Background Virtual reality (VR) relaxation is a promising mental health intervention that may be an effective tool for stress reduction but has hardly been tested in clinical trials with psychiatric patients. We developed an easy-to-use VR self-management relaxation tool (VRelax) with immersive 360° nature videos and interactive animated elements. Objective To investigate the immediate effects of VR relaxation on negative and positive affective states and short-term effects on perceived stress and symptoms in patients with a psychiatric disorder, compared to standard relaxation exercises. Methods A randomized crossover trial was conducted in 50 patients receiving ambulatory treatment for anxiety, psychotic, depressive, or bipolar disorder. Participants were randomly assigned to start with VRelax or standard relaxation and used both interventions for 10 days at home. They completed 8 visual analog scales of momentary negative and positive affective states before and after each session. Global perceived stress and psychiatric symptoms were measured before and after both intervention periods. Treatment effects were analyzed with multilevel mixed model regression analyses and 2-way analysis of variance. Results Both VRelax and standard relaxation exercises led to a statistically significant immediate improvement of all negative and positive affective states. Compared to standard relaxation, VRelax resulted in a significantly greater reduction of total negative affective state (change 16.2% versus 21.2%; t1684=−2.02, 95% CI −18.70 to −0.28; P=.04). Specifically, VRelax had a stronger beneficial effect on momentary anxiety (t1684=−3.24, 95% CI −6.86 to −1.69), sadness (t1684=−2.32, 95% CI −6.51 to −0.55), and cheerfulness (t1684=2.35, 95% CI 0.51 to 5.75). There were no significant differences between short-term effects of the two treatments on global perceived stress and symptoms. Conclusions If the results of this trial are replicated and extended, VRelax may provide a much-needed, effective, easy-to-use self-management relaxation intervention to enhance psychiatric treatments. Trial Registration Netherlands Trial Register NTR7294; https://www.trialregister.nl/trial/7096

During the COVID-19 pandemic ICU nurses endure high levels of stress. VR relaxation (VRelax, containing 360° immersive environments) provides an easy-to-use and effective means to induce positive affect and reduce perceived stress. We investigated feasibility and immediate effect on perceived stress of VRelax use by ICU nurses during work shifts. ICU nurses working with COVID-19 patients in an academic hospital could use VRelax as a 10-min break during their shift. Primary outcome was the difference between perceived stress immediately before and after VRelax use measured by a single-question VAS-stress scale. Statistically significant difference of the mean VAS-stress before and after use was determined using the paired t student test. A socio-demographic questionnaire, a questionnaire on perceived stress and stress resilience and VRelax user experiences were sent by email. Eighty-six (26%) nurses used VRelax at least once; 77% (N=66) of these filled out the VAS-stress scale before and after use of VRelax. Mean perceived stress lowered with 39.9% after use of VRelax (mean difference=14.0, SD=13.3, p<0.005). Mean score on the perceived stress scale-10 was 11.4 (SD=6.50), mean score on the Connor-Davidson Resilience Scale-10 was 29.0 (SD=5.51). Sixty-two percentage of the ICU nurses thought VRelax was helpful to reduce stress. Main barrier for use was a high workload. It is feasible for nurses to use VRelax in an ICU context. VRelax is an effective intervention to reduce immediate perceived stress and is of added value in stressful situations as during the COVID-19 pandemic, inducing a positive affective state and lowering perceived stress.

Background Virtual reality (VR) enables the administration of realistic and dynamic stimuli within a social context for the assessment and training of emotion recognition. We tested a novel VR emotion recognition task by comparing emotion recognition across a VR, video and photo task, investigating covariates of recognition and exploring visual attention in VR. Methods Healthy individuals (n = 100) completed three emotion recognition tasks; a photo, video and VR task. During the VR task, emotions of virtual characters (avatars) in a VR street environment were rated, and eye-tracking was recorded in VR. Results Recognition accuracy in VR (overall 75%) was comparable to the photo and video task. However, there were some differences; disgust and happiness had lower accuracy rates in VR, and better accuracy was achieved for surprise and anger in VR compared to the video task. Participants spent more time identifying disgust, fear and sadness than surprise and happiness. In general, attention was directed longer to the eye and nose areas than the mouth. Discussion Immersive VR tasks can be used for training and assessment of emotion recognition. VR enables easily controllable avatars within environments relevant for daily life. Validated emotional expressions and tasks will be of relevance for clinical applications.

Background Seventy per cent of patients with psychotic disorders has paranoid delusions. Paranoid delusions are associated with significant distress, hospital admission and social isolation. Cognitive-behavioural therapy for psychosis (CBTp) is the primary psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve the effectiveness of CBTp. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is superior to waiting list. As a next step, a direct comparison with CBTp is needed. The present study aims to investigate whether VRcbt is more effective and cost-effective than regular CBTp in treating paranoid delusions and improving daily life social functioning of patients with psychotic disorders. Methods A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be recruited for this multicentre randomized controlled trial (RCT). Patients will be randomized to either VRcbt or standard CBTp for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8–12 week time frame. Standard CBTp also consists of maximum 16 sessions including exposure and behavioural experiments, delivered in an 8–12 week time frame. The two groups will be compared at baseline, post-treatment and six months follow-up. Primary outcome is the level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate the level of paranoid ideation and global clinical impression. Discussion Comparison of VRcbt and CBTp will provide information about the relative (cost-) effectiveness of VRcbt for this population. VRcbt may become a preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder. Trial registration Netherlands Trial Register, NL7758. Registered on 23 May 2019.

