michael
and Lambe, Sin{\'e}ad
and Beckley, Ariane
and Rosebrock, Laina
and Dudley, Robert
and Chapman, Kate
and Morrison, Anthony
and O'Regan, Eileen
and Grabey, Jenna
and Bergin, Aislinn
and Kabir, Thomas
and Waite, Felicity
and Freeman, Daniel
and Leal, Jos{\'e}",
title="Estimating the Economic Value of Automated Virtual Reality Cognitive Therapy for Treating Agoraphobic Avoidance in Patients With Psychosis: Findings From the gameChange Randomized Controlled Clinical Trial",
journal="J Med Internet Res",
year="2022",
month="Nov",
day="18",
volume="24",
number="11",
pages="e39248",
keywords="gameChange",
keywords="virtual reality",
keywords="National Health Service",
keywords="NHS",
keywords="cost-effectiveness",
keywords="economic evaluation",
keywords="maximum price",
abstract="Background: An automated virtual reality cognitive therapy (gameChange) has demonstrated its effectiveness to treat agoraphobia in patients with psychosis, especially for high or severe anxious avoidance. Its economic value to the health care system is not yet established. Objective: In this study, we aimed to estimate the potential economic value of gameChange for the UK National Health Service (NHS) and establish the maximum cost-effective price per patient. Methods: Using data from a randomized controlled trial with 346 patients with psychosis (ISRCTN17308399), we estimated differences in health-related quality of life, health and social care costs, and wider societal costs for patients receiving virtual reality therapy in addition to treatment as usual compared with treatment as usual alone. The maximum cost-effective prices of gameChange were calculated based on UK cost-effectiveness thresholds. The sensitivity of the results to analytical assumptions was tested. Results: Patients allocated to gameChange reported higher quality-adjusted life years (0.008 QALYs, 95\% CI --0.010 to 0.026) and lower NHS and social care costs (--{\textsterling}105, 95\% CI --{\textsterling}1135 to {\textsterling}924) compared with treatment as usual ({\textsterling}1=US \$1.28); however, these differences were not statistically significant. gameChange was estimated to be worth up to {\textsterling}341 per patient from an NHS and social care (NHS and personal social services) perspective or {\textsterling}1967 per patient from a wider societal perspective. In patients with high or severe anxious avoidance, maximum cost-effective prices rose to {\textsterling}877 and {\textsterling}3073 per patient from an NHS and personal social services perspective and societal perspective, respectively. Conclusions: gameChange is a promising, cost-effective intervention for the UK NHS and is particularly valuable for patients with high or severe anxious avoidance. This presents an opportunity to expand cost-effective psychological treatment coverage for a population with significant health needs. Trial Registration: ISRCTN Registry ISRCTN17308399; https://www.isrctn.com/ISRCTN17308399 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2019-031606 ",
doi="10.2196/39248",
url="https://www.jmir.org/2022/11/e39248",
url="http://www.ncbi.nlm.nih.gov/pubmed/36399379"
}


@Article{info:doi/10.2196/42651,
author="Lai, Byron
and Davis, Drew
and Young, Raven
and Swanson-Kimani, Erin
and Wozow, Cynthia
and Chaviano, Kelli
and Rimmer, H. James",
title="Group Telegaming Through Immersive Virtual Reality to Improve Mental Health Among Adolescents With Physical Disabilities: Pre- and Posttrial Protocol",
journal="JMIR Res Protoc",
year="2022",
month="Oct",
day="13",
volume="11",
number="10",
pages="e42651",
keywords="disability",
keywords="physical activity",
keywords="active video gaming",
keywords="mindfulness",
abstract="Background: Adolescents with physical disabilities have higher rates of mental health conditions and issues than adolescents without disabilities, and this disparity was exacerbated by the onset of the COVID-19 pandemic. They also have limited access to on-site programs and nearby peers. Objective: This pilot aims to investigate the potential effects of a low-dose multiplayer virtual reality telegaming program on depression, socialization, and loneliness among a cohort of children with physical disabilities. A secondary aim is to describe feasibility metrics, namely, recruitment and adherence rates and perceived program enjoyment and satisfaction. The tertiary aim is to describe behavioral mechanisms that affect participant adherence and social participation in the classes. Methods: This study is a single-group pre- and posttest--designed trial. A single cohort of 12 children with physical disabilities will pilot a 1-month program that includes 2 supervised 1-hour sessions per week of group-based exergaming. Participants will complete questionnaires before and after the program. The primary aim measures will include the Children's Depression Inventory 2 Short Form, a measure of feelings of depression, and the UCLA Loneliness Scale, a measure of both loneliness and social isolation. Secondary aim measures will include three posttest Likert scale questionnaires: perceived program enjoyment, program satisfaction, and satisfaction with multiplayer experiences. At postintervention or dropout, participants will undergo semistructured interviews to identify behavioral mechanisms that underlie participation. Data will be reported descriptively and be supported by t tests as appropriate. Results: Recruitment procedures started in July 2022. All data are expected to be collected by January 2023. Full trial results are expected to be published by March 2023. Secondary analyses of data will be subsequently published. Conclusions: This trial tests a peer-to-peer virtual reality telegaming program that includes a completely remote enrollment, assessment, and intervention protocol. This program is accessible and short in duration and frequency, allowing it to be integrated into other interventions. Knowledge obtained from this study will inform the development of a larger trial for improving the mental health and well-being of adolescents with physical disabilities. Trial Registration: ClinicalTrials.gov NCT05259462; https://clinicaltrials.gov/ct2/show/NCT05259462 International Registered Report Identifier (IRRID): PRR1-10.2196/42651 ",
doi="10.2196/42651",
url="https://www.researchprotocols.org/2022/10/e42651",
url="http://www.ncbi.nlm.nih.gov/pubmed/36194864"
}


@Article{info:doi/10.2196/38284,
author="Chun, Young Joo
and Kim, Hyun-Jin
and Hur, Ji-Won
and Jung, Dooyoung
and Lee, Heon-Jeong
and Pack, Pil Seung
and Lee, Sungkil
and Kim, Gerard
and Cho, Chung-Yean
and Lee, Seung-Moo
and Lee, Hyeri
and Choi, Seungmoon
and Cheong, Taesu
and Cho, Chul-Hyun",
title="Prediction of Specific Anxiety Symptoms and Virtual Reality Sickness Using In Situ Autonomic Physiological Signals During Virtual Reality Treatment in Patients With Social Anxiety Disorder: Mixed Methods Study",
journal="JMIR Serious Games",
year="2022",
month="Sep",
day="16",
volume="10",
number="3",
pages="e38284",
keywords="social anxiety",
keywords="virtual reality",
keywords="autonomic physiological signals",
keywords="machine learning",
keywords="virtual reality sickness",
abstract="Background: Social anxiety disorder (SAD) is the fear of social situations where a person anticipates being evaluated negatively. Changes in autonomic response patterns are related to the expression of anxiety symptoms. Virtual reality (VR) sickness can inhibit VR experiences. Objective: This study aimed to predict the severity of specific anxiety symptoms and VR sickness in patients with SAD, using machine learning based on in situ autonomic physiological signals (heart rate and galvanic skin response) during VR treatment sessions. Methods: This study included 32 participants with SAD taking part in 6 VR sessions. During each VR session, the heart rate and galvanic skin response of all participants were measured in real time. We assessed specific anxiety symptoms using the Internalized Shame Scale (ISS) and the Post-Event Rumination Scale (PERS), and VR sickness using the Simulator Sickness Questionnaire (SSQ) during 4 VR sessions (\#1, \#2, \#4, and \#6). Logistic regression, random forest, and na{\"i}ve Bayes classification classified and predicted the severity groups in the ISS, PERS, and SSQ subdomains based on in situ autonomic physiological signal data. Results: The severity of SAD was predicted with 3 machine learning models. According to the F1 score, the highest prediction performance among each domain for severity was determined. The F1 score of the ISS mistake anxiety subdomain was 0.8421 using the logistic regression model, that of the PERS positive subdomain was 0.7619 using the na{\"i}ve Bayes classifier, and that of total VR sickness was 0.7059 using the random forest model. Conclusions: This study could predict specific anxiety symptoms and VR sickness during VR intervention by autonomic physiological signals alone in real time. Machine learning models can predict the severe and nonsevere psychological states of individuals based on in situ physiological signal data during VR interventions for real-time interactive services. These models can support the diagnosis of specific anxiety symptoms and VR sickness with minimal participant bias. Trial Registration: Clinical Research Information Service KCT0003854; https://cris.nih.go.kr/cris/search/detailSearch.do/13508 ",
doi="10.2196/38284",
url="https://games.jmir.org/2022/3/e38284",
url="http://www.ncbi.nlm.nih.gov/pubmed/36112407"
}


@Article{info:doi/10.2196/38490,
author="Preston, M. A'mie
and Brown, Lana
and Padala, P. Kalpana
and Padala, R. Prasad",
title="Veterans Affairs Health Care Provider Perceptions of Virtual Reality: Brief Exploratory Survey",
journal="Interact J Med Res",
year="2022",
month="Sep",
day="2",
volume="11",
number="2",
pages="e38490",
keywords="virtual reality",
keywords="older adults",
keywords="provider perception",
abstract="Background: Virtual reality (VR), a simulated experience that can be similar to or completely different from the real world, has become increasingly useful within the psychiatric and medical fields. This VR technology has been applied in medical school trainings, exposure therapy for individuals with posttraumatic stress disorder (PTSD), and reminiscence therapy associated with mood disorders for older adults. Perceptions of VR through the lens of the health care provider require further exploration. VR has grown in popularity; however, this modality continues to be underused in most Veterans Affairs (VA) hospitals. Objective: A web-based survey was used to explore health care provider perceptions of immersive VR availability and use for older adults and identify potential barriers for immersive VR use in older adults with cognitive impairment. Methods: An 8-item web-based survey was developed to obtain health care provider feedback. This survey was disseminated throughout a single Veterans Integrated Services Network (VISN). The VR survey was developed via the Survey Monkey platform and distributed through the secure VA email network. Providers were asked to voluntarily participate in the brief, anonymous survey and offer their perceptions of immersive VR use within their patient population. Survey data were reviewed and interpreted using descriptive statistics. Results: A total of 49 respondents completed the survey over a 15-day period. Of them, 36 respondents (73\%) had heard of a VR device, though the majority (n=44, 90\%) had never used or prescribed a VR device. Respondents identified several potential barriers to immersive VR use in older adults with cognitive impairment (eg, hearing difficulties, perceptions of technology, cognitive concerns, access to resources, and visual impairment). Despite the barriers identified, providers (n=48, 98\%) still reported that they would feel comfortable prescribing immersive VR as an intervention for their patient population. Conclusions: Survey findings revealed that health care providers within this VISN for VAs have heard of VR, although they may not have actively engaged in its use. Most of the providers reported that they would prescribe the use of an immersive VR intervention for their older adult patients. This key point highlights the desire to implement VR strategies for patient use by their providers. If underlying barriers can be addressed and relatively resolved, this technological intervention has the potential to create substantial breakthroughs in clinical care. ",
doi="10.2196/38490",
url="https://www.i-jmr.org/2022/2/e38490",
url="http://www.ncbi.nlm.nih.gov/pubmed/36053568"
}


@Article{info:doi/10.2196/35835,
author="Suryavanshi, Nishi
and Dhumal, Gauri
and Cox, R. Samyra
and Sangle, Shashikala
and DeLuca, Andrea
and Santre, Manjeet
and Gupta, Amita
and Chander, Geetanjali
and Hutton, Heidi",
title="Acceptability, Adaptability, and Feasibility of a Novel Computer-Based Virtual Counselor--Delivered Alcohol Intervention: Focus Group and In-depth Interview Study Among Adults With HIV or Tuberculosis in Indian Clinical Settings",
journal="JMIR Form Res",
year="2022",
month="May",
day="27",
volume="6",
number="5",
pages="e35835",
keywords="computer-based-intervention",
keywords="HIV/TB clinical setting",
keywords="alcohol use disorder (AUD)",
keywords="alcohol",
keywords="India",
keywords="HIV",
keywords="TB",
keywords="feasibility",
keywords="acceptability",
abstract="Background: Unhealthy alcohol use is associated with increased morbidity and mortality among persons with HIV and tuberculosis (TB). Computer-based interventions (CBIs) can reduce unhealthy alcohol use, are scalable, and may improve outcomes among patients with HIV or TB. Objective: We assessed the acceptability, adaptability, and feasibility of a novel CBI for alcohol reduction in HIV and TB clinical settings in Pune, India. Methods: We conducted 10 in-depth interviews with persons with alcohol use disorder (AUD): TB (6/10), HIV (2/10), or HIV-TB co-infected (1/10) selected using convenience sampling method, no HIV or TB disease (1/10), 1 focus group with members of Alcoholics Anonymous (AA; n=12), and 2 focus groups with health care providers (HCPs) from a tertiary care hospital (n=22). All participants reviewed and provided feedback on a CBI for AUD delivered by a 3D virtual counselor. Qualitative data were analyzed using structured framework analysis. Results: The majority (9/10) of in-depth interview respondents were male, with median age 42 (IQR 38-45) years. AA focus group participants were all male (12/12), and HCP focus group participants were predominantly female (n=15). Feedback was organized into 3 domains: (1) virtual counselor acceptability, (2) intervention adaptability, and (3) feasibility of the CBI intervention in clinic settings. Overall, in-depth interview participants found the virtual counselor to be acceptable and felt comfortable honestly answering alcohol-related questions. All focus group participants preferred a human virtual counselor to an animal virtual counselor so as to potentially increase CBI engagement. Additionally, interaction with a live human counselor would further enhance the program's effectiveness by providing more flexible interaction. HCP focus group participants noted the importance of adding information on the effects of alcohol on HIV and TB outcomes because patients were not viewed as appreciating these linkages. For local adaptation, more information on types of alcoholic drinks, additional drinking triggers, motivators, and activities to substitute for drinking alcohol were suggested by all focus group participants. Intervention duration (about 20 minutes) and pace were deemed appropriate. HCPs reported that the CBI provides systematic, standardized counseling. All focus group and in-depth interview participants reported that the CBI could be implemented in Indian clinical settings with assistance from HIV or TB program staff. Conclusions: With cultural tailoring to patients with HIV and TB in Indian clinical care settings, a virtual counselor--delivered alcohol intervention is acceptable and appears feasible to implement, particularly if coupled with person-delivered counseling. ",
doi="10.2196/35835",
url="https://formative.jmir.org/2022/5/e35835",
url="http://www.ncbi.nlm.nih.gov/pubmed/35622406"
}


@Article{info:doi/10.2196/34884,
author="Knobel, Johannes Samuel Elia
and Kaufmann, Charlotte Brigitte
and Geiser, Nora
and Gerber, Moreno Stephan
and M{\"u}ri, M. Ren{\'e}
and Nef, Tobias
and Nyffeler, Thomas
and Cazzoli, Dario",
title="Effects of Virtual Reality--Based Multimodal Audio-Tactile Cueing in Patients With Spatial Attention Deficits: Pilot Usability Study",
journal="JMIR Serious Games",
year="2022",
month="May",
day="25",
volume="10",
number="2",
pages="e34884",
keywords="virtual reality",
keywords="search task",
keywords="stroke",
keywords="neglect, multimodal cueing",
keywords="bird search task",
abstract="Background: Virtual reality (VR) devices are increasingly being used in medicine and other areas for a broad spectrum of applications. One of the possible applications of VR involves the creation of an environment manipulated in a way that helps patients with disturbances in the spatial allocation of visual attention (so-called hemispatial neglect). One approach to ameliorate neglect is to apply cross-modal cues (ie, cues in sensory modalities other than the visual one, eg, auditory and tactile) to guide visual attention toward the neglected space. So far, no study has investigated the effects of audio-tactile cues in VR on the spatial deployment of visual attention in neglect patients. Objective: This pilot study aimed to investigate the feasibility and usability of multimodal (audio-tactile) cueing, as implemented in a 3D VR setting, in patients with neglect, and obtain preliminary results concerning the effects of different types of cues on visual attention allocation compared with noncued conditions. Methods: Patients were placed in a virtual environment using a head-mounted display (HMD). The inlay of the HMD was equipped to deliver tactile feedback to the forehead. The task was to find and flag appearing birds. The birds could appear at 4 different presentation angles (lateral and paracentral on the left and right sides), and with (auditory, tactile, or audio-tactile cue) or without (no cue) a spatially meaningful cue. The task usability and feasibility, and 2 simple in-task measures (performance and early orientation) were assessed in 12 right-hemispheric stroke patients with neglect (5 with and 7 without additional somatosensory impairment). Results: The new VR setup showed high usability (mean score 10.2, SD 1.85; maximum score 12) and no relevant side effects (mean score 0.833, SD 0.834; maximum score 21). A repeated measures ANOVA on task performance data, with presentation angle, cue type, and group as factors, revealed a significant main effect of cue type (F30,3=9.863; P<.001) and a significant 3-way interaction (F90,9=2.057; P=.04). Post-hoc analyses revealed that among patients without somatosensory impairment, any cue led to better performance compared with no cue, for targets on the left side, and audio-tactile cues did not seem to have additive effects. Among patients with somatosensory impairment, performance was better with both auditory and audio-tactile cueing than with no cue, at every presentation angle; conversely, tactile cueing alone had no significant effect at any presentation angle. Analysis of early orientation data showed that any type of cue triggered better orientation in both groups for lateral presentation angles, possibly reflecting an early alerting effect. Conclusions: Overall, audio-tactile cueing seems to be a promising method to guide patient attention. For instance, in the future, it could be used as an add-on method that supports attentional orientation during established therapeutic approaches. ",
doi="10.2196/34884",
url="https://games.jmir.org/2022/2/e34884",
url="http://www.ncbi.nlm.nih.gov/pubmed/35612894"
}


@Article{info:doi/10.2196/35159,
author="Philippe, J. Tristan
and Sikder, Naureen
and Jackson, Anna
and Koblanski, E. Maya
and Liow, Eric
and Pilarinos, Andreas
and Vasarhelyi, Krisztina",
title="Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review",
journal="JMIR Ment Health",
year="2022",
month="May",
day="12",
volume="9",
number="5",
pages="e35159",
keywords="digital health",
keywords="telepsychology",
keywords="computer-assisted therapy",
keywords="online therapy",
keywords="mobile applications",
keywords="mobile apps",
keywords="telemedicine",
keywords="telepsychiatry",
keywords="virtual reality exposure therapy",
keywords="mental health",
keywords="COVID-19",
abstract="Background: The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of?mental health conditions. Objective: To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions. Methods: We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care. Results: Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52\%) of research involved the treatment of substance use disorders, 29\% focused on mood, anxiety, and traumatic stress disorders, and >5\% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence. Conclusions: Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions. ",
doi="10.2196/35159",
url="https://mental.jmir.org/2022/5/e35159",
url="http://www.ncbi.nlm.nih.gov/pubmed/35551058"
}


