Imagining virtual reality as a simple tool to treat depression

Some of the 17 million Americans afflicted with major depressive disorder each year may soon receive a surprising new prescription from their clinician: Have fun on a virtual reality device.

Engaging in activities that make you feel good may seem like overly simplistic advice, especially when directed at people with severe depression. But the science behind this idea, called "behavioral activation," is well established. Multiple studies have found that encouraging people to get outside, exercise, socialize, volunteer or immerse themselves in enjoyable activities in a prescribed, systematic way can help ease the symptoms of depression.

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Now, Stanford researchers have discovered that engaging in these behaviors within a virtual reality system may show just as much efficacy in treating depression as carrying them out in the real world. And for those depressed to a level that makes leaving the house a challenge, it could provide the benefits of getting outside -- and even motivate them to get out.

"People who might otherwise have barriers to getting treatment might be open to using this technology in their own homes," said Kim Bullock, MD, a clinical professor of psychiatry and behavioral sciences.

The study by Bullock's team, published in JMIR Mental Health, followed 26 people with major depressive disorder. Half were assigned traditional behavioral activation, and half used a virtual reality headset to participate in activities ranging from table tennis and mini-golf to touring foreign cities or attending shows. People in both groups saw their depression scores decrease by similar amounts.

"We've found that using virtual reality in an outpatient group of patients was both simple and efficacious in treating symptoms of depression," said Bullock, founder and director of Stanford's Neurobehavioral Clinic and Virtual Reality and Immersive Technologies (VRIT) program. "It can reduce the barriers to getting mental health treatment in a number of ways."

Bullock and her colleagues at the Stanford VRIT program have long studied the diverse ways to treat mental illnesses with virtual reality (VR) platforms, in which users donning headsets are immersed in simulated, three-dimensional environments.

Previous studies have examined how VR can be used to conduct therapy appointments, help people overcome anxieties and phobias, ease pain, learn social skills, and treat eating disorders and hoarding. But few research projects had focused on how to use the technology to treat anything as pervasive as major depressive disorder or other mood disorders

Depression impacts so many people right now, and we thought VR could have a large impact.
Kim Bullock

"Depression impacts so many people right now, and we thought VR could have a large impact," said Bullock, who received support for the project from the Neuroscience:Translate Grant Program. "There can be significant barriers to behavioral activation in some patients -- they might be stuck in a hospital bed, or not have the means to access joyful activities or the motivation to leave their house. We started wondering whether simulated, pleasant activities might be a good first step for some people."

Bullock, along with clinical assistant professor Margot Paul, PsyD, first carried out a small feasibility study to see whether people with depression could use a VR headset with pre-loaded videos to engage in behavioral activation homework assigned by their therapist. After positive feedback from participants, the researchers conducted the randomized, controlled trial to test the efficacy of a more immersive and interactive VR approach.

The participants in the trial, all adults diagnosed with major depressive disorder who had not recently changed medications, met weekly with a clinical psychologist at Stanford who assigned them behavioral activation homework between sessions -- scheduling and committing to at least four pleasurable activities each week, either in virtual reality or real life.

Thirteen people in the study received a VR Meta Quest 2 headset as well as a list of potential activity ideas they could engage in using the headset, including games, travel videos, fitness classes, chat programs and education apps. The other 13 people were told to plan and partake in real life activities in a more typical fashion -- by going on outings in their community or socializing with friends.

After four weeks, both groups saw a significant decrease in their symptoms of depression and their depression rating on a widely used scale. Moreover, many people who had used the VR devices said the virtual activities had helped push them to get out of the house and be more involved in in-person activities.

"One of the most common pieces of feedback we got was that using the VR inspired people to get out and do things in the real world," Paul said. "These virtual activities got their motors running just enough to get out of bed."

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The only negative feedback pertained to learning how to set up the device, as well as the need for alerts or reminders to keep people accountable for engaging in the behavioral activation. Paul and Bullock have since developed a companion VR behavioral activation app that will help address some of these concerns.

The team says larger and longer-term studies are needed to find the best ways to administer virtual behavioral activation, as well as which patient populations might be best targeted with the VR treatment. They also think more efforts are needed to inform clinicians -- from therapists and psychologists to primary care doctors -- about how to prescribe VR behavioral activation appropriately.

These virtual activities got their motors running just enough to get out of bed.
Margot Paul

But Paul, Bullock and their colleagues at Stanford VRIT believe the cost and ease of many VR platforms -- especially those that use mobile phones inserted into cheap cardboard headsets -- make it an easy treatment to scale up. They also believe the technology's relatability to a younger audience can only bring more openness to treating serious conditions like depression.

"As something that seems cool to young people, it serves not only to enhance but also de-stigmatize mental health treatments," Bullock said.

Illustration: Emily Moskal