%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e22494 %T Managing Game-Related Conflict With Parents of Young Adults With Internet Gaming Disorder: Development and Feasibility Study of a Virtual Reality App %A Shin,Yu-Bin %A Kim,Jae-Jin %A Kim,Hyunji %A Kim,Soo-Jeong %A Eom,Hyojung %A Jung,Young Hoon %A Kim,Eunjoo %+ Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Eonju-ro 211, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3340, ejkim96@yuhs.ac %K internet gaming disorder %K family conflict %K coping behavior %K virtual reality %D 2021 %7 18.1.2021 %9 Original Paper %J JMIR Serious Games %G English %X 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). %M 33459603 %R 10.2196/22494 %U http://games.jmir.org/2021/1/e22494/ %U https://doi.org/10.2196/22494 %U http://www.ncbi.nlm.nih.gov/pubmed/33459603 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e24331 %T Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 781 572 4136, mdpaul@stanford.edu %K virtual reality %K case report %K major depressive disorder %K behavioral activation %K VR %K depression %K COVID-19 %K behavior %K intervention %K feasibility %K acceptability %K telehealth %K pilot study %D 2020 %7 3.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X 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 %M 33031046 %R 10.2196/24331 %U https://mental.jmir.org/2020/11/e24331 %U https://doi.org/10.2196/24331 %U http://www.ncbi.nlm.nih.gov/pubmed/33031046 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e17808 %T Dynamic Interactive Social Cognition Training in Virtual Reality (DiSCoVR) for People With a Psychotic Disorder: Single-Group Feasibility and Acceptability Study %A Nijman,Saskia Anne %A Veling,Wim %A Greaves-Lord,Kirstin %A Vos,Maarten %A Zandee,Catharina Elizabeth Regina %A Aan het Rot,Marije %A Geraets,Chris Neeltje Wil %A Pijnenborg,Gerdina Hendrika Maria %+ Department of Psychotic Disorders, GGZ Drenthe, Dennenweg 9, PO Box 30007, Assen, 9404LA, Netherlands, 31 592 4703, s.a.nijman@umcg.nl %K social cognition %K virtual reality %K psychotic disorder %K cognitive remediation therapy %K emotion perception %K theory of mind %K social cognition training %D 2020 %7 7.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X 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. %M 32763880 %R 10.2196/17808 %U https://mental.jmir.org/2020/8/e17808 %U https://doi.org/10.2196/17808 %U http://www.ncbi.nlm.nih.gov/pubmed/32763880 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17096 %T Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults’ Psychological Health: Quasi-Experimental Study %A Cheng,Vivian Ya-Wen %A Huang,Chiu-Mieh %A Liao,Jung-Yu %A Hsu,Hsiao-Pei %A Wang,Shih-Wen %A Huang,Su-Fei %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, 162, Section 1, He-ping East Road, Taipei, 10610, Taiwan, 886 277493705, jonglong@ntnu.edu.tw %K three-dimensional %K virtual reality %K aromatherapy %K older adult %K happiness %K stress %K sleep quality %K meditation %K life satisfaction %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X 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. %M 32706660 %R 10.2196/17096 %U http://www.jmir.org/2020/7/e17096/ %U https://doi.org/10.2196/17096 %U http://www.ncbi.nlm.nih.gov/pubmed/32706660 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14369 %T Can Social Communication Skills for Children Diagnosed With Autism Spectrum Disorder Rehearsed Inside the Video Game Environment of Minecraft Generalize to the Real World? %A Cadieux,Lee %A Keenan,Mickey %+ School of Arts and Humanities, Ulster University, MA205 Magee Campus, Northland Road, Londonderry, BT48 7JL, United Kingdom, 44 2871675025, l.cadieux@ulster.ac.uk %K autism %K behavior analysis %K serious games %K social skills %K gamification %K Lego %K neurodiversity %K Minecraft %K virtual worlds %K virtual reality %D 2020 %7 12.5.2020 %9 Viewpoint %J JMIR Serious Games %G English %X In this paper, we outline opportunities within the video game environment for building skills applicable to real-world issues faced by some children. The game Minecraft is extremely popular and of particular interest to children diagnosed with autism spectrum disorder. Although the game has been used by support communities to facilitate the social interaction of children and peer support for their parents, little has been done to examine how social skills developed within the game environment generalize to the real world. Social Craft aims to establish a framework in which key social communication skills would be