@Article{info:doi/10.2196/35224,
author="Ho, Ying Ka
and Cheung, Mang Po
and Cheng, Wing Tap
and Suen, Yin Wing
and Ho, Ying Hiu
and Cheung, Ki Daphne Sze",
title="Virtual Reality Intervention for Managing Apathy in People With Cognitive Impairment: Systematic Review",
journal="JMIR Aging",
year="2022",
month="May",
day="11",
volume="5",
number="2",
pages="e35224",
keywords="virtual reality",
keywords="apathy",
keywords="cognitive impairment",
keywords="dementia",
keywords="systematic review",
abstract="Background: Apathy is common in people with cognitive impairment. It leads to different consequences, such as more severe cognitive deficits, rapid functional decline, and decreased quality of life. Virtual reality (VR) interventions are increasingly being used to manage apathy in individuals with cognitive impairment. However, reports of VR interventions are scattered across studies, which has hindered the development and use of the interventions. Objective: This study aimed to systematically review existing evidence on the use of VR interventions for managing apathy in people with cognitive impairment with regard to the effectiveness, contents, and implementation of the interventions. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The PubMed, Embase, CINAHL, and PsycINFO databases were systematically searched for experimental studies published up to March 13, 2022, that reported the effects of VR interventions on apathy in older adults with cognitive impairment. Hand searching and citation chasing were conducted. The results of the included studies were synthesized by using a narrative synthesis. Their quality was appraised by using the Effective Public Health Practice Project quality assessment tool. However, because the VR interventions varied in duration, content, and implementation across studies, a meta-analysis was not conducted. Results: A total of 22 studies were identified from the databases, of which 6 (27\%) met the inclusion criteria. Of these 6 studies, 2 (33\%) were randomized controlled trials, 1 (17\%) was a controlled clinical trial, and 3 (50\%) were quasi-experimental studies. Individual studies showed significant improvement in apathy and yielded within-group medium to large effect sizes. The level of immersion ranged from low to high. Minor adverse effects were reported. The VR content mostly included natural scenes, followed by city views and game-based activities. A background soundtrack was often used with natural scenes. Most (5/6, 83\%) of the studies were conducted in a residential care setting and were implemented by health care professionals or researchers. Safety precautions were taken in most (5/6, 83\%) of the studies. Conclusions: Although preliminary evidence shows that VR interventions may be effective and feasible for alleviating apathy in people with cognitive impairment, the methodological limitations in the included studies make it difficult to reach a firm conclusion on these points. The implementation of the interventions was highlighted and discussed. More rigorous studies are encouraged. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021268289; https://www.crd.york.ac.uk/prospero/display\_record.php?ID=CRD42021268289 ",
doi="10.2196/35224",
url="https://aging.jmir.org/2022/2/e35224",
url="http://www.ncbi.nlm.nih.gov/pubmed/35544317"
}


@Article{info:doi/10.2196/34402,
author="Goudman, Lisa
and Jansen, Julie
and Billot, Maxime
and Vets, Nieke
and De Smedt, Ann
and Roulaud, Manuel
and Rigoard, Philippe
and Moens, Maarten",
title="Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis",
journal="JMIR Serious Games",
year="2022",
month="May",
day="10",
volume="10",
number="2",
pages="e34402",
keywords="virtual reality",
keywords="chronic pain",
keywords="systematic review",
keywords="multilevel meta-analysis",
keywords="immersive technologies",
keywords="clinical outcomes",
keywords="mobile phone",
abstract="Background: Virtual reality (VR) is a computer technology that immerses a user in a completely different reality. The application of VR in acute pain settings is well established. However, in chronic pain, the applications and outcome parameters influenced by VR are less clear. Objective: This review aimed to systematically identify all outcome parameters that are reported in relation to VR in patients with chronic pain. Methods: A total of 4 electronic databases (PubMed, Scopus, Web of Science, and Embase) were searched for relevant studies. Multilevel random-effect meta-analyses were performed, whereby the standardized mean difference was chosen as the effect size to denote the difference between measurements before and after a VR intervention. Results: The initial database search identified 1430 studies, of which 41 (2.87\%) were eventually included in the systematic review. Evidence has been found for the effects of VR on pain, functioning, mobility, functional capacity, psychological outcomes, quality of life, neuropsychological outcomes, and physical sensations. The overall effect size (a total of 194 effect sizes from 25 studies) based on a three level meta-analysis was estimated at 1.22 (95\% CI 0.55-1.89; z=3.56; P<.001), in favor of improvements after a VR intervention. When categorizing effect sizes, the overall effect sizes were reported as follows: 1.60 (95\% CI 0.83-2.36; z=4.09; P<.001) for the effect of VR on pain (n=31), 1.40 (95\% CI 0.13-2.67; z=2.17; P=.03) for functioning (n=60), 0.49 (95\% CI ?0.71 to 1.68; z=0.80; P=.42) for mobility (n=24), and 0.34 (95\% CI ?1.52 to 2.20; z=0.36; P=.72) for functional capacity (n=21). Conclusions: This systematic review revealed a broad range of outcome variables influenced by an intervention of VR technology, with statistically significant pain relief and improvements in functioning. These findings indicate that VR not only has applications in acute pain management but also in chronic pain settings, whereby VR might be able to become a promising first-line intervention as complementary therapy for patients with chronic pain. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227016; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=227016 ",
doi="10.2196/34402",
url="https://games.jmir.org/2022/2/e34402",
url="http://www.ncbi.nlm.nih.gov/pubmed/35536641"
}


@Article{info:doi/10.2196/35526,
author="Paul, Margot
and Bullock, Kim
and Bailenson, Jeremy",
title="Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2022",
month="May",
day="6",
volume="9",
number="5",
pages="e35526",
keywords="virtual reality",
keywords="major depressive disorder",
keywords="behavioral activation",
keywords="depression",
abstract="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  ",
doi="10.2196/35526",
url="https://mental.jmir.org/2022/5/e35526",
url="http://www.ncbi.nlm.nih.gov/pubmed/35404830"
}


@Article{info:doi/10.2196/30260,
author="Hoag, A. Jennifer
and Karst, Jeffrey
and Bingen, Kristin
and Palou-Torres, Akasha
and Yan, Ke",
title="Distracting Through Procedural Pain and Distress Using Virtual Reality and Guided Imagery in Pediatric, Adolescent, and Young Adult Patients: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2022",
month="Apr",
day="18",
volume="24",
number="4",
pages="e30260",
keywords="virtual reality",
keywords="procedural",
keywords="pain",
keywords="anxiety",
keywords="pediatric",
keywords="guided imagery",
abstract="Background: Children with acute and chronic illness undergo frequent, painful, and distressing procedures. Objective: This randomized controlled trial was used to evaluate the effectiveness of guided imagery (GI) versus virtual reality (VR) on the procedural pain and state anxiety of children and young adults undergoing unsedated procedures. We explored the role of trait anxiety and pain catastrophizing in intervention response. Methods: Children and young adults were recruited from the hematology, oncology, and blood and marrow transplant clinics at a children's hospital. Each study participant completed the GI and VR intervention during separate but consecutive unsedated procedures. Self-report measures of pain and anxiety were completed before and after the procedures. Results: A total of 50 participants (median age 13 years) completed both interventions. GI and VR performed similarly in the management of procedural pain. Those with high pain catastrophizing reported experiencing less nervousness about pain during procedures that used VR than those using GI. State anxiety declined pre- to postprocedure in both interventions; however, the decrease reached the level of significance during the VR intervention only. Those with high trait anxiety had less pain during GI. Conclusions: In our sample, VR worked as well as GI to manage the pain and distress associated with common procedures experienced by children with acute or chronic illnesses. Children who are primed for pain based on beliefs about pain or because of their history of chronic pain had a better response to VR. GI was a better intervention for those with high trait anxiety. Trial Registration: ClinicalTrials.gov NCT04892160; https://clinicaltrials.gov/ct2/show/NCT04892160 ",
doi="10.2196/30260",
url="https://www.jmir.org/2022/4/e30260",
url="http://www.ncbi.nlm.nih.gov/pubmed/35436209"
}


@Article{info:doi/10.2196/34225,
author="Brown, Poppy
and Waite, Felicity
and Lambe, Sinead
and Jones, Julia
and Jenner, Lucy
and Diamond, Rowan
and Freeman, Daniel",
title="Automated Virtual Reality Cognitive Therapy (gameChange) in Inpatient Psychiatric Wards: Qualitative Study of Staff and Patient Views Using an Implementation Framework",
journal="JMIR Form Res",
year="2022",
month="Apr",
day="12",
volume="6",
number="4",
pages="e34225",
keywords="virtual reality",
keywords="automated",
keywords="therapy",
keywords="inpatient psychiatric care",
keywords="implementation",
abstract="Background: Automated virtual reality (VR) therapy could allow a greater number of patients to receive evidence-based psychological therapy. The aim of the gameChange VR therapy is to help patients overcome anxious avoidance of everyday social situations. gameChange has been evaluated with outpatients, but it may also help inpatients prepare for discharge from psychiatric hospital. Objective: The aim of this study is to explore the views of patients and staff on the provision of VR therapy on psychiatric wards. Methods: Focus groups or individual interviews were conducted with patients (n=19) and National Health Service staff (n=22) in acute psychiatric wards. Questions were derived from the nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability framework. Expectations of VR therapy were discussed, and participants were then given the opportunity to try out the gameChange VR therapy before they were asked questions that focused on opinions about the therapy and feasibility of adoption. Results: There was great enthusiasm for the use of gameChange VR therapy on psychiatric wards. It was considered that gameChange could help build confidence, reduce anxiety, and ``bridge that gap'' between the differences of being in hospital and being discharged to the community. However, it was reflected that the VR therapy may not suit everyone, especially if they are acutely unwell. VR on hospital wards for entertainment and relaxation was also viewed positively. Participants were particularly impressed by the immersive quality of gameChange and the virtual coach. It was considered that a range of staff groups could support VR therapy delivery. The staff thought that implementation would be facilitated by having a lead staff member, having ongoing training accessible, and involving the multidisciplinary team in decision-making for VR therapy use. The most significant barrier to implementation identified by patients and staff was a practical one: access to sufficient, private space to provide the therapy. Conclusions: Patients and staff were keen for VR to be used on psychiatric wards. In general, patients and staff viewed automated VR therapy as possible to implement within current care provision, with few significant barriers other than constraints of space. Patients and staff thought of many further uses of VR on psychiatric wards. The value of VR therapy on psychiatric wards now requires systematic evaluation. International Registered Report Identifier (IRRID): RR2-10.2196/20300 ",
doi="10.2196/34225",
url="https://formative.jmir.org/2022/4/e34225",
url="http://www.ncbi.nlm.nih.gov/pubmed/35412462"
}


@Article{info:doi/10.2196/29164,
author="Thabrew, Hiran
and Chubb, A. Laura
and Kumar, Harshali
and Fouch{\'e}, Christa",
title="Immersive Reality Experience Technology for Reducing Social Isolation and Improving Social Connectedness and Well-being of Children and Young People Who Are Hospitalized: Open Trial",
journal="JMIR Pediatr Parent",
year="2022",
month="Mar",
day="25",
volume="5",
number="1",
pages="e29164",
keywords="immersive reality experiences",
keywords="social isolation",
keywords="hospitalized children",
keywords="well-being",
keywords="social connectedness",
keywords="immersive reality",
keywords="virtual reality",
keywords="serious games",
keywords="pediatrics",
keywords="mental health",
keywords="isolation",
keywords="hospitalized patients",
keywords="adolescents",
abstract="Background: Children and young people who are hospitalized can feel disconnected from their peers and families, which can, in turn, predispose them to psychological problems, including anxiety and depression. Immersive reality experience technology, recently developed by the New Zealand Patience Project Charitable Trust, may help to overcome these issues. Immersive reality experience technology uses immersive 360{\textdegree} live streaming and a virtual reality headset to enable children and young people who are hospitalized to connect through cameras located in either their school or home environment and via SMS text messaging with a designated buddy. Objective: This trial aims to expand qualitative findings from a previous smaller proof of concept trial to ascertain the views of New Zealand children and young people who are hospitalized, their caregivers, and teachers regarding immersive reality experience technology and quantitatively evaluate the effectiveness of immersive reality experience technology in reducing social isolation and improving social connectedness and well-being using validated outcome measures. Methods: An open trial of immersive reality experience technology was conducted between December 2019 and December 2020 for which 19 New Zealand children and young people aged 13 to 18 years who had been hospitalized at Starship Hospital---a specialist pediatric hospital in Auckland---for at least 2 weeks were recruited. All young people completed the Short Warwick--Edinburgh Mental Well-Being Scale, an abbreviated version of the Social Connectedness Scale, and the Social Inclusion Scale at baseline. Of the 19 participants, 10 (53\%) used immersive reality experience technology as often as they wished over a 6-week period and completed postintervention measures. Semistructured interviews with a subset of the 10 young people, 4 caregivers, and 6 teachers were conducted immediately after the intervention. Results: Participants reported improvements in social inclusion (mean change 3.9, SD 2.8; P=.06), social connectedness (mean change 14.2, SD 10.0; P=.002), and well-being (mean change 5.7, SD 4.0; P=.001). Key themes from interviews with participants, caregivers, and teachers were the importance of support for using immersive reality experience technology, connecting versus connectedness, choice and connection, and the value of setting it up and getting it right. Recommendations for improving connectedness via immersive reality experience and related technologies were also provided. Conclusions: Immersive reality experience technology can improve the social inclusion, social connectedness, and well-being of New Zealand children and young people who are hospitalized. With some technological modifications and simplified implementation, immersive reality experience and related technology could become part of standard care and support children and young people who are hospitalized in New Zealand and elsewhere to sustain family and peer cohesion, experience fewer psychological problems, and more easily return to normal life following the completion of treatment. Trial Registration: Australian New Zealand Clinical Trials Network Registry ACTRN12619000252112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376837\&isReview=true ",
doi="10.2196/29164",
url="https://pediatrics.jmir.org/2022/1/e29164",
url="http://www.ncbi.nlm.nih.gov/pubmed/35333184"
}


@Article{info:doi/10.2196/30882,
author="Wu, Jinlong
and Zhang, Hui
and Chen, Ziyan
and Fu, Ruijia
and Yang, Hao
and Zeng, Hongfa
and Ren, Zhanbing",
title="Benefits of Virtual Reality Balance Training for Patients With Parkinson Disease: Systematic Review, Meta-analysis, and Meta-Regression of a Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2022",
month="Mar",
day="1",
volume="10",
number="1",
pages="e30882",
keywords="virtual reality",
keywords="Parkinson disease",
keywords="balance",
keywords="systematic review",
keywords="meta-analysis",
keywords="meta-regression",
keywords="serious games",
keywords="VR",
keywords="rehabilitation",
keywords="VR training",
abstract="Background: Virtual reality (VR) balance training is increasingly being pursued in biomedical research, specifically with respect to investigating balance ability with VR. However, existing systematic reviews have found inconsistent conclusions about the efficacy of VR in improving balance in Parkinson disease (PD) patients. Objective: The goal of the research was to evaluate the impact of VR balance training on the balance ability of patients with PD. Methods: All major databases, including Web of Science, PubMed, Scopus, China National Knowledge Infrastructure, and Wanfang, were searched to identify all relevant studies published in English or Chinese since September 15, 2010. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation. Results: A total of 16 randomized controlled trials were analyzed (n=583 patients with PD), with the methodological quality evaluation score ranging from 5 to 8 points. A random effects model was selected to combine effect sizes. Meta-analysis showed that the balance ability of PD was significantly improved after VR training compared with the control group (standardized mean difference [SMD] 2.127, 95\% CI 1.202 to 3.052, P<.001, I2=95.1, df=15). It is worth noting that the intervention platform may be the main reason for heterogeneity. Meta regression analysis showed that no training program could predict the impact of VR training (P=.57 to .94) on PD balance ability. Subgroup result showed that a single training time of 0 to 20 minutes (SMD 6.446), 4 to 6 times per week (SMD 4.067), training for 3 to 5 weeks (SMD 62.478), training course reached more than 30 times (SMD 4.405), and 201 to 300 minutes per week (SMD 4.059) maybe have more benefit. Conclusions: A systematic review and meta-analysis confirmed that VR balance training is a highly effective means to improve balance performance with large effects in PD. In addition, we preliminarily extracted dose-effect relationships for training volume, informing clinicians and practitioners to design effective VR balance training for balance ability. Further research is needed to reveal optimal dose-response relationships following VR balance training. ",
doi="10.2196/30882",
url="https://games.jmir.org/2022/1/e30882",
url="http://www.ncbi.nlm.nih.gov/pubmed/35230242"
}