Background Seventy percent of patients with schizophrenia and other psychotic disorders has paranoid delusions. Paranoid delusions are associated with great distress, hospital admission and social isolation. Cognitive behavioral therapy (CBT) is the main psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve psychological treatment of paranoid delusions. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is effective compared to waiting list. As a next step, a direct comparison with standard CBT is needed. The aim of this project is to investigate if VRcbt is more (cost-)effective than standard CBT for treatment of paranoid delusions and improving daily life social functioning of patients with schizophrenia and related psychotic disorders. Three research questions will be addressed: 1. Does VRcbt lead to better clinical and social outcomes? 2. Are fewer treatment sessions needed to achieve meaningful clinical change? 3. Is VRcbt more cost-effective at 6 months follow-up? Methods A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be randomized to either VRcbt or standard CBT treatment for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8–12 week time frame. Standard CBT also consists of maximum 16 sessions, aiming at reappraisal of the meaning of paranoid beliefs to reduce distress and improve coping in daily life, including the use of exposure and behavioral experiments. Participants will be interviewed and tested at baseline, post-treatment and at six months follow-up. Primary outcome is level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate level of paranoid ideation and global clinical impression. Results Seven mental health services throughout the Netherlands participate in this RCT. Up until now, fourteen psychologists have been trained in VRcbt and the first patients have been included in the trial. Discussion Comparison of VRcbt and cbt will provide information about the relative (cost-)effectiveness of VRcbt for this population. VRcbt may become the preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder.

Background Psychosocial stress is associated with onset and relapse of psychosis, and stress-reactivity is high in patients with psychotic disorder. Stress management is an important part of treatment, but stress-reducing interventions are challenging for people with psychotic or other psychiatric disorder. We developed a virtual reality self-management relaxation tool (VRelax; 360o nature videos with interactive elements) and investigated its immediate effects on stress level, mood states and symptoms in patients with a psychotic or other psychiatric disorder, compared to standard relaxation exercises. Methods A randomized cross-over trial was conducted in 50 patients receiving ambulatory treatment for psychotic, anxiety, depressive or bipolar disorder. Participants were randomly assigned to start with VRelax or standard relaxation, and used both interventions for 10 days at home. They completed Visual Analogue Scales (VAS) of stress level and mood states before and after each session. Global perceived stress and psychiatric symptoms were measured before and after both intervention periods. Treatment effects were analyzed with multilevel repeated-measures regression models and two-way ANOVA. Results Both VRelax and standard relaxation exercises reduced subjective stress and improved momentary mood states. Compared to standard relaxation, VRelax resulted in a significantly greater immediate improvement of anxiety (B=-4.30, 95%CI=-5.86;-2.73), sadness (B=-3.65, 95%CI =-5.39;-1.91), cheerfulness (B=3.67, 95%CI=2.15;5.18), overall positive mood (B=7.59, 95%CI=2.28;12.89), and overall negative mood (B=10.88, 95%CI=5.89;15.87). There were no significant differences between short-term effects of the two treatments on symptoms and global perceived stress. Discussion If the results of this trial are replicated and extended, VRelax may provide a much needed effective self-management stress intervention to enhance treatment of patients with psychotic and other psychiatric disorders.

BACKGROUND Virtual reality (VR) relaxation is a promising mental health intervention that may be an effective tool for stress reduction but has hardly been tested in clinical trials with psychiatric patients. We developed an easy-to-use VR self-management relaxation tool (VRelax) with immersive 360° nature videos and interactive animated elements. OBJECTIVE To investigate the immediate effects of VR relaxation on negative and positive affective states and short-term effects on perceived stress and symptoms in patients with a psychiatric disorder, compared to standard relaxation exercises. METHODS A randomized crossover trial was conducted in 50 patients receiving ambulatory treatment for anxiety, psychotic, depressive, or bipolar disorder. Participants were randomly assigned to start with VRelax or standard relaxation and used both interventions for 10 days at home. They completed 8 visual analog scales of momentary negative and positive affective states before and after each session. Global perceived stress and psychiatric symptoms were measured before and after both intervention periods. Treatment effects were analyzed with multilevel mixed model regression analyses and 2-way analysis of variance. RESULTS Both VRelax and standard relaxation exercises led to a statistically significant immediate improvement of all negative and positive affective states. Compared to standard relaxation, VRelax resulted in a significantly greater reduction of total negative affective state (change 16.2% versus 21.2%; t₁₆₈₄=−2.02, 95% CI −18.70 to −0.28; <i>P</i>=.04). Specifically, VRelax had a stronger beneficial effect on momentary anxiety (t₁₆₈₄=−3.24, 95% CI −6.86 to −1.69), sadness (t₁₆₈₄=−2.32, 95% CI −6.51 to −0.55), and cheerfulness (t₁₆₈₄=2.35, 95% CI 0.51 to 5.75). There were no significant differences between short-term effects of the two treatments on global perceived stress and symptoms. CONCLUSIONS If the results of this trial are replicated and extended, VRelax may provide a much-needed, effective, easy-to-use self-management relaxation intervention to enhance psychiatric treatments. CLINICALTRIAL Netherlands Trial Register NTR7294; https://www.trialregister.nl/trial/7096