rehearsed in-game with a view to facilitating their replication in a similarly contained real-world environment. Central to this approach is an understanding of the basic principles of behavior and the engagement of a sound methodology for the collection of data inside and outside the respective environments. %M 32396129 %R 10.2196/14369 %U http://games.jmir.org/2020/2/e14369/ %U https://doi.org/10.2196/14369 %U http://www.ncbi.nlm.nih.gov/pubmed/32396129 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e17098 %T Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial %A Pot-Kolder,Roos %A Veling,Wim %A Geraets,Chris %A Lokkerbol,Joran %A Smit,Filip %A Jongeneel,Alyssa %A Ising,Helga %A van der Gaag,Mark %+ Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 641034764, roos.potkolder@gmail.com %K psychosis %K virtual reality %K cognitive behavioral therapy %K cost-effectiveness %D 2020 %7 5.5.2020 %9 Original Paper %J J Med Internet Res %G English %X 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 €8079 and €19,525, with 90.74%-99.74% showing improvement. The average incremental cost per QALY was €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 €6800 and €16,597, while the average cost per QALY gained was €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 %M 32369036 %R 10.2196/17098 %U https://www.jmir.org/2020/5/e17098 %U https://doi.org/10.2196/17098 %U http://www.ncbi.nlm.nih.gov/pubmed/32369036 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17807 %T Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia: Qualitative Study %A Lindner,Philip %A Rozental,Alexander %A Jurell,Alice %A Reuterskiöld,Lena %A Andersson,Gerhard %A Hamilton,William %A Miloff,Alexander %A Carlbring,Per %+ Department of Psychology, Stockholm University, Frescati hagväg 8, 104 05, Stockholm, , Sweden, 46 704522587, philip.lindner@ki.se %K virtual reality %K gamification %K serious game %K exposure therapy %K phobia %K user experience %D 2020 %7 29.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X 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. %M 32347803 %R 10.2196/17807 %U http://games.jmir.org/2020/2/e17807/ %U https://doi.org/10.2196/17807 %U http://www.ncbi.nlm.nih.gov/pubmed/32347803 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16724 %T Multidimensional Evaluation of Virtual Reality Paradigms in Clinical Neuropsychology: Application of the VR-Check Framework %A Krohn,Stephan %A Tromp,Johanne %A Quinque,Eva M %A Belger,Julia %A Klotzsche,Felix %A Rekers,Sophia %A Chojecki,Paul %A de Mooij,Jeroen %A Akbal,Mert %A McCall,Cade %A Villringer,Arno %A Gaebler,Michael %A Finke,Carsten %A Thöne-Otto,Angelika %+ Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany, 49 30 45050, stephan.krohn@charite.de %K virtual reality %K neuropsychology %K cognition %K research design %D 2020 %7 27.4.2020 %9 Viewpoint %J J Med Internet Res %G English %X Virtual reality (VR) represents a key technology of the 21st century, attracting substantial interest from a wide range of scientific disciplines. With regard to clinical neuropsychology, a multitude of new VR applications are being developed to overcome the limitations of classical paradigms. Consequently, researchers increasingly face the challenge of systematically evaluating the characteristics and quality of VR applications to design the optimal paradigm for their specific research question and study population. However, the multifaceted character of contemporary VR is not adequately captured by the traditional quality criteria (ie, objectivity, reliability, validity), highlighting the need for an extended paradigm evaluation framework. To address this gap, we propose a multidimensional evaluation framework for VR applications in clinical neuropsychology, summarized as an easy-to-use checklist (VR-Check). This framework rests on 10 main evaluation dimensions encompassing cognitive domain specificity, ecological relevance, technical feasibility, user feasibility, user motivation, task adaptability, performance quantification, immersive capacities, training feasibility, and predictable pitfalls. We show how VR-Check enables systematic and comparative paradigm optimization by illustrating its application in an exemplary research project on the assessment of spatial cognition and executive functions with immersive VR. This application furthermore demonstrates how the framework allows researchers to identify across-domain trade-offs, makes deliberate design decisions explicit, and optimizes the allocation of study resources. Complementing