@Article{info:doi/10.2196/32117,
author="Zhu, KaiYan
and Zhang, QiongYao
and He, BingWei
and Huang, MeiZhen
and Lin, Rong
and Li, Hong",
title="Immersive Virtual Reality--Based Cognitive Intervention for the Improvement of Cognitive Function, Depression, and Perceived Stress in Older Adults With Mild Cognitive Impairment and Mild Dementia: Pilot Pre-Post Study",
journal="JMIR Serious Games",
year="2022",
month="Feb",
day="21",
volume="10",
number="1",
pages="e32117",
keywords="cognitive intervention",
keywords="dementia",
keywords="immersive virtual reality",
keywords="mild cognitive impairment",
keywords="cognitive impairment",
keywords="virtual reality",
keywords="VR",
keywords="older patients",
keywords="usability",
keywords="memory",
keywords="stress",
abstract="Background: The incidence of dementia is increasing annually, resulting in varying degrees of adverse effects for individuals, families, and society. With the continuous development of computer information technology, cognitive interventions are constantly evolving. The use of immersive virtual reality (IVR) as a cognitive intervention for older adults with mild cognitive impairment (MCI) and mild dementia (MD) is promising, although only few studies have focused on its use. Objective: The Chinese virtual supermarket (CVSM) IVR system was developed to provide a comprehensive and individual cognitive intervention program for older patients with MCI and MD. The aim of this study was to explore the feasibility and clinical effectiveness of this 5-week IVR-based cognitive intervention. Methods: A pretest-posttest study design was conducted with 31 older adults with MCI and MD from August 2020 to January 2021. All participants participated in a 5-week immersive virtual cognitive training program using the CVSM system. Feasibility was assessed as the incidence and severity of cybersickness symptoms and participant satisfaction based on questionnaires conducted after the intervention. Clinical effectiveness was evaluated using neuropsychological assessments, including several commonly used measures of cognitive function, depression, perceived stress, and activities of daily living. Measurements were obtained at baseline and after the intervention period. Results: A total of 18 patients with MCI (mean age 82.94 [SD 5.44] years; 12 females) and 13 patients with MD (mean age 85.7 [SD 4.67] years, 10 females) participated in this pilot study. Both groups showed significant improvements in all cognitive function measurements (P<.001). The MD group had a significantly greater improvement in general cognitive function compared to the MCI group in Montreal Cognitive Assessment Scale, Symbol Digit Modalities Test, Shape Trail Test, and Auditory Verbal Learning Test. Furthermore, an intervention effect was observed in the improvement of perceived stress (P=.048 for MD group, P=.03 for MCI group ). Conclusions: The use of the CVSM system may be effective in enhancing the cognitive function of patients with MCI and MD, including general cognitive function, memory, executive function, and attention. IVR technology enriches cognitive intervention approaches and provides acceptable, professional, personalized, and interesting cognitive training for older adults with cognitive impairment. Trial Registration: ClinicalTrials ChiCTR2100043753; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2100043753 ",
doi="10.2196/32117",
url="https://games.jmir.org/2022/1/e32117",
url="http://www.ncbi.nlm.nih.gov/pubmed/35188466"
}


@Article{info:doi/10.2196/28502,
author="Schroeder, H. Alexandra
and Bogie, M. Bryce J.
and Rahman, T. Tabassum
and Th{\'e}rond, Alexandra
and Matheson, Hannah
and Guimond, Synthia",
title="Feasibility and Efficacy of Virtual Reality Interventions to Improve Psychosocial Functioning in Psychosis: Systematic Review",
journal="JMIR Ment Health",
year="2022",
month="Feb",
day="18",
volume="9",
number="2",
pages="e28502",
keywords="auditory verbal hallucinations",
keywords="cognitive remediation",
keywords="functional outcomes",
keywords="neurocognition",
keywords="paranoia",
keywords="psychosis",
keywords="schizophrenia",
keywords="social skills",
keywords="virtual reality (VR)",
keywords="vocational skills",
abstract="Background: Functional recovery in psychosis remains a challenge despite current evidence-based treatment approaches. To address this problem, innovative interventions using virtual reality (VR) have recently been developed. VR technologies have enabled the development of realistic environments in which individuals with psychosis can receive psychosocial treatment interventions in more ecological settings than traditional clinics. These interventions may therefore increase the transfer of learned psychosocial skills to real-world environments, thereby promoting long-term functional recovery. However, the overall feasibility and efficacy of such interventions within the psychosis population remain unclear. Objective: This systematic review aims to investigate whether VR-based psychosocial interventions are feasible and enjoyable for individuals with psychosis, synthesize current evidence on the efficacy of VR-based psychosocial interventions for psychosis, and identify the limitations in the current literature to guide future research. Methods: This research followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches were conducted in PubMed and PsycINFO in May 2021. We searched for peer-reviewed English articles that used a psychosocial intervention with a VR component. Participants in the included studies were diagnosed with schizophrenia, schizoaffective disorder, or another psychotic disorder. The included studies were divided into four categories as follows: cognitive remediation interventions, social skills interventions, vocational skills interventions, and auditory verbal hallucinations and paranoia interventions. The risk of bias assessment was performed for each study. Results: A total of 18 studies were included in this systematic review. Of these 18 studies, 4 (22\%) studies used a cognitive remediation intervention, 4 (22\%) studies used a social skills intervention, 3 (17\%) studies used a vocational skills intervention, and 7 (39\%) studies implemented an intervention aimed at improving auditory verbal hallucinations or paranoia. A total of 745 individuals with psychosis were included in the study. All the studies that evaluated feasibility showed that VR-based psychosocial interventions were feasible and enjoyable for individuals with psychosis. The preliminary evidence on efficacy included in this review suggests that VR-based psychosocial interventions can improve cognitive, social, and vocational skills in individuals with psychosis. VR-based interventions may also improve the symptoms of auditory verbal hallucinations and paranoia. The skills that participants learned through these interventions were durable, transferred into real-world environments, and led to improved functional outcomes, such as autonomy, managing housework, and work performance. Conclusions: VR-based interventions may represent a novel and efficacious approach for improving psychosocial functioning in psychosis. Therefore, VR-based psychosocial interventions represent a promising adjunctive therapy for the treatment of psychosis, which may be used to improve psychosocial skills, community functioning, and quality of life. ",
doi="10.2196/28502",
url="https://mental.jmir.org/2022/2/e28502",
url="http://www.ncbi.nlm.nih.gov/pubmed/35179501"
}


@Article{info:doi/10.2196/32240,
author="Nguyen, Binh
and Torres, Andrei
and Sim, Walter
and Kenny, Deborah
and Campbell, M. Douglas
and Beavers, Lindsay
and Lou, Wendy
and Kapralos, Bill
and Peter, Elizabeth
and Dubrowski, Adam
and Krishnan, Sridhar
and Bhat, Venkat",
title="Digital Interventions to Reduce Distress Among Health Care Providers at the Frontline: Protocol for a Feasibility Trial",
journal="JMIR Res Protoc",
year="2022",
month="Feb",
day="16",
volume="11",
number="2",
pages="e32240",
keywords="virtual reality",
keywords="mobile app",
keywords="moral distress",
keywords="simulation",
keywords="moral injury",
keywords="COVID-19",
abstract="Background: Stress, anxiety, distress, and depression are high among health care workers during the COVID-19 pandemic, and they have reported acting in ways that are contrary to their moral values and professional commitments that degrade their integrity. This creates moral distress and injury due to constraints they have encountered, such as limited resources. Objective: The purpose of this study is to develop and show the feasibility of digital platforms (a virtual reality and a mobile platform) to understand the causes and ultimately reduce the moral distress of health care providers during the COVID-19 pandemic. Methods: This will be a prospective, single cohort, pre- and posttest study examining the effect of a brief informative video describing moral distress on perceptual, psychological, and physiological indicators of stress and decision-making during a scenario known to potentially elicit moral distress. To accomplish this, we have developed a virtual reality simulation that will be used before and after the digital intervention for monitoring short-term impacts. The simulation involves an intensive care unit setting during the COVID-19 pandemic, and participants will be placed in morally challenging situations. The participants will be engaged in an educational intervention at the individual, team, and organizational levels. During each test, data will be collected for (1) physiological measures of stress and after each test, data will be collected regarding (2) thoughts, feelings and behaviors during a morally challenging situation, and (3) perceptual estimates of psychological stress. In addition, participants will continue to be monitored for moral distress and other psychological stresses for 8 weeks through our Digital intervention/intelligence Group mobile platform. Finally, a comparison will be conducted using machine learning and biostatistical techniques to analyze the short- and long-term impacts of the virtual reality intervention. Results: The study was funded in November 2020 and received research ethics board approval in March 2021. The study is ongoing. Conclusions: This project is a proof-of-concept integration to demonstrate viability over 6 months and guide future studies to develop these state-of-the-art technologies to help frontline health care workers work in complex moral contexts. In addition, the project will develop innovations that can be used for future pandemics and in other contexts prone to producing moral distress and injury. This project aims to demonstrate the feasibility of using digital platforms to understand the continuum of moral distress that can lead to moral injury. Demonstration of feasibility will lead to future studies to examine the efficacy of digital platforms to reduce moral distress. Trial Registration: ClinicalTrials.gov NCT05001542; https://clinicaltrials.gov/ct2/show/NCT05001542 International Registered Report Identifier (IRRID): DERR1-10.2196/32240 ",
doi="10.2196/32240",
url="https://www.researchprotocols.org/2022/2/e32240",
url="http://www.ncbi.nlm.nih.gov/pubmed/34871178"
}


@Article{info:doi/10.2196/26736,
author="van Loenen, Inge
and Scholten, Willemijn
and Muntingh, Anna
and Smit, Johannes
and Batelaan, Neeltje",
title="The Effectiveness of Virtual Reality Exposure--Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis",
journal="J Med Internet Res",
year="2022",
month="Feb",
day="10",
volume="24",
number="2",
pages="e26736",
keywords="anxiety disorders",
keywords="virtual reality",
keywords="virtual reality exposure therapy",
keywords="cognitive behavioral therapy",
keywords="meta-analysis",
keywords="mobile phone",
abstract="Background: In recent years, virtual reality exposure--based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders. Objective: The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared. Methods: Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95\% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions. Results: A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (nco=10) was medium and significant, favoring VRE-CBT (Hedges g=?0.490, 95\% CI ?0.82 to ?0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (nco=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95\% CI ?0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (nco=10) showed no significant difference (odds ratio 0.79, 95\% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias. Conclusions: The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings. ",
doi="10.2196/26736",
url="https://www.jmir.org/2022/2/e26736",
url="http://www.ncbi.nlm.nih.gov/pubmed/35142632"
}


@Article{info:doi/10.2196/32368,
author="Vlake, H. Johan
and van Bommel, Jasper
and Wils, Evert-Jan
and Bienvenu, Joe
and Hellemons, E. Merel
and Korevaar, IM Tim
and Schut, FC Anna
and Labout, AM Joost
and Schreuder, LH Lois
and van Bavel, P. Marten
and Gommers, Diederik
and van Genderen, E. Michel",
title="Intensive Care Unit--Specific Virtual Reality for Critically Ill Patients With COVID-19: Multicenter Randomized Controlled Trial",
journal="J Med Internet Res",
year="2022",
month="Jan",
day="31",
volume="24",
number="1",
pages="e32368",
keywords="SARS-CoV-2",
keywords="intensive care",
keywords="post-intensive care syndrome",
keywords="virtual reality",
keywords="quality of life",
keywords="satisfaction",
keywords="COVID-19",
abstract="Background: Although psychological sequelae after intensive care unit (ICU) treatment are considered quite intrusive, robustly effective interventions to treat or prevent these long-term sequelae are lacking. Recently, it was demonstrated that ICU-specific virtual reality (ICU-VR) is a feasible and acceptable intervention with potential mental health benefits. However, its effect on mental health and ICU aftercare in COVID-19 ICU survivors is unknown. Objective: This study aimed to explore the effects of ICU-VR on mental health and on patients' perceived quality of, satisfaction with, and rating of ICU aftercare among COVID-19 ICU survivors. Methods: This was a multicenter randomized controlled trial. Patients were randomized to either the ICU-VR (intervention) or the control group. All patients were invited to an COVID-19 post-ICU follow-up clinic 3 months after hospital discharge, during which patients in the intervention group received ICU-VR. One month and 3 months later (4 and 6 months after hospital discharge), mental health, quality of life, perceived quality, satisfaction with, and rating of ICU aftercare were scored using questionnaires. Results: Eighty-nine patients (median age 58 years; 63 males, 70\%) were included. The prevalence and severity of psychological distress were limited throughout follow-up, and no differences in psychological distress or quality of life were observed between the groups. ICU-VR improved satisfaction with (mean score 8.7, SD 1.6 vs 7.6, SD 1.6 [ICU-VR vs control]; t64=--2.82, P=.006) and overall rating of ICU aftercare (mean overall rating of aftercare 8.9, SD 0.9 vs 7.8, SD 1.7 [ICU-VR vs control]; t64=--3.25; P=.002) compared to controls. ICU-VR added to the quality of ICU aftercare according to 81\% of the patients, and all patients would recommend ICU-VR to other ICU survivors. Conclusions: ICU-VR is a feasible and acceptable innovative method to improve satisfaction with and rating of ICU aftercare and adds to its perceived quality. We observed a low prevalence of psychological distress after ICU treatment for COVID-19, and ICU-VR did not improve psychological recovery or quality of life. Future research is needed to confirm our results in other critical illness survivors to potentially facilitate ICU-VR's widespread availability and application during follow-up. Trial Registration: Netherlands Trial Register NL8835; https://www.trialregister.nl/trial/8835 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-021-05271-z ",
doi="10.2196/32368",
url="https://www.jmir.org/2022/1/e32368",
url="http://www.ncbi.nlm.nih.gov/pubmed/34978530"
}


@Article{info:doi/10.2196/31844,
author="Lee, Hojun
and Choi, JongKwan
and Jung, Dooyoung
and Hur, Ji-Won
and Cho, Chul-Hyun",
title="The Effects of Virtual Reality Treatment on Prefrontal Cortex Activity in Patients With Social Anxiety Disorder: Participatory and Interactive Virtual Reality Treatment Study",
journal="J Med Internet Res",
year="2021",
month="Dec",
day="17",
volume="23",
number="12",
pages="e31844",
keywords="anxiety",
keywords="social anxiety disorder",
keywords="virtual reality",
keywords="fNIRS",
keywords="brain activity",
keywords="prefrontal cortex",
keywords="effectiveness",
abstract="Background: Attempts to use virtual reality (VR) as a treatment for various psychiatric disorders have been made recently, and many researchers have identified the effects of VR in psychiatric disorders. Studies have reported that VR therapy is effective in social anxiety disorder (SAD). However, there is no prior study on the neural correlates of VR therapy in patients with SAD. Objective: The aim of this study is to find the neural correlates of VR therapy by evaluating the treatment effectiveness of VR in patients with SAD using portable functional near-infrared spectroscopy (fNIRS). Methods: Patients with SAD (n=28) were provided with 6 sessions of VR treatment that was developed for exposure to social situations with a recording system of each participant's self-introduction in VR. After each VR treatment session, the first-person view (video 1) and third-person view (video 2) clips of the participant's self-introduction were automatically generated. The functional activities of prefrontal regions were measured by fNIRS while watching videos 1 and 2 with a cognitive task, before and after whole VR treatment sessions, and after the first session of VR treatment. We compared the data of fNIRS between patients with SAD and healthy controls (HCs; n=27). Results: We found that reduction in activities of the right frontopolar prefrontal cortex (FPPFC) in HCs was greater than in the SAD group at baseline (t=--2.01, P=.049). Comparing the frontal cortex activation before and after VR treatment sessions in the SAD group showed significant differences in activities of the FPPFC (right: t=--2.93, P<.001; left: t=--2.25, P=.03) and the orbitofrontal cortex (OFC) (right: t=--2.10, P=.045; left: t=--2.21, P=.04) while watching video 2. Conclusions: Activities of the FPPFC and OFC were associated with symptom reduction after VR treatment for SAD. Our study findings might provide a clue to understanding the mechanisms underlying VR treatment for SAD. Trial Registration: Clinical Research Information Service (CRIS) KCT0003854; https://tinyurl.com/559jp2kp ",
doi="10.2196/31844",
url="https://www.jmir.org/2021/12/e31844",
url="http://www.ncbi.nlm.nih.gov/pubmed/34801979"
}


@Article{info:doi/10.2196/30919,
author="Yan, Mingli
and Yin, Huiru
and Meng, Qiuyan
and Wang, Shuo
and Ding, Yiwen
and Li, Guichen
and Wang, Chunyan
and Chen, Li",
title="A Virtual Supermarket Program for the Screening of Mild Cognitive Impairment in Older Adults: Diagnostic Accuracy Study",
journal="JMIR Serious Games",
year="2021",
month="Dec",
day="3",
volume="9",
number="4",
pages="e30919",
keywords="virtual reality",
keywords="mild cognitive impairment",
keywords="dementia",
keywords="ambient intelligence",
keywords="digital health",
keywords="elderly population",
keywords="aging",
abstract="Background: Mild cognitive impairment (MCI) is often a precursor of dementia, and patients with MCI develop dementia at a higher rate than healthy older adults. Early detection of cognitive decline at the MCI stage supports better planning of care and interventions. At present, the use of virtual reality (VR) in screening for MCI in older adults is promising, but there is little evidence regarding the use of virtual supermarkets to screen for MCI. Objective: The objectives of this study are to validate a VR game--based test, namely, the Virtual Supermarket Program (VSP), for differentiating patients with MCI and healthy controls and to identify cutoff scores for different age levels. Methods: Subjects were recruited from several nursing homes and communities in Changchun, China. They were divided into a healthy control group (n=64) and an MCI group (n=62). All subjects were administered the VSP and a series of neuropsychological examinations. The study determined the optimal cutoff, discriminating validity, concurrent validity, and retest reliability of the VSP. We used the area under the receiver operating characteristic curve (AUC) to evaluate the discriminating validity and obtain the optimal cutoff values. Pearson correlation analysis and the intraclass correlation coefficient were used to evaluate the concurrent validity and retest reliability, respectively. Results: A cutoff score of 46.4 was optimal for the entire sample, yielding a sensitivity of 85.9\% and specificity of 79.0\% for differentiating individuals with MCI and healthy controls, and the AUC was 0.870 (95\% CI 0.799-0.924). The median index of VSP score was 51.1 (range 42.6-60.0). There was a moderate positive correlation between the VSP total score and Mini-Mental State Examination score (r=0.429, P<.001). There was a strong positive correlation between VSP total score and Montreal Cognitive Assessment score (r=0.645, P<.001). The retest reliability of the VSP was feasible (r=0.588, P=.048). Conclusions: The VSP is interesting and feasible for subjects. It shows high sensitivity and specificity for the identification of MCI in older adults, which makes it a promising screening method. The VSP may be generalized to older adults in other countries, although some cultural adaptation may be necessary. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040074; https://www.chictr.org.cn/showprojen.aspx?proj=64639 ",
doi="10.2196/30919",
url="https://games.jmir.org/2021/4/e30919",
url="http://www.ncbi.nlm.nih.gov/pubmed/34870610"
}


@Article{info:doi/10.2196/30249,
author="Kim, Euisung
and Han, Jieun
and Choi, Hojin
and Pri{\'e}, Yannick
and Vigier, Toinon
and Bulteau, Samuel
and Kwon, Hyun Gyu",
title="Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review",
journal="JMIR Serious Games",
year="2021",
month="Nov",
day="24",
volume="9",
number="4",
pages="e30249",
keywords="virtual reality",
keywords="neuropsychological test",
keywords="executive function",
keywords="cognitive ability",
keywords="brain disorder",
keywords="immersive",
keywords="digital health",
keywords="cognition",
keywords="academic trends",
keywords="neurology",
abstract="Background: In neuropsychology, fully immersive virtual reality (VR) has been spotlighted as a promising tool. It is considered that VR not only overcomes the existing limitation of neuropsychological tests but is also appropriate for treating executive functions (EFs) within activities of daily living (ADL) due to its high ecological validity. While fully immersive VR offers new possibilities of neuropsychological tests, there are few studies that overview the intellectual landscape and academic trends in the research related to mainly targeted EFs with fully immersive VR. Objective: The objective of this study is to get an overview of the research trends that use VR in neuropsychological tests and to analyze the research trends using fully immersive VR neuropsychological tests with experimental articles. Methods: This review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were searched in three web databases using keywords related to VR, EFs, and cognitive abilities. The study was conducted in two steps, keyword analysis and in-depth systematic review. In the web database search from 2000 to 2019, 1167 articles were initially collected, of which 234 articles in the eligibility phase were used to conduct keyword analysis and a total of 47 articles were included for systematic review. Results: In keyword analysis, the number of articles focused on dementia including the keywords ``MCI,'' ``SCD,'' and ``dementia'' were highlighted over the period, rather than other symptoms. In addition, we identified that the use of behavioral and physiological data in virtual environments (VEs) has dramatically increased in recent studies. In the systematic review, we focused on the purpose of study, assessment, treatment, and validation of usability and structure. We found that treatment studies and uncategorized studies including presence and cybersickness issues have emerged in the recent period. In addition, the target symptoms and range of participants were diversified. Conclusions: There has been a continuously increasing interest in dealing with neuropsychology by using fully immersive VR. Target cognitive abilities have been diversified, as well as target symptoms. Moreover, the concept of embodied cognition was transplanted in this research area. ",
doi="10.2196/30249",
url="https://games.jmir.org/2021/4/e30249",
url="http://www.ncbi.nlm.nih.gov/pubmed/34822341"
}


@Article{info:doi/10.2196/30590,
author="Shin, Bokyoung
and Oh, Jooyoung
and Kim, Byung-Hoon
and Kim, Erin Hesun
and Kim, Hyunji
and Kim, Suji
and Kim, Jae-Jin",
title="Effectiveness of Self-Guided Virtual Reality--Based Cognitive Behavioral Therapy for Panic Disorder: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2021",
month="Nov",
day="22",
volume="8",
number="11",
pages="e30590",
keywords="virtual reality",
keywords="panic disorder",
keywords="cognitive behavioral therapy",
keywords="exposure therapy",
keywords="intervention",
abstract="Background: Virtual reality (VR) is as effective a technique as traditional cognitive behavioral therapy (CBT) and a promising tool for treating panic disorder symptoms because VR exposure can be safer and has better acceptability than in vivo exposure and is more immersive than exposure through imagination. CBT techniques can be delivered more effectively using VR as well. So far, VR has required high-quality devices, but the development of mobile VR technology has improved user availability. At the same time, a well-structured form of VR can be reproduced and used anywhere. This means that VR can be used to provide a self-guided form of treatment and address the high treatment costs of evidence-based therapy and the lack of professional therapists. This study aimed to investigate the potential of self-guided VR as an alternative to high-cost treatment. Objective: The main goal of this study was to offer data about the efficacy of a mobile app-based self-led VR CBT in the treatment of panic disorder. Methods: A total of 54 subjects with panic disorder were enrolled in this study and randomly assigned to either the VR treatment group or waitlist group. The VR treatment was designed to be total 12 sessions for 4 weeks. The VR treatment consists of 4 steps in which patients are gradually exposed to phobic stimuli while learning to cope with panic symptoms in each stage. The effectiveness of treatment was assessed through the Panic Disorder Severity Scale, Hamilton Rating Scale for Depression, Body Sensations Questionnaire, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Korean Inventory of Social Avoidance and Distress Scale, Korean Inventory of Depressive Symptomatology, and Perceived Stress Scale. In addition, physiological changes using heart rate variability were evaluated. Results: In within-group analyses, the VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after 4 weeks, while the waitlist group did not show any significant improvement. Compared to the waitlist group, the VR treatment group showed significantly greater improvements in the Panic Disorder Severity Scale in both completer analysis and intention-to-treat analysis. Heart rate variability in the VR treatment group showed improvement in normalized high frequency from baseline to postassessment with no significant differences in any outcome measure between groups. Conclusions: The self-guided, mobile app-based VR intervention was effective in the treatment of panic symptoms and restoring the autonomic nervous system demonstrating the validity of the use of VR for self-guided treatment. VR treatment can be a cost-effective therapeutic approach. Trial Registration: ClinicalTrials.gov NCT04985019; https://clinicaltrials.gov/ct2/show/NCT04985019 ",
doi="10.2196/30590",
url="https://mental.jmir.org/2021/11/e30590",
url="http://www.ncbi.nlm.nih.gov/pubmed/34813486"
}


@Article{info:doi/10.2196/29330,
author="Xu, Wenge
and Liang, Hai-Ning
and Baghaei, Nilufar
and Ma, Xiaoyue
and Yu, Kangyou
and Meng, Xuanru
and Wen, Shaoyue",
title="Effects of an Immersive Virtual Reality Exergame on University Students' Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Nov",
day="22",
volume="9",
number="4",
pages="e29330",
keywords="university students",
keywords="depression",
keywords="anxiety",
keywords="stress",
keywords="immersive virtual reality",
keywords="exergame",
abstract="Background: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. Objective: This study aimed to explore the feasibility of a 6-week iVR exergame--based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. Methods: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. Results: A total of 15 participants completed the 6-week study. Our results suggested that participants' mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93\%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93\%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73\%) would recommend the iVR exergame to their friends. Conclusions: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students. ",
doi="10.2196/29330",
url="https://games.jmir.org/2021/4/e29330",
url="http://www.ncbi.nlm.nih.gov/pubmed/34813487"
}


@Article{info:doi/10.2196/31007,
author="Zhang, Qi
and Fu, Yu
and Lu, Yanhui
and Zhang, Yating
and Huang, Qifang
and Yang, Yajie
and Zhang, Ke
and Li, Mingzi",
title="Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis",
journal="J Med Internet Res",
year="2021",
month="Nov",
day="17",
volume="23",
number="11",
pages="e31007",
keywords="virtual reality",
keywords="stroke",
keywords="cognition",
keywords="depression",
keywords="mental health",
abstract="Background: Stroke remains one of the major chronic illnesses worldwide that health care organizations will need to address for the next several decades. Individuals poststroke are subject to levels of cognitive impairment and mental health problems. Virtual reality (VR)-based therapies are new technologies used for cognitive rehabilitation and the management of psychological outcomes. Objective: This study performed a meta-analysis to evaluate the effects of VR-based therapies on cognitive function and mental health in patients with stroke. Methods: A comprehensive database search was performed using PubMed, MEDLINE (Ovid), Embase, Cochrane Library, and APA PsycINFO databases for randomized controlled trials (RCTs) that studied the effects of VR on patients with stroke. We included trials published up to April 15, 2021, that fulfilled our inclusion and exclusion criteria. The literature was screened, data were extracted, and the methodological quality of the included trials was assessed. Meta-analysis was performed using RevMan 5.3 software. Results: A total of 894 patients from 23 RCTs were included in our meta-analysis. Compared to traditional rehabilitation therapies, the executive function (standard mean difference [SMD]=0.88, 95\% confidence interval [CI]=0.06-1.70, P=.03), memory (SMD=1.44, 95\% CI=0.21-2.68, P=.02), and visuospatial function (SMD=0.78, 95\% CI=0.23-1.33, P=.006) significantly improved among patients after VR intervention. However, there were no significant differences observed in global cognitive function, attention, verbal fluency, depression, and the quality of life (QoL). Conclusions: The findings of our meta-analysis showed that VR-based therapies are efficacious in improving executive function, memory, and visuospatial function in patients with stroke. For global cognitive function, attention, verbal fluency, depression, and the QoL, further research is required. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021252788; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=252788 ",
doi="10.2196/31007",
url="https://www.jmir.org/2021/11/e31007",
url="http://www.ncbi.nlm.nih.gov/pubmed/34787571"
}


@Article{info:doi/10.2196/26629,
author="Gagnon Shaigetz, Vincent
and Proulx, Catherine
and Cabral, Anne
and Choudhury, Nusrat
and Hewko, Mark
and Kohlenberg, Elicia
and Segado, Melanie
and Smith, D. Michael S.
and Debergue, Patricia",
title="An Immersive and Interactive Platform for Cognitive Assessment and Rehabilitation (bWell): Design and Iterative Development Process",
journal="JMIR Rehabil Assist Technol",
year="2021",
month="Nov",
day="3",
volume="8",
number="4",
pages="e26629",
keywords="virtual reality",
keywords="clinical psychology",
keywords="cognitive assessment",
keywords="neuropsychology",
keywords="mental health",
keywords="cognitive rehabilitation",
keywords="digital therapeutics",
keywords="mobile phone",
keywords="cognitive training",
abstract="Background: Immersive technologies like virtual reality can enable clinical care that meaningfully aligns with real-world deficits in cognitive functioning. However, options in immersive 3D environments are limited, partly because of the unique challenges presented by the development of a clinical care platform. These challenges include selecting clinically relevant features, enabling tasks that capture the full breadth of deficits, ensuring longevity in a rapidly changing technology landscape, and performing the extensive technical and clinical validation required for digital interventions. Complicating development, is the need to integrate recommendations from domain experts at all stages. Objective: The Cognitive Health Technologies team at the National Research Council Canada aims to overcome these challenges with an iterative process for the development of bWell, a cognitive care platform providing multisensory cognitive tasks for adoption by treatment providers. Methods: The team harnessed the affordances of immersive technologies while taking an interdisciplinary research and developmental approach, obtaining active input from domain experts with iterative deliveries of the platform. The process made use of technology readiness levels, agile software development, and human-centered design to advance four main activities: identification of basic requirements and key differentiators, prototype design and foundational research to implement components, testing and validation in lab settings, and recruitment of external clinical partners. Results: bWell was implemented according to the findings from the design process. The main features of bWell include multimodal (fully, semi, or nonimmersive) and multiplatform (extended reality, mobile, and PC) implementation, configurable exercises that pair standardized assessment with adaptive and gamified variants for therapy, a therapist-facing user interface for task administration and dosing, and automated activity data logging. bWell has been designed to serve as a broadly applicable toolkit, targeting general aspects of cognition that are commonly impacted across many disorders, rather than focusing on 1 disorder or a specific cognitive domain. It comprises 8 exercises targeting different domains: states of attention (Egg), visual working memory (Theater), relaxation (Tent), inhibition and cognitive control (Mole), multitasking (Lab), self-regulation (Butterfly), sustained attention (Stroll), and visual search (Cloud). The prototype was tested and validated with healthy adults in a laboratory environment. In addition, a cognitive care network (5 sites across Canada and 1 in Japan) was established, enabling access to domain expertise and providing iterative input throughout the development process. Conclusions: Implementing an interdisciplinary and iterative approach considering technology maturity brought important considerations for the development of bWell. Altogether, this harnesses the affordances of immersive technology and design for a broad range of applications, and for use in both cognitive assessment and rehabilitation. The technology has attained a maturity level of prototype implementation with preliminary validation carried out in laboratory settings, with next steps to perform the validation required for its eventual adoption as a clinical tool. ",
doi="10.2196/26629",
url="https://rehab.jmir.org/2021/4/e26629",
url="http://www.ncbi.nlm.nih.gov/pubmed/34730536"
}


@Article{info:doi/10.2196/29862,
author="Chiang, Chih-Huei
and Huang, Chiu-Mieh
and Sheu, Jiunn-Jye
and Liao, Jung-Yu
and Hsu, Hsiao-Pei
and Wang, Shih-Wen
and Guo, Jong-Long",
title="Examining the Effectiveness of 3D Virtual Reality Training on Problem-solving, Self-efficacy, and Teamwork Among Inexperienced Volunteers Helping With Drug Use Prevention: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2021",
month="Nov",
day="2",
volume="23",
number="11",
pages="e29862",
keywords="3D virtual reality",
keywords="volunteers",
keywords="problem-solving",
keywords="self-efficacy",
keywords="teamwork",
abstract="Background: Illegal drug usage among adolescents is a critical health problem. The Taiwanese government provides an accompanying volunteer program to prevent students who experiment with drugs from reusing them. An appropriate training program can improve volunteers' abilities to assist students using drugs. Problem-solving, self-efficacy, and teamwork are critical abilities for inexperienced volunteers who help with drug use prevention. By interacting with the animation or 3D virtual reality (VR) in the virtual scene, learners can immerse themselves in the virtual environment to learn, and 3D VR can increase learning opportunities and reduce the cost of human and material resources. Objective: The aim of this study was to examine the effectiveness of spherical video-based virtual reality (SVVR) training in improving problem-solving, self-efficacy, and teamwork among volunteers who helped prevent adolescents from using illegal drugs. Methods: This study used a randomized controlled design with a total of 68 participants in the experimental (n=35) and control (n=33) groups. The participants in the experimental group received the SVVR training program and their counterparts in the control group did not receive any training. Results: Generalized estimating equation analyses indicated that the experimental group showed significant posttraining improvements in problem-solving and self-efficacy but not teamwork when compared with the control group. Conclusions: The results of this study revealed that SVVR could improve participants' problem-solving skills and self-efficacy for assisting students in not using illegal drugs. However, future studies are suggested to develop effective SVVR to assist inexperienced volunteers in enhancing their teamwork abilities. We believed that introducing the training program to more sites can enhance volunteer training so that volunteers can have a better companionship effect when helping students quit drugs. Trial Registration: ClinicalTrials.gov NCT05072431; https://clinicaltrials.gov/ct2/show/NCT05072431 ",
doi="10.2196/29862",
url="https://www.jmir.org/2021/11/e29862",
url="http://www.ncbi.nlm.nih.gov/pubmed/34726606"
}


@Article{info:doi/10.2196/31742,
author="Bond, Jessica
and Robotham, Dan
and Kenny, Alexandra
and Pinfold, Vanessa
and Kabir, Thomas
and Andleeb, Humma
and Larkin, Michael
and Martin, L. Jennifer
and Brown, Susan
and Bergin, D. Aislinn
and Petit, Ariane
and Rosebrock, Laina
and Lambe, Sin{\'e}ad
and Freeman, Daniel
and Waite, Felicity",
title="Automated Virtual Reality Cognitive Therapy for People With Psychosis: Protocol for a Qualitative Investigation Using Peer Research Methods",
journal="JMIR Res Protoc",
year="2021",
month="Oct",
day="25",
volume="10",
number="10",
pages="e31742",
keywords="virtual reality",
keywords="therapy",
keywords="schizophrenia",
keywords="agoraphobia",
keywords="peer research",
keywords="qualitative methods",
keywords="implementation",
keywords="mental health",
keywords="psychosis",
keywords="cognitive therapy",
abstract="Background: Many people with psychosis experience difficulties in everyday social situations. Anxiety can make life challenging, leading to withdrawal. Cognitive therapy, using active in vivo learning, enables people to overcome fears. These treatments are not readily available to people with psychosis. Automated virtual reality (VR) therapy is a potential route to increase accessibility. The gameChange automated VR cognitive therapy is designed to help people overcome anxious avoidance and build confidence in everyday social situations. A virtual coach guides the person through the treatment. Understanding user experience is key to facilitating future implementation. Peer research methods, in which people with lived experience of the issues being studied are involved in collecting and analyzing data, may be useful in developing this understanding. This encourages researchers to draw on their lived experience to explore participant perspectives and co-create knowledge. Objective: The primary objective is to use a peer research approach to explore the participant experience of a novel automated VR therapy for anxious social avoidance. This includes understanding (1) the experience of anxious social avoidance in people with psychosis, (2) the experience of the gameChange automated VR cognitive therapy, and (3) any potential impact of the therapy in people's lives. This will inform future implementation strategies. The secondary objective is to explore how peer research can be used to co-create knowledge. Methods: Semistructured interviews will be conducted with approximately 25 people with psychosis participating in the gameChange trial (ISRCTN17308399). Participants will be recruited from the five trial centers based in National Health Service mental health trusts across England. Interviews will be conducted by two researchers. One is a peer researcher with similar lived experience to the trial participants. The other has lived experiences of mental health issues that do not directly overlap with those of the trial participants. Interview questions will focus on an individual's experience of anxious social avoidance, experiences of participating in the gameChange VR therapy, and any changes or impact following therapy. The interview schedule was developed in collaboration with the gameChange Lived Experience Advisory Panel (LEAP), comprising 10 project advisors with lived experience of psychosis. Interpretative phenomenological analysis and template analysis will be used to explore individual accounts. The LEAP will contribute to the analysis. Results: Data collection will be conducted from April to September 2021, and analysis will be conducted from June to October 2021. As of September 28, 2021, 20 participants had been interviewed, and coding is underway. Conclusions: The study, employing a peer research approach, may provide a unique insight into the experiences of anxious social avoidance in people with psychosis and its treatment using automated VR therapy. This will inform potential future implementation of VR automated therapies in mental health services. International Registered Report Identifier (IRRID): DERR1-10.2196/31742 ",
doi="10.2196/31742",
url="https://www.researchprotocols.org/2021/10/e31742",
url="http://www.ncbi.nlm.nih.gov/pubmed/34694236"
}