recent approaches to standardize clinical VR studies, the VR-Check framework enables systematic and project-specific paradigm optimization for behavioral and cognitive research in neuropsychology. %M 32338614 %R 10.2196/16724 %U https://www.jmir.org/2020/4/e16724 %U https://doi.org/10.2196/16724 %U http://www.ncbi.nlm.nih.gov/pubmed/32338614 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16386 %T Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy %A Brown,Theresa %A Nauman Vogel,Emily %A Adler,Sarah %A Bohon,Cara %A Bullock,Kim %A Nameth,Katherine %A Riva,Giuseppe %A Safer,Debra L %A Runfola,Cristin D %+ Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Stanford, CA, 94304, United States, 1 650 498 9111, dlsafer@stanford.edu %K virtual reality %K exposure therapy %K eating disorders %K translational research %K technological innovation %D 2020 %7 23.4.2020 %9 Viewpoint %J J Med Internet Res %G English %X Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally. %M 32324145 %R 10.2196/16386 %U http://www.jmir.org/2020/4/e16386/ %U https://doi.org/10.2196/16386 %U http://www.ncbi.nlm.nih.gov/pubmed/32324145 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 12 %P e15872 %T A Virtual Reality Video to Improve Information Provision and Reduce Anxiety Before Cesarean Delivery: Randomized Controlled Trial %A Noben,Lore %A Goossens,Simone Maria Theresia Anna %A Truijens,Sophie Eva Marieke %A van Berckel,Marijn Marthe Georgine %A Perquin,Christel Wilhelmina %A Slooter,Gerrit Dirk %A van Rooijen,Stefanus Johannes %+ Department of Obstetrics and Gynecology, Máxima Medical Center, PO Box 7777, Veldhoven, 5500 MB, Netherlands, 31 643123997, lore.noben94@gmail.com %K virtual reality %K cesarean section %K counseling %K preoperative care %K surgery %K anxiety %K childbirth %D 2019 %7 18.12.2019 %9 Original Paper %J JMIR Ment Health %G English %X 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 (ΔVAS-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; ΔVAS-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) %M 31850850 %R 10.2196/15872 %U http://mental.jmir.org/2019/12/e15872/ %U https://doi.org/10.2196/15872 %U http://www.ncbi.nlm.nih.gov/pubmed/31850850 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12972 %T The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care %A Kip,Hanneke %A Kelders,Saskia M %A Bouman,Yvonne H A %A van Gemert-Pijnen,Lisette J E W C %+ Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 534896536, h.kip@utwente.nl %K eHealth %K technology development %K virtual reality %K forensic psychiatry %K community-based participatory research %K human-centered design %K case study %D 2019 %7 19.08.2019 %9 Original Paper %J J Med Internet Res %G English %X 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. %M 31429415 %R 10.2196/12972 %U http://www.jmir.org/2019/8/e12972/ %U https://doi.org/10.2196/12972 %U http://www.ncbi.nlm.nih.gov/pubmed/31429415 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13633 %T 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 %A Ose,Solveig Osborg %A Færevik,Hilde %A Kaasbøll,Jannike %A Lindgren,Martin %A Thaulow,Kristin %A Antonsen,Stig %A Burkeland,Olav %+ SINTEF AS Digital, Klaebuveien 153, Trondheim,, Norway, 47 90728684, solveig.ose@sintef.no %K virtual reality %K severe mental illness %K collaborative research %K technology %K social work %D 2019 %7 10.6.2019 %9 Original Paper %J JMIR Form Res %G English %X 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. %M 31199315 %R 10.2196/13633 %U http://formative.jmir.org/2019/2/e13633/ %U https://doi.org/10.2196/13633 %U http://www.ncbi.nlm.nih.gov/pubmed/31199315 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e11973 %T Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study %A Birckhead,Brandon %A Khalil,Carine %A Liu,Xiaoyu %A Conovitz,Samuel %A Rizzo,Albert %A Danovitch,Itai %A Bullock,Kim %A Spiegel,Brennan %+ Division of Health Services Research, Department of Medicine, Cedars-Sinai Health System, Pacific Theaters Building, Suite 800, 116 North Robertson Boulevard, Los Angeles, CA, 90048, United States, 1 310 423 6784, Brennan.Spiegel@cshs.org %K clinical trials %K consensus %K virtual reality %D 2019 %7 31.01.2019 %9 Viewpoint %J JMIR Ment Health %G English %X 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. %M 30702436 %R 10.2196/11973 %U https://mental.jmir.org/2019/1/e11973/ %U https://doi.org/10.2196/11973 %U http://www.ncbi.nlm.nih.gov/pubmed/30702436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e151 %T Embodied Conversational