@Article{info:doi/10.2196/27298,
author="Hu, Xiao-Su
and Beard, Katherine
and Sherbel, Catherine Mary
and Nascimento, D. Thiago
and Petty, Sean
and Pantzlaff, Eddie
and Schwitzer, David
and Kaciroti, Niko
and Maslowski, Eric
and Ashman, M. Lawrence
and Feinberg, E. Stephen
and DaSilva, F. Alexandre",
title="Brain Mechanisms of Virtual Reality Breathing Versus Traditional Mindful Breathing in Pain Modulation: Observational Functional Near-infrared Spectroscopy Study",
journal="J Med Internet Res",
year="2021",
month="Oct",
day="12",
volume="23",
number="10",
pages="e27298",
keywords="virtual reality breathing",
keywords="traditional mindful breathing",
keywords="pain",
keywords="functional near-infrared spectroscopy",
keywords="mobile phone",
abstract="Background: Pain is a complex experience that involves sensory-discriminative and cognitive-emotional neuronal processes. It has long been known across cultures that pain can be relieved by mindful breathing (MB). There is a common assumption that MB exerts its analgesic effect through interoception. Interoception refers to consciously refocusing the mind's attention to the physical sensation of internal organ function. Objective: In this study, we dissect the cortical analgesic processes by imaging the brains of healthy subjects exposed to traditional MB (TMB) and compare them with another group for which we augmented MB to an outside sensory experience via virtual reality breathing (VRB). Methods: The VRB protocol involved in-house--developed virtual reality 3D lungs that synchronized with the participants' breathing cycles in real time, providing them with an immersive visual-auditory exteroception of their breathing. Results: We found that both breathing interventions led to a significant increase in pain thresholds after week-long practices, as measured by a thermal quantitative sensory test. However, the underlying analgesic brain mechanisms were opposite, as revealed by functional near-infrared spectroscopy data. In the TMB practice, the anterior prefrontal cortex uniquely modulated the premotor cortex. This increased its functional connection with the primary somatosensory cortex (S1), thereby facilitating the S1-based sensory-interoceptive processing of breathing but inhibiting its other role in sensory-discriminative pain processing. In contrast, virtual reality induced an immersive 3D exteroception with augmented visual-auditory cortical activations, which diminished the functional connection with the S1 and consequently weakened the pain processing function of the S1. Conclusions: In summary, our study suggested two analgesic neuromechanisms of VRB and TMB practices---exteroception and interoception---that distinctively modulated the S1 processing of the ascending noxious inputs. This is in line with the concept of dualism (Yin and Yang). ",
doi="10.2196/27298",
url="https://www.jmir.org/2021/10/e27298",
url="http://www.ncbi.nlm.nih.gov/pubmed/34636731"
}


@Article{info:doi/10.2196/29763,
author="Persson, Johanna
and Clifford, Douglas
and Wallerg{\aa}rd, Mattias
and Sand{\'e}n, Ulrika",
title="A Virtual Smash Room for Venting Frustration or Just Having Fun: Participatory Design of Virtual Environments in Digitally Reinforced Cancer Rehabilitation",
journal="JMIR Rehabil Assist Technol",
year="2021",
month="Oct",
day="7",
volume="8",
number="4",
pages="e29763",
keywords="virtual reality",
keywords="virtual environment",
keywords="cancer rehabilitation",
keywords="emotions",
keywords="participatory design",
keywords="virtual smash room",
keywords="human factors",
abstract="Background: Cancer rehabilitation is central for helping patients and relatives create a functional everyday life based on the changes in life conditions. The needs are highly individual and include physical, mental, and social challenges. Cancer rehabilitation programs offer coping strategies, including guidelines on how to handle emotions. Objective: This paper presents a participatory design activity where patients in cancer rehabilitation use a virtual smash room, which is a virtual environment where the user can break things, mainly porcelain or glass items such as vases or plates. The objective is to understand attitudes to, and some effects of, using this application, as well as eliciting ideas of other virtual environments that would be desired. Methods: The virtual environment presented here, the virtual smash room, was designed at the request of a patient with cancer who wanted a tool for venting frustration. In this virtual environment, the user can break porcelain, vases, and plates. Patients participating in a week-long cancer rehabilitation program tested the virtual smash room and reported their experiences through a questionnaire. The questionnaire comprised three sections: (1) a subset of the Intrinsic Motivation Inventory (IMI), (2) a subset of the Virtual Reality Symptoms Questionnaire (VRSQ), and (3) a free-text response section. Results: A total of 101 responses were gathered. The results from the IMI questions showed that the participants found the virtual experience enjoyable (mean 4.52, maximum 5, SD 0.73), and it helped them retain their focus (mean 4.44, maximum 5, SD 0.74). The VRSQ revealed that there were only minor symptoms related to general discomfort (5.9\%, n=6), fatigue (5.9\%, n=6), nausea (3.0\%, n=3), and tired eyes (8.9\%, n=9), while several participants experienced dizziness (22.8\%, n=23). Since only postmeasurements were gathered, nothing could be concluded about the prevalence of these symptoms before testing. The free-text responses indicated that the user group had many ideas for other virtual environments to use in cancer rehabilitation. Conclusions: This study presents a concept of using virtual reality in the cancer rehabilitation process and exemplifies activities of patient participation in the design process. Virtual reality has potential in being both distracting and enjoyable, while certain aspects of cybersickness might be especially important to consider for a user group already experiencing physical and mental issues. The results will act as input in the process of further designing virtual applications in digitally reinforced cancer rehabilitation. ",
doi="10.2196/29763",
url="https://rehab.jmir.org/2021/4/e29763",
url="http://www.ncbi.nlm.nih.gov/pubmed/34617913"
}


@Article{info:doi/10.2196/29681,
author="Baghaei, Nilufar
and Chitale, Vibhav
and Hlasnik, Andrej
and Stemmet, Lehan
and Liang, Hai-Ning
and Porter, Richard",
title="Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review",
journal="JMIR Ment Health",
year="2021",
month="Sep",
day="23",
volume="8",
number="9",
pages="e29681",
keywords="virtual reality",
keywords="mental health",
keywords="depression",
keywords="anxiety",
keywords="CBT",
abstract="Background: Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression. Objective: This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety. Methods: We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum. Results: Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26\%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56\%) studies, whereas in the remaining 4 (44\%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression. Conclusions: Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression. ",
doi="10.2196/29681",
url="https://mental.jmir.org/2021/9/e29681",
url="http://www.ncbi.nlm.nih.gov/pubmed/34554097"
}


@Article{info:doi/10.2196/26623,
author="Sarkar, Urmimala
and Lee, E. Jane
and Nguyen, H. Kim
and Lisker, Sarah
and Lyles, R. Courtney",
title="Barriers and Facilitators to the Implementation of Virtual Reality as a Pain Management Modality in Academic, Community, and Safety-Net Settings: Qualitative Analysis",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="22",
volume="23",
number="9",
pages="e26623",
keywords="virtual reality",
keywords="medical informatics",
keywords="information technology",
keywords="implementation science",
keywords="qualitative research",
abstract="Background: Prior studies have shown that virtual reality (VR) is an efficacious treatment modality for opioid-sparing pain management. However, the majority of these studies were conducted among primarily White, relatively advantaged populations and in well-resourced settings. Objective: We conducted a qualitative, theory-informed implementation science study to assess the readiness for VR in safety-net settings. Methods: Using the theoretical lens of the Consolidated Framework for Implementation Research (CFIR) framework, we conducted semistructured interviews with current VR users and nonusers based in safety-net health systems (n=15). We investigated barriers and facilitators to a commercially available, previously validated VR technology platform AppliedVR (Los Angeles, CA, USA). We used deductive qualitative analysis using the overarching domains of the CFIR framework and performed open, inductive coding to identify specific themes within each domain. Results: Interviewees deemed the VR intervention to be useful, scalable, and an appealing alternative to existing pain management approaches. Both users and nonusers identified a lack of reimbursement for VR as a significant challenge for adoption. Current users cited positive patient feedback, but safety-net stakeholders voiced concern that existing VR content may not be relevant or appealing to diverse patients. All respondents acknowledged the challenge of integrating and maintaining VR in current pain management workflows across a range of clinical settings, and this adoption challenge was particularly acute, given resource and staffing constraints in safety-net settings. Conclusions: VR for pain management holds interest for frontline pain management clinicians and leadership in safety-net health settings but will require significant tailoring and adaption to address the needs of diverse populations. Integration into complex workflows for pain management is a significant barrier to adoption, and participants cited structural cost and reimbursement concerns as impediments to initial implementation and scaling of VR use. ",
doi="10.2196/26623",
url="https://www.jmir.org/2021/9/e26623",
url="http://www.ncbi.nlm.nih.gov/pubmed/34550074"
}


@Article{info:doi/10.2196/22942,
author="Stunden, Chelsea
and Stratton, Kirsten
and Zakani, Sima
and Jacob, John",
title="Comparing a Virtual Reality--Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="22",
volume="23",
number="9",
pages="e22942",
keywords="virtual reality",
keywords="magnetic resonance imaging simulation",
keywords="certified child life specialists",
keywords="pediatrics",
keywords="magnetic resonance imaging procedures",
keywords="alternatives to sedation",
keywords="preparing children for MRI",
abstract="Background: The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed. Objective: This study aims to compare the effectiveness of a virtual reality (VR)---based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers' reported anxiety, procedural data, caregiver usability, child satisfaction, and fun. Methods: This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers' reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales). Results: A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36\%; SPM: 24/84, 29\%; and CLP: 30/84, 36\%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children's reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r84=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37). Conclusions: Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting. Trial Registration: Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382 ",
doi="10.2196/22942",
url="https://www.jmir.org/2021/9/e22942",
url="http://www.ncbi.nlm.nih.gov/pubmed/34550072"
}


@Article{info:doi/10.2196/29210,
author="Saredakis, Dimitrios
and Keage, AD Hannah
and Corlis, Megan
and Ghezzi, S. Erica
and Loffler, Helen
and Loetscher, Tobias",
title="The Effect of Reminiscence Therapy Using Virtual Reality on Apathy in Residential Aged Care: Multisite Nonrandomized Controlled Trial",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="20",
volume="23",
number="9",
pages="e29210",
keywords="reminiscence",
keywords="head-mounted display",
keywords="apathy",
keywords="cognitive aging",
keywords="dementia",
keywords="residential facilities",
keywords="virtual reality",
abstract="Background: Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited. Objective: This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care. Methods: In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group. Results: Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=?2.24, SE 1.89; t40=?1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=?0.26, SE 1.66; t40=?0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen ($\Chi$22=11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores. Conclusions: Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-046030 ",
doi="10.2196/29210",
url="https://www.jmir.org/2021/9/e29210",
url="http://www.ncbi.nlm.nih.gov/pubmed/34542418"
}


@Article{info:doi/10.2196/24307,
author="Keijsers, Merel
and Vega-Corredor, Cecilia Maria
and Tomintz, Melanie
and Hoermann, Simon",
title="Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I ``Virtually'' Quit): Systematic Review",
journal="J Med Internet Res",
year="2021",
month="Sep",
day="17",
volume="23",
number="9",
pages="e24307",
keywords="virtual reality technology",
keywords="nicotine dependency",
keywords="nicotine addiction",
keywords="smoking addiction",
keywords="smoking intervention",
keywords="smoking therapy",
keywords="Electronic Nicotine Delivery Systems",
abstract="Background: Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy. Objective: This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development. Methods: A literature review of smoking interventions using VRT was conducted. Results: Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT. Conclusions: The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures. ",
doi="10.2196/24307",
url="https://www.jmir.org/2021/9/e24307",
url="http://www.ncbi.nlm.nih.gov/pubmed/34533471"
}


@Article{info:doi/10.2196/28400,
author="Kwan, Cho Rick Yiu
and Liu, Wa Justina Yat
and Fong, Kuen Kenneth Nai
and Qin, Jing
and Leung, Kwok-Yuen Philip
and Sin, Kan Olive Suk
and Hon, Yuen Pik
and Suen, W. Lydia
and Tse, Man-Kei
and Lai, KY Claudia",
title="Feasibility and Effects of Virtual Reality Motor-Cognitive Training in Community-Dwelling Older People With Cognitive Frailty: Pilot Randomized Controlled Trial",
journal="JMIR Serious Games",
year="2021",
month="Aug",
day="6",
volume="9",
number="3",
pages="e28400",
keywords="virtual reality",
keywords="motor-cognitive training",
keywords="cognitive frailty",
keywords="game",
keywords="feasibility",
keywords="VR",
keywords="training",
keywords="older adults",
keywords="frail",
keywords="pilot study",
keywords="randomized controlled trial",
abstract="Background: Cognitive frailty refers to the coexistence of physical frailty and cognitive impairment, and is associated with many adverse health outcomes. Although cognitive frailty is prevalent in older people, motor-cognitive training is effective at enhancing cognitive and physical function. We proposed a virtual reality (VR) simultaneous motor-cognitive training program, which allowed older people to perform daily activities in a virtual space mimicking real environments. Objective: We aimed to (1) explore the feasibility of offering VR simultaneous motor-cognitive training to older people with cognitive frailty and (2) compare its effects with an existing motor-cognitive training program in the community on the cognitive function and physical function of older people with cognitive frailty. Methods: A two-arm (1:1), assessor-blinded, parallel design, randomized controlled trial was employed. The eligibility criteria for participants were: (1) aged ?60 years, (2) community dwelling, and (3) with cognitive frailty. Those in the intervention group received cognitive training (ie, cognitive games) and motor training (ie, cycling on an ergometer) simultaneously on a VR platform, mimicking the daily living activities of older people. Those in the control group received cognitive training (ie, cognitive games) on tablet computers and motor training (ie, cycling on the ergometer) sequentially on a non-VR platform. Both groups received a 30-minute session twice a week for 8 weeks. Feasibility was measured by adherence, adverse outcomes, and successful learning. The outcomes were cognitive function, physical frailty level, and walking speed. Results: Seventeen participants were recruited and randomized to either the control group (n=8) or intervention group (n=9). At baseline, the median age was 74.0 years (IQR 9.5) and the median Montreal Cognitive Assessment score was 20.0 (IQR 4.0). No significant between-group differences were found in baseline characteristics except in the number of chronic illnesses (P=.04). At postintervention, the intervention group (Z=--2.67, P=.01) showed a significantly larger improvement in cognitive function than the control group (Z=--1.19, P=.24). The reduction in physical frailty in the intervention group (Z=--1.73, P=.08) was similar to that in the control group (Z=--1.89, P=.06). Improvement in walking speed based on the Timed Up-and-Go test was moderate in the intervention group (Z=--0.16, P=.11) and greater in the control group (Z=--2.52, P=.01). The recruitment rate was acceptable (17/33, 52\%). Both groups had a 100\% attendance rate. The intervention group had a higher completion rate than the control group. Training was terminated for one participant (1/9, 11\%) due to minimal VR sickness (Virtual Reality Sickness Questionnaire score=18.3/100). Two participants (2/8, 25\%) in the control group withdrew due to moderate leg pain. No injuries were observed in either group. Conclusions: This study provides preliminary evidence that the VR simultaneous motor-cognitive training is effective at enhancing the cognitive function of older people with cognitive frailty. The effect size on frailty was close to reaching a level of significance and was similar to that observed in the control group. VR training is feasible and safe for older people with cognitive frailty. Trial Registration: ClinicalTrials.gov NCT04467216; https://clinicaltrials.gov/ct2/show/NCT04467216 ",
doi="10.2196/28400",
url="https://games.jmir.org/2021/3/e28400",
url="http://www.ncbi.nlm.nih.gov/pubmed/34383662"
}


@Article{info:doi/10.2196/23683,
author="Yuen, Y. Anna S.
and Mak, S. Winnie W.",
title="The Effects of Immersive Virtual Reality in Reducing Public Stigma of Mental Illness in the University Population of Hong Kong: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2021",
month="Jul",
day="14",
volume="23",
number="7",
pages="e23683",
keywords="immersive virtual reality",
keywords="narrative persuasion",
keywords="public stigma",
keywords="mental health stigma",
keywords="sense of embodiment",
keywords="story transportation",
keywords="stigma intervention",
abstract="Background: Public stigma in mental health often brings various adverse effects on people with mental illness. Researchers have been developing different interventions in combating public stigma. Objective: This study investigates the effects of immersive virtual reality (IVR) in reducing the public stigma of mental illness using a single-blinded randomized control trial. Methods: A pre-post experimental design with a 1-week follow-up was conducted. Participants (N=206) were recruited through the mass mail system of The Chinese University of Hong Kong and randomized into 3 conditions: immersive animation, text, and control. In the immersive animation condition (n=72), participants experienced the simulation of daily life and the stigma experienced as an animated story protagonist with mixed anxiety and depressive disorder with IVR. In the text condition (n=65), participants experienced an identical story to the immersive animation condition with first-person audio narration using the same virtual reality headset. In the control condition (n=69), participants watched a video about planets with IVR. All participants received interventions with a researcher-assisted Oculus Go virtual reality headset. Participants' public stigma was measured through self-administered online questionnaires and compared across conditions and at different time points using repeated measures analysis of variance. Simple and sequential mediation analyses on the relationship of condition (immersive animation vs text) and follow-up public stigma with possible mediators, including sense of embodiment and story transportation, were conducted using PROCESS. Results: Public stigma did not differ significantly across conditions at pre-experiment (P>.99). In the immersive animation and text conditions, public stigma was significantly reduced at postexperiment and at the 1-week follow-up compared to pre-experiment (all with P<.001). Public stigma in the control condition at postexperiment and follow-up remained unchanged compared with pre-experiment (P=.69). Immersive animation had significantly lower public stigma than the control at postexperiment (P=.003) and follow-up (P=.02). Text also had lower public stigma than the control at postexperiment (P=.007) and follow-up (P=.03). However, immersive animation did not significantly differ from text in public stigma at postexperiment and follow-up (both P>.99). In simple mediation models, both sense of embodiment (95\% CI --0.22 to 0.46) and story transportation (95\% CI --0.18 to 0.00) were not significant mediators. In the sequential mediation model, both sense of embodiment and story transportation were significant sequential mediators. Sense of embodiment was positively associated with story transportation (P<.001), while story transportation was negatively associated with public stigma (P<.001). The indirect effect of the sequential mediation model was significant (95\% CI --0.38 to --0.11). Conclusions: This study provides novel findings and a rigorous comparison in understanding the effects of IVR on public stigma. The findings showed that IVR and text with audio narration performed similarly and significantly in stigma reduction. Sense of embodiment and story transportation were found to be sequentially associated with public stigma reduction. Trial Registration: Centre for Clinical Research and Biostatistics Clinical Trial Registry CUHK\_Ccrb00638; https://www2.ccrb.cuhk.edu.hk/registry/public/632 ",
doi="10.2196/23683",
url="https://www.jmir.org/2021/7/e23683",
url="http://www.ncbi.nlm.nih.gov/pubmed/34259636"
}


@Article{info:doi/10.2196/29182,
author="Knobel, Johannes Samuel Elia
and Kaufmann, Charlotte Brigitte
and Gerber, Moreno Stephan
and Urwyler, Prabitha
and Cazzoli, Dario
and M{\"u}ri, M. Ren{\'e}
and Nef, Tobias
and Nyffeler, Thomas",
title="Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study",
journal="JMIR Serious Games",
year="2021",
month="Jul",
day="2",
volume="9",
number="3",
pages="e29182",
keywords="virtual reality",
keywords="serious game",
keywords="search task",
keywords="stroke",
keywords="neglect",
keywords="usability",
keywords="development",
keywords="immersion",
keywords="concept",
keywords="gaming",
abstract="Background: Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. Objective: This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. Methods: In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. Results: In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. Conclusions: The developed iVR serious game, ``bird search task,'' was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task. ",
doi="10.2196/29182",
url="https://games.jmir.org/2021/3/e29182",
url="http://www.ncbi.nlm.nih.gov/pubmed/34255653"
}


@Article{info:doi/10.2196/24967,
author="Ridout, Brad
and Kelson, Joshua
and Campbell, Andrew
and Steinbeck, Kate",
title="Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review",
journal="J Med Internet Res",
year="2021",
month="Jun",
day="28",
volume="23",
number="6",
pages="e24967",
keywords="virtual reality",
keywords="hospital",
keywords="pain",
keywords="anxiety",
keywords="adolescents",
abstract="Background: Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents' unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children. Objective: The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research. Methods: PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies. Results: Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality. Conclusions: Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents' interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display\_record.php?ID=CRD42020198760 ",
doi="10.2196/24967",
url="https://www.jmir.org/2021/6/e24967",
url="http://www.ncbi.nlm.nih.gov/pubmed/34185015"
}


@Article{info:doi/10.2196/24526,
author="Kang, Myeong Jae
and Kim, Nambeom
and Lee, Young Sook
and Woo, Kyun Soo
and Park, Geumjin
and Yeon, Kil Byeong
and Park, Woon Jung
and Youn, Jung-Hae
and Ryu, Seung-Ho
and Lee, Jun-Young
and Cho, Seong-Jin",
title="Effect of Cognitive Training in Fully Immersive Virtual Reality on Visuospatial Function and Frontal-Occipital Functional Connectivity in Predementia: Randomized Controlled Trial",
journal="J Med Internet Res",
year="2021",
month="May",
day="6",
volume="23",
number="5",
pages="e24526",
keywords="virtual reality",
keywords="cognitive training",
keywords="visuospatial function",
keywords="fMRI",
keywords="visual network",
keywords="mild cognitive impairment",
abstract="Background: Cognitive training can potentially prevent cognitive decline. However, the results of recent studies using semi-immersive virtual reality (VR)-assisted cognitive training are inconsistent. Objective: We aimed to examine the hypothesis that cognitive training using fully immersive VR, which may facilitate visuospatial processes, could improve visuospatial functioning, comprehensive neuropsychological functioning, psychiatric symptoms, and functional connectivity in the visual brain network in predementia. Methods: Participants over 60 years old with subjective cognitive decline or mild cognitive impairment from a memory clinic were randomly allocated to the VR (n=23) or the control (n=18) group. The VR group participants received multidomain and neuropsychologist-assisted cognitive training in a fully immersive VR environment twice a week for 1 month. The control group participants did not undergo any additional intervention except for their usual therapy such as pharmacotherapy. Participants of both groups were evaluated for cognitive function using face-to-face comprehensive neuropsychological tests, including the Rey-Osterrieth Complex Figure Test (RCFT) copy task; for psychiatric symptoms such as depression, apathy, affect, and quality of life; as well as resting-state functional magnetic resonance imaging (rsfMRI) at baseline and after training. Repeated-measures analysis of variance was used to compare the effect of cognitive training between groups. Seed-to-voxel--based analyses were used to identify the cognitive improvement--related functional connectivity in the visual network of the brain. Results: After VR cognitive training, significant improvement was found in the total score (F1,39=14.69, P=.001) and basic components score of the RCFT copy task (F1,39=9.27, P=.005) compared with those of the control group. The VR group also showed improvements, albeit not significant, in naming ability (F1,39=3.55, P=.07), verbal memory delayed recall (F1,39=3.03, P=.09), and phonemic fluency (F1,39=3.08, P=.09). Improvements in psychiatric symptoms such as apathy (F1,39=7.02, P=.01), affect (F1,39=14.40, P=.001 for positive affect; F1,39=4.23, P=.047 for negative affect), and quality of life (F1,39=4.49, P=.04) were found in the VR group compared to the control group. Improvement in the RCFT copy task was associated with a frontal-occipital functional connectivity increase revealed by rsfMRI in the VR group compared to the control group. Conclusions: Fully immersive VR cognitive training had positive effects on the visuospatial function, apathy, affect, quality of life, and increased frontal-occipital functional connectivity in older people in a predementia state. Future trials using VR cognitive training with larger sample sizes and more sophisticated designs over a longer duration may reveal greater improvements in cognition, psychiatric symptoms, and brain functional connectivity. Trial Registration: Clinical Research Information Service KCT0005243; https://tinyurl.com/2a4kfasa ",
doi="10.2196/24526",
url="https://www.jmir.org/2021/5/e24526",
url="http://www.ncbi.nlm.nih.gov/pubmed/33955835"
}


@Article{info:doi/10.2196/27164,
author="Albright, Glenn
and Khalid, Nikita
and Shockley, Kristen
and Robinson, Kelsey
and Hughes, Kevin
and Pace-Danley, Bethany",
title="Innovative Virtual Role Play Simulations for Managing Substance Use Conversations: Pilot Study Results and Relevance During and After COVID-19",
journal="JMIR Form Res",
year="2021",
month="Apr",
day="29",
volume="5",
number="4",
pages="e27164",
keywords="simulations",
keywords="behavior change",
keywords="motivational interviewing",
keywords="virtual humans",
keywords="role play",
keywords="substance use",
keywords="prevention",
keywords="alcohol",
keywords="public awareness",
keywords="innovation",
keywords="interview",
keywords="COVID-19",
keywords="pilot study",
keywords="simulation",
keywords="communication",
keywords="problem solving",
abstract="Background: Substance use places a substantial burden on our communities, both economically and socially. In light of COVID-19, it is predicted that as many as 75,000 more people will die from alcohol and other substance use and suicide as a result of isolation, new mental health concerns, and various other stressors related to the pandemic. Public awareness campaigns that aim to destigmatize substance use and help individuals have meaningful conversations with friends, coworkers, or family members to address substance use concerns are a timely and cost-effective means of augmenting existing behavioral health efforts related to substance use. These types of interventions can supplement the work being done by existing public health initiatives. Objective: This pilot study examines the impact of the One Degree: Shift the Influence role play simulation, designed to teach family, friends, and coworkers to effectively manage problem-solving conversations with individuals that they are concerned about regarding substance use. Methods: Participants recruited for this mixed methods study completed a presurvey, the simulation, and a postsurvey, and were sent a 6-week follow-up survey. The simulation involves practicing a role play conversation with a virtual human coded with emotions, a memory, and a personality. A virtual coach provides feedback in using evidence-based communication strategies such as motivational interviewing. Results: A matched sample analysis of variance revealed significant increases at follow-up in composite attitudinal constructs of preparedness (P<.001) and self-efficacy (P=.01), including starting a conversation with someone regarding substance use, avoiding upsetting someone while bringing up concerns, focusing on observable facts, and problem solving. Qualitative data provided further evidence of the simulation's positive impact on the ability to have meaningful conversations about substance use. Conclusions: This study provides preliminary evidence that conversation-based simulations like One Degree: Shift the Influence that use role play practice can teach individuals to use evidence-based communication strategies and can cost-effectively reach geographically dispersed populations to support public health initiatives for primary prevention. ",
doi="10.2196/27164",
url="https://formative.jmir.org/2021/4/e27164",
url="http://www.ncbi.nlm.nih.gov/pubmed/33848972"
}


@Article{info:doi/10.2196/25504,
author="Gold, I. Jeffrey
and Annick, T. Erin
and Lane, S. Arianna
and Ho, Katherine
and Marty, T. Ryan
and Espinoza, C. Juan",
title="``Doc McStuffins: Doctor for a Day'' Virtual Reality (DocVR) for Pediatric Preoperative Anxiety and Satisfaction: Pediatric Medical Technology Feasibility Study",
journal="J Med Internet Res",
year="2021",
month="Apr",
day="19",
volume="23",
number="4",
pages="e25504",
keywords="virtual reality (VR)",
keywords="pediatric",
keywords="anxiety",
keywords="preoperative",
keywords="satisfaction",
keywords="Doc McStuffins",
abstract="Background: Preoperative anxiety is a common occurrence among children and is associated with a host of maladaptive postoperative behaviors. Consequently, increased attention has been placed on interventions to reduce preoperative anxiety and its associated outcomes. Child Life preparation prior to surgery includes evidence-based practices such as age-appropriate distraction and therapeutic play. Virtual reality (VR) is a promising addition to the Child Life toolbox to address anxiety prior to surgery. The current study evaluates the implementation and feasibility of a VR experience, ``Doc McStuffins: Doctor for a Day Virtual Reality Experience'' (DocVR), developed by Disney Junior in collaboration with Children's Hospital Los Angeles, to target pediatric preoperative anxiety. Objective: The primary aim of this study was to examine the feasibility and efficacy of DocVR for preoperative anxiety. A secondary aim was to improve patient, caregiver, and health care provider satisfaction with the preoperative experience. Methods: In this study, 51 patients (age 6-14 years) scheduled for surgery in the ambulatory surgery center and the main operating room at Children's Hospital Los Angeles were approached to participate in Disney's DocVR experience. The patients played the DocVR experience for an average of 18 minutes (3-55 minutes). Irrespective of surgical procedure, patients and their families were eligible, as long as they had no known marked cognitive or visual impairments that would interfere with completing the survey and engaging in the DocVR experience. Results: Patients who tried the DocVR experience (n=51) responded overwhelmingly positively to both the VR technology and to the game itself. Patients experienced a statistically significant decrease in anxiety following DocVR game play (Z=--3.26, P=.001). On the Facial Affective Scale, the percentage of patients who chose the face with the most positive facial expression to represent their affect increased from 23\% (12/51) pre-VR to 49\% (25/47) post-VR. Furthermore, 97\% (38/39) of patients reported feeling more comfortable at the hospital, and 74\% (28/38) reported feeling less scared at the hospital after playing the game. The game was enjoyed by 94\% (46/49) of patients, and 88\% (30/34) of patients reported feeling both ``Interested'' and ``Involved'' in the game. Conclusions: DocVR is a feasible and beneficial VR experience to relieve pediatric preoperative anxiety and improve satisfaction in the preoperative area. The VR experience resulted in a decrease in overall anxiety and an increase in overall positive affect during the preoperative time. Patients also responded positively to the game, confirming their interest in the content and affirming the quality of the DocVR experience. The positive response to the game indicates that DocVR has the potential to make the overall preoperative experience less anxiety-producing and more comfortable, which leads to improved patient satisfaction. Naturally, improved patient outcomes lead to improved caregiver and health care provider satisfaction. ",
doi="10.2196/25504",
url="https://www.jmir.org/2021/4/e25504",
url="http://www.ncbi.nlm.nih.gov/pubmed/33730687"
}


@Article{info:doi/10.2196/25731,
author="Hur, Ji-Won
and Shin, Hyemin
and Jung, Dooyoung
and Lee, Heon-Jeong
and Lee, Sungkil
and Kim, J. Gerard
and Cho, Chung-Yean
and Choi, Seungmoon
and Lee, Seung-Moo
and Cho, Chul-Hyun",
title="Virtual Reality--Based Psychotherapy in Social Anxiety Disorder: fMRI Study Using a Self-Referential Task",
journal="JMIR Ment Health",
year="2021",
month="Apr",
day="14",
volume="8",
number="4",
pages="e25731",
keywords="virtual reality",
keywords="VR",
keywords="social anxiety",
keywords="social phobia",
keywords="exposure therapy",
keywords="fMRI",
keywords="unctional magnetic resonance imaging",
abstract="Background: Although it has been well demonstrated that the efficacy of virtual reality therapy for social anxiety disorder is comparable to that of traditional cognitive behavioral therapy, little is known about the effect of virtual reality on pathological self-referential processes in individuals with social anxiety disorder. Objective: We aimed to determine changes in self-referential processing and their neural mechanisms following virtual reality treatment. Methods: We recruited participants with and without a primary diagnosis of social anxiety disorder to undergo clinical assessments (Social Phobia Scale and Post-Event Rumination Scale) and functional magnetic resonance imaging (fMRI) scans. Participants with social anxiety disorder received virtual reality--based exposure treatment for 6 sessions starting immediately after baseline testing. After the sixth session, participants with social anxiety disorder completed follow-up scans during which they were asked to judge whether a series of words (positive, negative, neutral) was relevant to them. Results: Of 25 individuals with social anxiety disorder who participated in the study, 21 completed the sessions and follow-up; 22 control individuals also participated. There were no significant differences in age (P=.36), sex (P=.71), or handedness (P=.51) between the groups. Whole-brain analysis revealed that participants in the social anxiety disorder group had increased neural responses during positive self-referential processing in the medial temporal and frontal cortexes compared with those in the control group. Participants in the social anxiety disorder group also showed increased left insular activation and decreased right middle frontal gyrus activation during negative self-referential processing. After undergoing virtual reality--based therapy, overall symptoms of the participants with social anxiety disorder were reduced, and these participants exhibited greater activity in a brain regions responsible for self-referential and autobiographical memory processes while viewing positive words during postintervention fMRI scans. Interestingly, the greater the blood oxygen level dependent changes related to positive self-referential processing, the lower the tendency to ruminate on the negative events and the lower the social anxiety following the virtual reality session. Compared with that at baseline, higher activation was also found within broad somatosensory areas in individuals with social anxiety disorder during negative self-referential processing following virtual reality therapy. Conclusions: These fMRI findings might reflect the enhanced physiological and cognitive processing in individuals with social anxiety disorder in response to self-referential information. They also provide neural evidence of the effect of virtual reality exposure therapy on social anxiety and self-derogation. ",
doi="10.2196/25731",
url="https://mental.jmir.org/2021/4/e25731",
url="http://www.ncbi.nlm.nih.gov/pubmed/33851931"
}


@Article{info:doi/10.2196/24998,
author="Langlet, Sundstr{\"o}m Billy
and Odegi, Dorothy
and Zandian, Modjtaba
and Nolstam, Jenny
and S{\"o}dersten, Per
and Bergh, Cecilia",
title="Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study",
journal="JMIR Serious Games",
year="2021",
month="Apr",
day="13",
volume="9",
number="2",
pages="e24998",
keywords="feeding and eating disorders",
keywords="anorexia nervosa",
keywords="bulimia nervosa",
keywords="binge eating disorder",
keywords="immersive virtual reality",
keywords="eating disorders",
keywords="virtual reality",
abstract="Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50\%, a dropout rate from 20\% to 50\%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall ``good'' rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the ``accuracy'' item. During the cognitive walkthrough, 32\% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. ",
doi="10.2196/24998",
url="https://games.jmir.org/2021/2/e24998",
url="http://www.ncbi.nlm.nih.gov/pubmed/33847593"
}


@Article{info:doi/10.2196/22008,
author="Fehribach, Rhiannon Jamie
and Toffolo, Jolien Marieke Bianca
and Cornelisz, Ilja
and van Klaveren, Chris
and van Straten, Annemieke
and van Gelder, Jean-Louis
and Donker, Tara",
title="Virtual Reality Self-help Treatment for Aviophobia: Protocol for a Randomized Controlled Trial",
journal="JMIR Res Protoc",
year="2021",
month="Apr",
day="12",
volume="10",
number="4",
pages="e22008",
keywords="aviophobia",
keywords="specific phobia",
keywords="virtual reality",
keywords="cognitive behavioral therapy",
keywords="exposure therapy",
abstract="Background: Aviophobia (the fear of flying) can greatly impact the daily life functioning of people with the condition. Traditional exposure-based treatment is hampered by the limited availability of airplane practice situations, which is a result of economical and practical concerns. Easily accessible and low-cost virtual reality exposure therapy may address these challenges. Objective: The purpose of our study is to investigate the effectiveness of ZeroPhobia: Aviophobia (a self-help mobile app--based treatment) in reducing flight anxiety symptoms and depressive and anxiety symptoms. We will also investigate the effects of usage intensity, the sense of immersion, inherent absorption ability, and perceived user-friendliness on the treatment effect. Methods: Participants (N=114) who are aged 18-64 years and experience at least mild symptoms of aviophobia will be recruited from the general Dutch population and randomized into a treatment group or waitlist control group. By using their own phones and rudimentary mobile virtual reality headsets, participants will receive six modules of psychoeducation and cognitive behavioral therapy, which will include six levels of virtual reality exposure therapy over a period of 6 weeks. Assessments will be conducted at baseline, posttest (ie, after 6 weeks), and 3- and 12-month follow-ups. The primary outcome measure of our study is the Flight Anxiety Situations Questionnaire. The secondary outcome measures include anxiety and depression measures and additional covariates (including usage intensity, the degree of immersion, etc). We will test treatment effectiveness by conducting an intention-to-treat analysis and estimating average treatment effects on the treated. The mechanisms of treatment effect will also be explored. Results: The study was funded on September 25, 2018. Ethical approval was received on October 11, 2019. Recruitment closed on May 7, 2020. Conclusions: Our study will further the scientific understanding and clinical implications of technology's current ability to aid in providing effective, accessible treatment for the fear of flying. Trial Registration: Netherlands Trial Registry NL70238.029.19; https://www.trialregister.nl/trial/8257. International Registered Report Identifier (IRRID): DERR1-10.2196/22008 ",
doi="10.2196/22008",
url="https://www.researchprotocols.org/2021/4/e22008",
url="http://www.ncbi.nlm.nih.gov/pubmed/33843605"
}