Agents in Clinical Psychology: A Scoping Review %A Provoost,Simon %A Lau,Ho Ming %A Ruwaard,Jeroen %A Riper,Heleen %+ Department of Clinical, Neuro & Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 205985059, s.j.provoost@vu.nl %K eHealth %K review %K embodied conversational agent %K human computer interaction %K clinical psychology %K mental disorders %K intelligent agent %K health behavior %D 2017 %7 09.05.2017 %9 Original Paper %J J Med Internet Res %G English %X 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. %M 28487267 %R 10.2196/jmir.6553 %U http://www.jmir.org/2017/5/e151/ %U https://doi.org/10.2196/jmir.6553 %U http://www.ncbi.nlm.nih.gov/pubmed/28487267 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 1 %P e9 %T Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial %A Tashjian,Vartan C %A Mosadeghi,Sasan %A Howard,Amber R %A Lopez,Mayra %A Dupuy,Taylor %A Reid,Mark %A Martinez,Bibiana %A Ahmed,Shahzad %A Dailey,Francis %A Robbins,Karen %A Rosen,Bradley %A Fuller,Garth %A Danovitch,Itai %A IsHak,Waguih %A Spiegel,Brennan %+ Cedars-Sinai Medical Center, Health Services Research, 8700 Beverly Blvd, Los Angeles,CA, CA, 90048, United States, 1 310 423 6239, brennan.spiegel@cshs.org %K pain %K virtual reality %K inpatients %K hospitalization %D 2017 %7 29.03.2017 %9 Original Paper %J JMIR Ment Health %G English %X 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) %M 28356241 %R 10.2196/mental.7387 %U http://mental.jmir.org/2017/1/e9/ %U https://doi.org/10.2196/mental.7387 %U http://www.ncbi.nlm.nih.gov/pubmed/28356241 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 2 %P e28 %T Feasibility of an Immersive Virtual Reality Intervention for Hospitalized Patients: An Observational Cohort Study %A Mosadeghi,Sasan %A Reid,Mark William %A Martinez,Bibiana %A Rosen,Bradley Todd %A Spiegel,Brennan Mason Ross %+ Cedars-Sinai Health System, Health Services Research, 116 N Robertson Boulevard, Suite 400, Los Angeles, CA, 90048, United States, 1 310 423 6467, Brennan.Spiegel@cshs.org %K virtual reality therapy %K hospitalization %K feasibility studies %D 2016 %7 27.06.2016 %9 Original Paper %J JMIR Ment Health %G English %X 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) %M 27349654 %R 10.2196/mental.5801 %U http://mental.jmir.org/2016/2/e28/ %U https://doi.org/10.2196/mental.5801 %U http://www.ncbi.nlm.nih.gov/pubmed/27349654 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 7 %P e167 %T Experiential Virtual Scenarios With Real-Time Monitoring (Interreality) for the Management of Psychological Stress: A Block Randomized Controlled Trial %A Gaggioli,Andrea %A Pallavicini,Federica %A Morganti,Luca %A Serino,Silvia %A Scaratti,Chiara %A Briguglio,Marilena %A Crifaci,Giulia %A Vetrano,Noemi %A Giulintano,Annunziata %A Bernava,Giuseppe %A Tartarisco,Gennaro %A Pioggia,Giovanni %A Raspelli,Simona %A Cipresso,Pietro %A Vigna,Cinzia %A Grassi,Alessandra %A Baruffi,Margherita %A Wiederhold,Brenda %A Riva,Giuseppe %+ Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Via Alessandro Magnasco 2, Milan, 20149, Italy, 39 0261911 ext 2892, andrea.gaggioli@auxologico.it %K psychological stress %K Interreality %K virtual reality %K biosensors %K heart rate %K heart rate variability %K biofeedback training %K relaxation training %K physiological monitoring %K smartphones %D 2014 %7 08.07.2014 %9 Original Paper %J J Med Internet Res %G English %X 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). %M 25004803 %R 10.2196/jmir.3235 %U http://www.jmir.org/2014/7/e167/ %U https://doi.org/10.2196/jmir.3235 %U http://www.ncbi.nlm.nih.gov/pubmed/25004803 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 2 %N 1 %P e6 %T A Functional Magnetic Resonance Imaging Assessment of Small Animals’ Phobia Using Virtual Reality as a Stimulus %A Clemente,Miriam %A Rey,Beatriz %A Rodriguez-Pujadas,Aina %A Breton-Lopez,Juani %A Barros-Loscertales,Alfonso %A Baños,Rosa M %A Botella,Cristina %A Alcañiz,Mariano %A Avila,Cesar %+ LabHuman, I3BH, Universitat Politecnica de Valencia, Ciudad Politécnica de la Innovación - Cubo Azul - Edif 8B - Acceso N, Camino de Vera s/n, Valencia, 46022, Spain, 34 96 387 75 18 ext 67042, yavanna12@gmail.com %K neuroimaging %K patient assessment %K virtual reality %K phobia %D 2014 %7 27.06.2014 %9 Original Paper %J JMIR Serious Games %G English %X 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. %M 25654753 %R 10.2196/games.2836 %U http://games.jmir.org/2014/1/e6/ %U https://doi.org/10.2196/games.2836 %U http://www.ncbi.nlm.nih.gov/pubmed/25654753