@Article{info:doi/10.2196/24170,
author="Hassandra, Mary
and Galanis, Evangelos
and Hatzigeorgiadis, Antonis
and Goudas, Marios
and Mouzakidis, Christos
and Karathanasi, Maria Eleni
and Petridou, Niki
and Tsolaki, Magda
and Zikas, Paul
and Evangelou, Giannis
and Papagiannakis, George
and Bellis, George
and Kokkotis, Christos
and Panagiotopoulos, Rafail Spyridon
and Giakas, Giannis
and Theodorakis, Yannis",
title="$\Alpha$ Virtual Reality App for Physical and Cognitive Training of Older People With Mild Cognitive Impairment: Mixed Methods Feasibility Study",
journal="JMIR Serious Games",
year="2021",
month="Mar",
day="24",
volume="9",
number="1",
pages="e24170",
keywords="virtual reality",
keywords="elderly",
keywords="mild cognitive impairment",
keywords="combined physical and cognitive function",
keywords="dual task",
abstract="Background: Therapeutic virtual reality (VR) has emerged as an effective treatment modality for cognitive and physical training in people with mild cognitive impairment (MCI). However, to replace existing nonpharmaceutical treatment training protocols, VR platforms need significant improvement if they are to appeal to older people with symptoms of cognitive decline and meet their specific needs. Objective: This study aims to design and test the acceptability, usability, and tolerability of an immersive VR platform that allows older people with MCI symptoms to simultaneously practice physical and cognitive skills on a dual task. Methods: On the basis of interviews with 20 older people with MCI symptoms (15 females; mean age 76.25, SD 5.03 years) and inputs from their health care providers (formative study VR1), an interdisciplinary group of experts developed a VR system called VRADA (VR Exercise App for Dementia and Alzheimer's Patients). Using an identical training protocol, the VRADA system was first tested with a group of 30 university students (16 females; mean age 20.86, SD 1.17 years) and then with 27 older people (19 females; mean age 73.22, SD 9.26 years) who had been diagnosed with MCI (feasibility studies VR2a and VR2b). Those in the latter group attended two Hellenic Association Day Care Centers for Alzheimer's Disease and Related Disorders. Participants in both groups were asked to perform a dual task training protocol that combined physical and cognitive exercises in two different training conditions. In condition A, participants performed a cycling task in a lab environment while being asked by the researcher to perform oral math calculations (single-digit additions and subtractions). In condition B, participants performed a cycling task in the virtual environment while performing calculations that appeared within the VR app. Participants in both groups were assessed in the same way; this included questionnaires and semistructured interviews immediately after the experiment to capture perceptions of acceptability, usability, and tolerability, and to determine which of the two training conditions each participant preferred. Results: Participants in both groups showed a significant preference for the VR condition (students: mean 0.66, SD 0.41, t29=8.74, P<.001; patients with MCI: mean 0.72, SD 0.51, t26=7.36, P<.001), as well as high acceptance scores for intended future use, attitude toward VR training, and enjoyment. System usability scale scores (82.66 for the students and 77.96 for the older group) were well above the acceptability threshold (75/100). The perceived adverse effects were minimal, indicating a satisfactory tolerability. Conclusions: The findings suggest that VRADA is an acceptable, usable, and tolerable system for physical and cognitive training of older people with MCI and university students. Randomized controlled trial studies are needed to assess the ef?cacy of VRADA as a tool to promote physical and cognitive health in patients with MCI. ",
doi="10.2196/24170",
url="https://games.jmir.org/2021/1/e24170",
url="http://www.ncbi.nlm.nih.gov/pubmed/33759797"
}


@Article{info:doi/10.2196/25322,
author="Xue, Jia
and Hu, Ran
and Zhang, Wenzhao
and Zhao, Yaxi
and Zhang, Bolun
and Liu, Nian
and Li, Sam-Chin
and Logan, Judith",
title="Virtual Reality or Augmented Reality as a Tool for Studying Bystander Behaviors in Interpersonal Violence: Scoping Review",
journal="J Med Internet Res",
year="2021",
month="Feb",
day="15",
volume="23",
number="2",
pages="e25322",
keywords="virtual reality",
keywords="augmented reality",
keywords="bystander behaviors",
keywords="interpersonal violence",
keywords="violent incidents",
keywords="people's responses",
keywords="dating violence",
keywords="sexual violence",
abstract="Background: To provide participants with a more real and immersive intervening experience, virtual reality (VR) and/or augmented reality (AR) technologies have been integrated into some bystander intervention training programs and studies measuring bystander behaviors. Objective: We focused on whether VR or AR can be used as a tool to enhance training bystanders. We reviewed the evidence from empirical studies that used VR and/or AR as a tool for examining bystander behaviors in the domain of interpersonal violence research. Methods: Two librarians searched for articles in databases, including APA PsycInfo (Ovid), Criminal Justice Abstracts (EBSCO), Medline (Ovid), Applied Social Sciences Index \& Abstracts (ProQuest), Sociological Abstracts (ProQuest), and Scopus till April 15, 2020. Studies focusing on bystander behaviors in conflict situations were included. All study types (except reviews) written in English in any discipline were included. Results: The search resulted in 12,972 articles from six databases, and the articles were imported into Covidence. Eleven studies met the inclusion and exclusion criteria. All 11 articles examined the use of VR as a tool for studying bystander behaviors. Most of the studies were conducted in US young adults. The types of interpersonal violence were school bullying, dating violence, sexual violence/assault, and soccer-associated violence. VR technology was used as an observational measure and bystander intervention program. We evaluated the different uses of VR for bystander behaviors and noted a lack of empirical evidence for AR as a tool. We also discuss the empirical evidence regarding the design, effectiveness, and limitations of implementing VR as a tool in the reviewed studies. Conclusions: The reviewed results have implications and recommendations for future research in designing and implementing VR/AR technology in the area of interpersonal violence. Future studies in this area may further contribute to the use of VR as an observational measure and explore the potential use of AR to study bystander behaviors. ",
doi="10.2196/25322",
url="http://www.jmir.org/2021/2/e25322/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33587044"
}


@Article{info:doi/10.2196/22406,
author="Appel, Lora
and Kisonas, Erika
and Appel, Eva
and Klein, Jennifer
and Bartlett, Deanna
and Rosenberg, Jarred
and Smith, NC Christopher",
title="Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study",
journal="JMIR Form Res",
year="2021",
month="Feb",
day="3",
volume="5",
number="2",
pages="e22406",
keywords="virtual reality",
keywords="wearable electronic devices",
keywords="sensory art therapies",
keywords="hospitalization",
keywords="hospitals, community",
keywords="hospitals, general",
keywords="aged",
keywords="humans",
keywords="dementia",
keywords="behavioral symptoms",
keywords="nature",
keywords="mobile phone",
abstract="Background: As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals. Objective: This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia. Methods: A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator--facilitated sessions of viewing immersive 360{\textdegree} VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience. Results: All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70\%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10\%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported. Conclusions: It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals. ",
doi="10.2196/22406",
url="https://formative.jmir.org/2021/2/e22406",
url="http://www.ncbi.nlm.nih.gov/pubmed/33533720"
}


@Article{info:doi/10.2196/22494,
author="Shin, Yu-Bin
and Kim, Jae-Jin
and Kim, Hyunji
and Kim, Soo-Jeong
and Eom, Hyojung
and Jung, Hoon Young
and Kim, Eunjoo",
title="Managing Game-Related Conflict With Parents of Young Adults With Internet Gaming Disorder: Development and Feasibility Study of a Virtual Reality App",
journal="JMIR Serious Games",
year="2021",
month="Jan",
day="18",
volume="9",
number="1",
pages="e22494",
keywords="internet gaming disorder",
keywords="family conflict",
keywords="coping behavior",
keywords="virtual reality",
abstract="Background: Individuals with internet gaming disorder (IGD) report facing family conflicts repeatedly because of their excessive internet gaming. With recent advancements in virtual reality (VR) technology, VR therapy has emerged as a promising method for the management of various psychiatric disorders, including IGD. Given that several risk and protective factors for young people with addiction can be influenced by their interpersonal context, the potential utility of VR-based apps for managing family conflicts needs to be examined with reference to IGD management. However, few studies have evaluated potential treatment modules related to interpersonal conflict management, such as emotion regulation and taking the perspective of others. Objective: This preliminary study aims to examine the potential use of a VR-based app in the management of game-related conflicts with parents of young adults with IGD and matched controls. Methods: In total, 50 young male adults (24 with IGD and 26 controls) were recruited to participate in the study. We developed a virtual room where game-related family conflicts arise. Using this room, participants completed 2 VR tasks that required them to express anger and then implement coping skills (ie, risk/benefit assessment of stopping a game and taking parents' perspective) to deal with negative emotions in interpersonal conflict situations and to decrease one's gaming behavior. Results: The results showed that immersion in our VR app tended to provoke negative emotions in individuals with IGD. In addition, after a risk/benefit assessment of stopping a game, the response of stopping a game immediately increased significantly in the IGD group, suggesting that patients' gaming behavior could be changed using our VR program. Furthermore, in individuals with IGD, longer gaming hours were associated with a lower level of perceived usefulness of the coping skills training. Conclusions: The findings of this study indicate that our VR app may be useful for implementing more desirable behaviors and managing gaming-related family conflicts in individuals with IGD. Our VR app may offer an alternative for individuals with IGD to learn how a vicious cycle of conflicts is developed and to easily and safely assess their dysfunctional thoughts behind the conflicts (ie, perceived unreasonable risks of stopping a game and thoughts acting as a barrier to taking the perspective of others). ",
doi="10.2196/22494",
url="http://games.jmir.org/2021/1/e22494/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33459603"
}


@Article{info:doi/10.2196/24331,
author="Paul, Margot
and Bullock, Kim
and Bailenson, Jeremy",
title="Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report",
journal="JMIR Ment Health",
year="2020",
month="Nov",
day="3",
volume="7",
number="11",
pages="e24331",
keywords="virtual reality",
keywords="case report",
keywords="major depressive disorder",
keywords="behavioral activation",
keywords="VR",
keywords="depression",
keywords="COVID-19",
keywords="behavior",
keywords="intervention",
keywords="feasibility",
keywords="acceptability",
keywords="telehealth",
keywords="pilot study",
abstract="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 ",
doi="10.2196/24331",
url="https://mental.jmir.org/2020/11/e24331",
url="http://www.ncbi.nlm.nih.gov/pubmed/33031046"
}


@Article{info:doi/10.2196/17808,
author="Nijman, Anne Saskia
and Veling, Wim
and Greaves-Lord, Kirstin
and Vos, Maarten
and Zandee, Regina Catharina Elizabeth
and Aan het Rot, Marije
and Geraets, Wil Chris Neeltje
and Pijnenborg, Maria Gerdina Hendrika",
title="Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) for People With a Psychotic Disorder: Single-Group Feasibility and Acceptability Study",
journal="JMIR Ment Health",
year="2020",
month="Aug",
day="7",
volume="7",
number="8",
pages="e17808",
keywords="social cognition",
keywords="virtual reality",
keywords="psychotic disorder",
keywords="cognitive remediation therapy",
keywords="emotion perception",
keywords="theory of mind",
keywords="social cognition training",
abstract="Background: People with a psychotic disorder commonly experience problems in social cognition and functioning. Social cognition training (SCT) improves social cognition, but may inadequately simulate real-life social interactions. Virtual reality (VR) provides a realistic, interactive, customizable, and controllable training environment, which could facilitate the application of skills in daily life. Objective: We developed a 16-session immersive VR SCT (Dynamic Interactive Social Cognition Training in Virtual Reality [DiSCoVR]) and conducted a single-group feasibility pilot study. Methods: A total of 22 people with a psychotic disorder and reported problems in social cognition participated. Feasibility and acceptability were assessed using a survey for participants and therapists, and by examining relevant parameters (eg, dropouts). We analyzed preliminary treatment effects on social cognition, neurocognition, and psychiatric symptoms. Results: A total of 17 participants completed the study. Participants enjoyed DiSCoVR (mean 7.25, SD 2.05; range 3-10), thought it was useful for daily social activities (mean 7.00, SD 2.05; range 3-10), and enjoyed the combination of VR and a therapist (mean 7.85, SD 2.11; range 3-10). The most frequently mentioned strength of DiSCoVR was the opportunity to practice with personalized social situations (14/20, 70\%). A significant improvement of emotion perception was observed (Ekman 60 Faces; t16=--4.79, P<.001, d=--0.67), but no significant change was found in other measures of social cognition, neurocognition, psychiatric symptoms, or self-esteem. Conclusions: DiSCoVR was feasible and acceptable to participants and therapists, and may improve emotion perception. ",
doi="10.2196/17808",
url="https://mental.jmir.org/2020/8/e17808",
url="http://www.ncbi.nlm.nih.gov/pubmed/32763880"
}


@Article{info:doi/10.2196/17096,
author="Cheng, Ya-Wen Vivian
and Huang, Chiu-Mieh
and Liao, Jung-Yu
and Hsu, Hsiao-Pei
and Wang, Shih-Wen
and Huang, Su-Fei
and Guo, Jong-Long",
title="Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults' Psychological Health: Quasi-Experimental Study",
journal="J Med Internet Res",
year="2020",
month="Jul",
day="23",
volume="22",
number="7",
pages="e17096",
keywords="three-dimensional",
keywords="virtual reality",
keywords="aromatherapy",
keywords="older adult",
keywords="happiness",
keywords="stress",
keywords="sleep quality",
keywords="meditation",
keywords="life satisfaction",
abstract="Background: In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown. Objective: A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan. Methods: A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention. Results: Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all P<.001). Another GEE analysis showed that the significant improvements in the 5 outcome variables persisted in participants aged 80 years and older (n=35; all P<.001). Conclusions: This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults' psychological health. The results are promising for the promotion of psychological health in institutionalized older adults. Trial Registration: ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216. ",
doi="10.2196/17096",
url="http://www.jmir.org/2020/7/e17096/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32706660"
}


@Article{info:doi/10.2196/14369,
author="Cadieux, Lee
and Keenan, Mickey",
title="Can Social Communication Skills for Children Diagnosed With Autism Spectrum Disorder Rehearsed Inside the Video Game Environment of Minecraft Generalize to the Real World?",
journal="JMIR Serious Games",
year="2020",
month="May",
day="12",
volume="8",
number="2",
pages="e14369",
keywords="autism",
keywords="behavior analysis",
keywords="serious games",
keywords="social skills",
keywords="gamification",
keywords="Lego",
keywords="neurodiversity",
keywords="Minecraft",
keywords="virtual worlds",
keywords="virtual reality",
doi="10.2196/14369",
url="http://games.jmir.org/2020/2/e14369/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32396129"
}


@Article{info:doi/10.2196/17098,
author="Pot-Kolder, Roos
and Veling, Wim
and Geraets, Chris
and Lokkerbol, Joran
and Smit, Filip
and Jongeneel, Alyssa
and Ising, Helga
and van der Gaag, Mark",
title="Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial",
journal="J Med Internet Res",
year="2020",
month="May",
day="5",
volume="22",
number="5",
pages="e17098",
keywords="psychosis",
keywords="virtual reality",
keywords="cognitive behavioral therapy",
keywords="cost-effectiveness",
abstract="Background: Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking. Objective: This study aimed to determine the short-term cost-effectiveness of VR-CBT. Methods: The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20\% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al's conversion factor to map a change in the standardized mean difference of Green's Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained. Results: The average mean incremental costs for a treatment responder on social participation ranged between {\texteuro}8079 and {\texteuro}19,525, with 90.74\%-99.74\% showing improvement. The average incremental cost per QALY was {\texteuro}48,868 over the 6 months of follow-up, with 99.98\% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between {\texteuro}6800 and {\texteuro}16,597, while the average cost per QALY gained was {\texteuro}42,030. Conclusions: This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients' health in a cost-effective manner. Long-term effects need further research. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657 ",
doi="10.2196/17098",
url="https://www.jmir.org/2020/5/e17098",
url="http://www.ncbi.nlm.nih.gov/pubmed/32369036"
}


@Article{info:doi/10.2196/17807,
author="Lindner, Philip
and Rozental, Alexander
and Jurell, Alice
and Reuterski{\"o}ld, Lena
and Andersson, Gerhard
and Hamilton, William
and Miloff, Alexander
and Carlbring, Per",
title="Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia:  Qualitative Study",
journal="JMIR Serious Games",
year="2020",
month="Apr",
day="29",
volume="8",
number="2",
pages="e17807",
keywords="virtual reality",
keywords="gamification",
keywords="serious game",
keywords="exposure therapy",
keywords="phobia",
keywords="user experience",
abstract="Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders,  and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention. Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods. Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis. Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal. Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences. ",
doi="10.2196/17807",
url="http://games.jmir.org/2020/2/e17807/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32347803"
}


@Article{info:doi/10.2196/16724,
author="Krohn, Stephan
and Tromp, Johanne
and Quinque, M. Eva
and Belger, Julia
and Klotzsche, Felix
and Rekers, Sophia
and Chojecki, Paul
and de Mooij, Jeroen
and Akbal, Mert
and McCall, Cade
and Villringer, Arno
and Gaebler, Michael
and Finke, Carsten
and Th{\"o}ne-Otto, Angelika",
title="Multidimensional Evaluation of Virtual Reality Paradigms in Clinical Neuropsychology: Application of the VR-Check Framework",
journal="J Med Internet Res",
year="2020",
month="Apr",
day="27",
volume="22",
number="4",
pages="e16724",
keywords="virtual reality",
keywords="neuropsychology",
keywords="cognition",
keywords="research design",
doi="10.2196/16724",
url="https://www.jmir.org/2020/4/e16724",
url="http://www.ncbi.nlm.nih.gov/pubmed/32338614"
}


@Article{info:doi/10.2196/16386,
author="Brown, Theresa
and Nauman Vogel, Emily
and Adler, Sarah
and Bohon, Cara
and Bullock, Kim
and Nameth, Katherine
and Riva, Giuseppe
and Safer, L. Debra
and Runfola, D. Cristin",
title="Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy",
journal="J Med Internet Res",
year="2020",
month="Apr",
day="23",
volume="22",
number="4",
pages="e16386",
keywords="virtual reality",
keywords="exposure therapy",
keywords="eating disorders",
keywords="translational research",
keywords="technological innovation",
doi="10.2196/16386",
url="http://www.jmir.org/2020/4/e16386/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32324145"
}


@Article{info:doi/10.2196/15872,
author="Noben, Lore
and Goossens, Anna Simone Maria Theresia
and Truijens, Marieke Sophie Eva
and van Berckel, Georgine Marijn Marthe
and Perquin, Wilhelmina Christel
and Slooter, Dirk Gerrit
and van Rooijen, Johannes Stefanus",
title="A Virtual Reality Video to Improve Information Provision and Reduce Anxiety Before Cesarean Delivery: Randomized Controlled Trial",
journal="JMIR Ment Health",
year="2019",
month="Dec",
day="18",
volume="6",
number="12",
pages="e15872",
keywords="virtual reality",
keywords="cesarean section",
keywords="counseling",
keywords="preoperative care",
keywords="surgery",
keywords="anxiety",
keywords="childbirth",
abstract="Background: Anxiety levels before cesarean delivery (CD) can lead to a negative birth experience, which may influence several aspects of the woman's life in the long term. Improving preoperative information may lower preoperative anxiety and lead to a more positive birth experience. Objective: This study aimed to determine whether a virtual reality (VR) video in addition to standard preoperative information decreases anxiety levels before a planned CD. Methods: Women scheduled to undergo term elective CD were recruited from the outpatient clinic. They were randomized and stratified based on history of emergency CD (yes or no). All participants received standard preoperative information (folder leaflets and counseling by the obstetrician); the VR group additionally watched the VR video showing all aspects of CD such as the ward admission, operating theater, spinal analgesia, and moment of birth. The primary outcome measure was a change in score on the Visual Analogue Scale for Anxiety ($\Delta$VAS-A) measured at admission for CD, compared with the baseline VAS-A score. Results: A total of 97 women were included for analysis. The baseline characteristics were similar in both groups, except for a significantly higher level of education in the control group. There was no significant decrease in the VAS-A score of the women in the VR group (n=49) compared with those in the control group (n=48; $\Delta$VAS-A=1.0; P=.08; 95\% CI ?0.1 to 2.0). Subgroup analysis for the group of women with a history of emergency CD showed a trend toward decreased preoperative anxiety, despite the small sample size of this subgroup (n=17; P=.06). Of the 26 participants who provided completed questionnaires, 22 (85\%) in the VR group reported feeling more prepared after seeing the VR video; of the 24 participants' partners who completed the questionnaires, 19 (79\%) agreed with the participants. No discomfort or motion sickness was reported. Conclusions: A VR video may help patients and their partners feel better prepared when planning a CD. This study showed that VR does not lead to a decrease in preoperative anxiety. However, subgroups such as women with a history of emergency CD may benefit from VR videos. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 74794447; http://www.isrctn.com/ISRCTN74794447 (retrospectively registered) ",
doi="10.2196/15872",
url="http://mental.jmir.org/2019/12/e15872/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31850850"
}


@Article{info:doi/10.2196/12972,
author="Kip, Hanneke
and Kelders, M. Saskia
and Bouman, A. Yvonne H.
and van Gemert-Pijnen, C. Lisette J. E. W.",
title="The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care",
journal="J Med Internet Res",
year="2019",
month="Aug",
day="19",
volume="21",
number="8",
pages="e12972",
keywords="eHealth",
keywords="technology development",
keywords="virtual reality",
keywords="forensic psychiatry",
keywords="community-based participatory research",
keywords="human-centered design",
keywords="case study",
abstract="Background: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them. Objective: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap). Methods: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method. Results: Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal. Conclusions: Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model's underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed. ",
doi="10.2196/12972",
url="http://www.jmir.org/2019/8/e12972/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31429415"
}


@Article{info:doi/10.2196/13633,
author="Ose, Osborg Solveig
and F{\ae}revik, Hilde
and Kaasb{\o}ll, Jannike
and Lindgren, Martin
and Thaulow, Kristin
and Antonsen, Stig
and Burkeland, Olav",
title="Exploring the Potential for Use of Virtual Reality Technology in the Treatment of Severe Mental Illness Among Adults in Mid-Norway: Collaborative Research Between Clinicians and Researchers",
journal="JMIR Form Res",
year="2019",
month="Jun",
day="10",
volume="3",
number="2",
pages="e13633",
keywords="virtual reality",
keywords="severe mental illness",
keywords="collaborative research",
keywords="technology",
keywords="social work",
abstract="Background: Virtual reality (VR) technology is not currently used in the treatment of severe mental health illness in Norway. Objective: We aimed to explore the potential of VR as a treatment for severe mental health illness in Norway, through collaborative research between clinicians and researchers. Methods: A collaborative research team was established, comprising researchers, the manager at a district psychiatric center, and the manager of the local municipal mental health service. An all-day workshop with eight clinicians---four from specialist mental health services and four from municipal mental health services---was conducted. The clinicians watched three different VR movies and after each one, they answered predefined questions designed to reflect their immediate thoughts about VR's potential use in clinical practice. At the end of the workshop, two focus group interviews, each with four clinicians from each service level, were conducted. Results: VR technology in specialist services might be a new tool for the treatment of severe mental health illness. In municipal mental health services, VR might particularly be useful in systematic social training that would otherwise take a very long time to complete. Conclusions: We found substantial potential for the use of VR in the treatment of severe mental health illness in specialist and municipal mental health services. One of the uses of VR technology with the greatest potential was helping individuals who had isolated themselves and needed training in social skills and everyday activity to enable them to have more active social lives. VR could also be used to simulate severe mental illness to provide a better understanding of how the person with severe mental illness experiences their situation. ",
doi="10.2196/13633",
url="http://formative.jmir.org/2019/2/e13633/",
url="http://www.ncbi.nlm.nih.gov/pubmed/31199315"
}


@Article{info:doi/10.2196/11973,
author="Birckhead, Brandon
and Khalil, Carine
and Liu, Xiaoyu
and Conovitz, Samuel
and Rizzo, Albert
and Danovitch, Itai
and Bullock, Kim
and Spiegel, Brennan",
title="Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study",
journal="JMIR Ment Health",
year="2019",
month="Jan",
day="31",
volume="6",
number="1",
pages="e11973",
keywords="clinical trials",
keywords="consensus",
keywords="virtual reality",
abstract="Background: Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed. Objective: We aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments. Methods: A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments. Results: The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs---VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided. Conclusions: Patients, providers, payers, and regulators should consider this best practice framework when assessing the validity of VR treatments. ",
doi="10.2196/11973",
url="https://mental.jmir.org/2019/1/e11973/",
url="http://www.ncbi.nlm.nih.gov/pubmed/30702436"
}


@Article{info:doi/10.2196/jmir.6553,
author="Provoost, Simon
and Lau, Ming Ho
and Ruwaard, Jeroen
and Riper, Heleen",
title="Embodied Conversational Agents in Clinical Psychology: A Scoping Review",
journal="J Med Internet Res",
year="2017",
month="May",
day="09",
volume="19",
number="5",
pages="e151",
keywords="eHealth",
keywords="review",
keywords="embodied conversational agent",
keywords="human computer interaction",
keywords="clinical psychology",
keywords="mental disorders",
keywords="intelligent agent",
keywords="health behavior",
abstract="Background: Embodied conversational agents (ECAs) are computer-generated characters that simulate key properties of human face-to-face conversation, such as verbal and nonverbal behavior. In Internet-based eHealth interventions, ECAs may be used for the delivery of automated human support factors. Objective: We aim to provide an overview of the technological and clinical possibilities, as well as the evidence base for ECA applications in clinical psychology, to inform health professionals about the activity in this field of research. Methods: Given the large variety of applied methodologies, types of applications, and scientific disciplines involved in ECA research, we conducted a systematic scoping review. Scoping reviews aim to map key concepts and types of evidence underlying an area of research, and answer less-specific questions than traditional systematic reviews. Systematic searches for ECA applications in the treatment of mood, anxiety, psychotic, autism spectrum, and substance use disorders were conducted in databases in the fields of psychology and computer science, as well as in interdisciplinary databases. Studies were included if they conveyed primary research findings on an ECA application that targeted one of the disorders. We mapped each study's background information, how the different disorders were addressed, how ECAs and users could interact with one another, methodological aspects, and the study's aims and outcomes. Results: This study included N=54 publications (N=49 studies). More than half of the studies (n=26) focused on autism treatment, and ECAs were used most often for social skills training (n=23). Applications ranged from simple reinforcement of social behaviors through emotional expressions to sophisticated multimodal conversational systems. Most applications (n=43) were still in the development and piloting phase, that is, not yet ready for routine practice evaluation or application. Few studies conducted controlled research into clinical effects of ECAs, such as a reduction in symptom severity. Conclusions: ECAs for mental disorders are emerging. State-of-the-art techniques, involving, for example, communication through natural language or nonverbal behavior, are increasingly being considered and adopted for psychotherapeutic interventions in ECA research with promising results. However, evidence on their clinical application remains scarce. At present, their value to clinical practice lies mostly in the experimental determination of critical human support factors. In the context of using ECAs as an adjunct to existing interventions with the aim of supporting users, important questions remain with regard to the personalization of ECAs' interaction with users, and the optimal timing and manner of providing support. To increase the evidence base with regard to Internet interventions, we propose an additional focus on low-tech ECA solutions that can be rapidly developed, tested, and applied in routine practice. ",
doi="10.2196/jmir.6553",
url="http://www.jmir.org/2017/5/e151/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28487267"
}


@Article{info:doi/10.2196/mental.7387,
author="Tashjian, C. Vartan
and Mosadeghi, Sasan
and Howard, R. Amber
and Lopez, Mayra
and Dupuy, Taylor
and Reid, Mark
and Martinez, Bibiana
and Ahmed, Shahzad
and Dailey, Francis
and Robbins, Karen
and Rosen, Bradley
and Fuller, Garth
and Danovitch, Itai
and IsHak, Waguih
and Spiegel, Brennan",
title="Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial",
journal="JMIR Ment Health",
year="2017",
month="Mar",
day="29",
volume="4",
number="1",
pages="e9",
keywords="pain",
keywords="virtual reality",
keywords="inpatients",
keywords="hospitalization",
abstract="Background: Improvements in software and design and reduction in cost have made virtual reality (VR) a practical tool for immersive, three-dimensional (3D), multisensory experiences that distract patients from painful stimuli. Objective: The objective of the study was to measure the impact of a onetime 3D VR intervention versus a two-dimensional (2D) distraction video for pain in hospitalized patients. Methods: We conducted a comparative cohort study in a large, urban teaching hospital in medical inpatients with an average pain score of ?3/10 from any cause. Patients with nausea, vomiting, dementia, motion sickness, stroke, seizure, and epilepsy and those placed in isolation were excluded. Patients in the intervention cohort viewed a 3D VR experience designed to reduce pain using the Samsung Gear Oculus VR headset; control patients viewed a high-definition, 2D nature video on a 14-inch bedside screen. Pre- and postintervention pain scores were recorded. Difference-in-difference scores and the proportion achieving a half standard deviation pain response were compared between groups. Results: There were 50 subjects per cohort (N=100). The mean pain reduction in the VR cohort was greater than in controls (?1.3 vs ?0.6 points, respectively; P=.008). A total of 35 (65\%) patients in the VR cohort achieved a pain response versus 40\% of controls (P=.01; number needed to treat=4). No adverse events were reported from VR. Conclusions: Use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. These results indicate that VR is an effective and safe adjunctive therapy for pain management in the acute inpatient setting; future randomized trials should confirm benefit with different visualizations and exposure periods. Trial Registration: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6pJ1P644S) ",
doi="10.2196/mental.7387",
url="http://mental.jmir.org/2017/1/e9/",
url="http://www.ncbi.nlm.nih.gov/pubmed/28356241"
}


@Article{info:doi/10.2196/mental.5801,
author="Mosadeghi, Sasan
and Reid, William Mark
and Martinez, Bibiana
and Rosen, Todd Bradley
and Spiegel, Ross Brennan Mason",
title="Feasibility of an Immersive Virtual Reality Intervention for Hospitalized Patients: An Observational Cohort Study",
journal="JMIR Ment Health",
year="2016",
month="Jun",
day="27",
volume="3",
number="2",
pages="e28",
keywords="virtual reality therapy",
keywords="hospitalization",
keywords="feasibility studies",
abstract="Background: Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that ``transport'' users to novel environments. Because VR is effective for acute pain and anxiety, it may have benefits for hospitalized patients; however, there are few reports using VR in this setting. Objective: The aim was to evaluate the acceptability and feasibility of VR in a diverse cohort of hospitalized patients. Methods: We assessed the acceptability and feasibility of VR in a cohort of patients admitted to an inpatient hospitalist service over a 4-month period. We excluded patients with motion sickness, stroke, seizure, dementia, nausea, and in isolation. Eligible patients viewed VR experiences (eg, ocean exploration; Cirque du Soleil; tour of Iceland) with Samsung Gear VR goggles. We then conducted semistructured patient interview and performed statistical testing to compare patients willing versus unwilling to use VR. Results: We evaluated 510 patients; 423 were excluded and 57 refused to participate, leaving 30 participants. Patients willing versus unwilling to use VR were younger (mean 49.1, SD 17.4 years vs mean 60.2, SD 17.7 years; P=.01); there were no differences by sex, race, or ethnicity. Among users, most reported a positive experience and indicated that VR could improve pain and anxiety, although many felt the goggles were uncomfortable. Conclusions: Most inpatient users of VR described the experience as pleasant and capable of reducing pain and anxiety. However, few hospitalized patients in this ``real-world'' series were both eligible and willing to use VR. Consistent with the ``digital divide'' for emerging technologies, younger patients were more willing to participate. Future research should evaluate the impact of VR on clinical and resource outcomes. ClinicalTrial: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6iFIMRNh3) ",
doi="10.2196/mental.5801",
url="http://mental.jmir.org/2016/2/e28/",
url="http://www.ncbi.nlm.nih.gov/pubmed/27349654"
}


@Article{info:doi/10.2196/jmir.3235,
author="Gaggioli, Andrea
and Pallavicini, Federica
and Morganti, Luca
and Serino, Silvia
and Scaratti, Chiara
and Briguglio, Marilena
and Crifaci, Giulia
and Vetrano, Noemi
and Giulintano, Annunziata
and Bernava, Giuseppe
and Tartarisco, Gennaro
and Pioggia, Giovanni
and Raspelli, Simona
and Cipresso, Pietro
and Vigna, Cinzia
and Grassi, Alessandra
and Baruffi, Margherita
and Wiederhold, Brenda
and Riva, Giuseppe",
title="Experiential Virtual Scenarios With Real-Time Monitoring (Interreality) for the Management of Psychological Stress: A Block Randomized Controlled Trial",
journal="J Med Internet Res",
year="2014",
month="Jul",
day="08",
volume="16",
number="7",
pages="e167",
keywords="psychological stress",
keywords="Interreality",
keywords="virtual reality",
keywords="biosensors",
keywords="heart rate",
keywords="heart rate variability",
keywords="biofeedback training",
keywords="relaxation training",
keywords="physiological monitoring",
keywords="smartphones",
abstract="Background: The recent convergence between technology and medicine is offering innovative methods and tools for behavioral health care. Among these, an emerging approach is the use of virtual reality (VR) within exposure-based protocols for anxiety disorders, and in particular posttraumatic stress disorder. However, no systematically tested VR protocols are available for the management of psychological stress. Objective: Our goal was to evaluate the efficacy of a new technological paradigm, Interreality, for the management and prevention of psychological stress. The main feature of Interreality is a twofold link between the virtual and the real world achieved through experiential virtual scenarios (fully controlled by the therapist, used to learn coping skills and improve self-efficacy) with real-time monitoring and support (identifying critical situations and assessing clinical change) using advanced technologies (virtual worlds, wearable biosensors, and smartphones). Methods: The study was designed as a block randomized controlled trial involving 121 participants recruited from two different worker populations---teachers and nurses---that are highly exposed to psychological stress. Participants were a sample of teachers recruited in Milan (Block 1: n=61) and a sample of nurses recruited in Messina, Italy (Block 2: n=60). Participants within each block were randomly assigned to the (1) Experimental Group (EG): n=40; B1=20, B2=20, which received a 5-week treatment based on the Interreality paradigm; (2) Control Group (CG): n=42; B1=22, B2=20, which received a 5-week traditional stress management training based on cognitive behavioral therapy (CBT); and (3) the Wait-List group (WL): n=39, B1=19, B2=20, which was reassessed and compared with the two other groups 5 weeks after the initial evaluation. Results: Although both treatments were able to significantly reduce perceived stress better than WL, only EG participants reported a significant reduction (EG=12\% vs CG=0.5\%) in chronic ``trait'' anxiety. A similar pattern was found for coping skills: both treatments were able to significantly increase most coping skills, but only EG participants reported a significant increase (EG=14\% vs CG=0.3\%) in the Emotional Support skill. Conclusions: Our findings provide initial evidence that the Interreality protocol yields better outcomes than the traditionally accepted gold standard for psychological stress treatment: CBT. Consequently, these findings constitute a sound foundation and rationale for the importance of continuing future research in technology-enhanced protocols for psychological stress management. Trial Registration: ClinicalTrials.gov: NCT01683617; http://clinicaltrials.gov/show/NCT01683617 (Archived by WebCite at http://www.webcitation.org/6QnziHv3h). ",
doi="10.2196/jmir.3235",
url="http://www.jmir.org/2014/7/e167/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25004803"
}


@Article{info:doi/10.2196/games.2836,
author="Clemente, Miriam
and Rey, Beatriz
and Rodriguez-Pujadas, Aina
and Breton-Lopez, Juani
and Barros-Loscertales, Alfonso
and Ba{\~n}os, M. Rosa
and Botella, Cristina
and Alca{\~n}iz, Mariano
and Avila, Cesar",
title="A Functional Magnetic Resonance Imaging Assessment of Small Animals' Phobia Using Virtual Reality as a Stimulus",
journal="JMIR Serious Games",
year="2014",
month="Jun",
day="27",
volume="2",
number="1",
pages="e6",
keywords="neuroimaging",
keywords="patient assessment",
keywords="virtual reality",
keywords="phobia",
abstract="Background: To date, still images or videos of real animals have been used in functional magnetic resonance imaging protocols to evaluate the brain activations associated with small animals' phobia. Objective: The objective of our study was to evaluate the brain activations associated with small animals' phobia through the use of virtual environments. This context will have the added benefit of allowing the subject to move and interact with the environment, giving the subject the illusion of being there. Methods: We have analyzed the brain activation in a group of phobic people while they navigated in a virtual environment that included the small animals that were the object of their phobia. Results: We have found brain activation mainly in the left occipital inferior lobe (P<.05 corrected, cluster size=36), related to the enhanced visual attention to the phobic stimuli; and in the superior frontal gyrus (P<.005 uncorrected, cluster size=13), which is an area that has been previously related to the feeling of self-awareness. Conclusions: In our opinion, these results demonstrate that virtual stimulus can enhance brain activations consistent with previous studies with still images, but in an environment closer to the real situation the subject would face in their daily lives. ",
doi="10.2196/games.2836",
url="http://games.jmir.org/2014/1/e6/",
url="http://www.ncbi.nlm.nih.gov/pubmed/25654753"
}