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Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment. (JMIR Serious Games 2018;6(3):e14) doi: 10.2196/games.9226 KEYWORDS virtual reality; well-being; behavior change http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al crisper resolution over their competition [9]. This suggests a Introduction potential new wave of VR products, thus, bringing down the prices of even the more sophisticated forms of VR today and Development of Virtual Reality making it an even more appealing tool for the health industry. Virtual reality (VR) is emerging as one of the key new With this in mind, now is the time to review the recent VR technological tools in a digital revolution sweeping across the research, taking a view of what technology is being used and health care industry. Immersive VR allows users to interact with how it is being used. a computer-generated world, where the users natural sensory Aims of This Literature Review perceptions are replaced with a digital three-dimensional (3D) alternative [1]. To create an immersive VR system, a computer In this review, we aim to critically assess the current state of is used to generate an image, a display system is required to head-mounted VR research in relation to mental health. By project the image, and, finally, a tracker is required to update doing so, we look to determine which conditions are more the image based on users’ movements. Traditionally, VR has susceptible to VR interventions, which conditions need more been confined to laboratories as expensive and powerful attention, and in what form VR interventions are most effective. computer(s) are needed to power it. VR, as we know it today, Our secondary aim is to understand more about VR used over has been around for decades; the vision of VR was first realized the past 5 years and compare it to the new generation of VR in by Ivan Sutherland in 1968 with the “Sword of Damocles” terms of accessibility and specifications. As there are indications head-mounted display (HMD) and later by Morton Heilig with that VR HMDs can be used at home as a self-help resource to his multisensory Sensorama [2]. Failed attempts at VR systems provide a valuable tool for public health, in this review, we will by Nintendo (Virtual Boy) and Sega (Sega VR) in the 1990s assess head-mounted VR health research to date to determine and a further lack of development in the 2000s had many of its whether this has been tested. critics arguing that the technology was “dead” [3]. However, Key Concepts as noted by Olson et al [4], the video games industry has driven advances in graphics cards that are able to handle increasingly HMD specifications are categorized into FoV, image resolution, sophisticated 3D constructed environments. Furthermore, and refresh rate (Hz). FoV refers to the view or surroundings a simultaneous developments in mobile phones and HMDs have human can see without any eye movement. The human eye has made VR an accessible commodity for consumers. Lately, a rotating FoV of up to 270° [10]; newer HMDs are attempting HMDs have markedly improved: an increased field of view to create a FoV closer to that of the human eye. Currently, we (FoV), higher-resolution images, lightweight comfortable can expect the Oculus Rift and HTC Vive to give an FoV of design, and an appealing price have added to its attraction [5]. 110°, while some prototypes such as the Pimax 8k claim to offer Steed and Julier [6] described how they designed an immersive an FoV of 200° [11]. Image or screen resolution refers to how VR system around an Apple mobile phone (iPhone 4s), which clean and crisp the picture quality is; this is determined by the had the computing power to act as a controller for a VR system. number of pixels in an image area and is reported by the number The implementation of gyroscope technology in mobile phones, of pixels arranged horizontally and vertically [12]. For example, which tracks user movements, has allowed HMDs to house a screen resolution of 1280   720, which we refer to as 720p, is mobile phones that act as the VR system itself. An example of classified as high-definition (HD) ready. High-end HMDs today the capabilities of gyroscope is the highly successful app give a resolution between full HD (1080p) and QHD (1440p); “Pokemon Go” that tracks users’ movements as part of an again, both the Oculus Rift and HTC Vive offer a screen augmented reality experience [7]. Collectively, these resolution of 2160   1200, which equates to 2,592,000 pixels developments have brought VR back into the public domain. per image. This method of reporting resolution has been key to Furthermore, low costs, innovative apps, and an increasing selling televisions, which we see advertized as “full HD 1080p” accessibility have captured the imaginations of researchers who or “4k.” The investment that companies put into screen have proposed its use in the treatment and assessment of a wide resolution can be seen by HTC’s upgrade of the Vive to the range of health care issues. Vive Pro, the two HMDs are essentially very similar with exception of the Vive Pro’s increased 2880   1600 resolution. Building the Case for a Review The refresh rate reported as hertz is the number of times a screen Evidently, VR is a rapidly emerging field of research. Since can change image. We refer to this refresh rate as frames per 2016, new HMDs from Oculus, HTC, HP, Acer, Dell, and Sony second (FPS); an increased FPS will give a more fluid motion and the arrival of a range of cheaper mobile phone alternatives of images. FPS is particularly important as we want movements have acted as a catalyst for a new wave of VR research. Despite to be realistic; an environment should act according to the user, recent investment in Oculus by Facebook, indicating VR is here which means the reduction of any lag between the users’ input to stay, its popularity among consumers is unlikely to affect the and the output of images. Furthermore, VR setups that operate quantity of research around it. VR research has been below 90 FPS are more likely to induce nausea and continuously expanding in a time where it has not been at the disorientation [13]. forefront of digital consumerism. Oculus’ chief scientist Michael We used a useful definition of mental health from a mental Abrash has suggested that in the next 5 years, we will see a new health foundation that defined it as: generation of VR products, which will operate with 4k screen resolution and with eye tracking that may allow for foveated A state of well-being in which the individual realises rendering [8]. This prediction would appear to be coming partly his or her own abilities, can cope with normal stresses true as companies race to produce HMDs with increasingly http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al of life, can work productively and fruitfully, and is the type of VR used, or stated they used an HMD but provided able to make a contribution to his or her community. no further information regarding its model or specifications, [14] the study was excluded. Studies involving the use of two-dimensional (2D) virtual environments such as those seen The World Health Organization acknowledges that positive in Second Life were excluded. Furthermore, augmented reality mental well-being is rooted within mental health; this state of studies were not included as although augmented images are well-being allows an individual to lead a fulfilling and computer generated, the environment itself is not. Future VR productive life [15]. In this review, we aim to look at conditions may well feature an augmented experience within it [21]; that offer a scope to deliver psychological change that can make however, at this time, the two technologies are separate, and a meaningful difference to one’s mental health. We excluded this is reflected in this study’s direction. severe mental illnesses that require a more complex approach to treatment. Mental health conditions were categorized as behavioral conditions that showed the potential to be modified upon Virtual Reality and Mental Health intervention. In accordance with the International Statistical Health care and VR first met in the 1990s as a simulation tool Classification of Diseases and Related Health Problems [22], for colonoscopy and upper gastrointestinal tract endoscopy we were primarily concerned with the areas of “Neurotic, simulation within medical education [16]. VR would have stress-related, and somatoform disorders,” “Behavioral remained as a simulation tool for physicians and surgeons, but syndromes associated with physiological disturbances and its interactive nature suggested it as an applicable tool for physical factors,” “Mood disorders,” and substance abuse. We psychological change. For example, in the therapy of phobias, included VR studies that featured any form of anxiety adaptability of virtual worlds means that contextually relevant (generalized anxiety disorders, social anxiety disorders or virtual worlds can be created that are used to enable systematic specific phobias, and PTSD), depression, eating disorder exposure to feared stimuli [17]. The ability to precisely control (anorexia and binge eating), sleep disorders, and substance stimuli has allowed VR ecological validity in its assessment of addiction or abuse. Pain management was also included as it behaviors, emotions, and cognitions [18]. As a result, established has profound psychological and emotional consequences that effective psychotherapeutic approaches, such as cognitive can lead to depression and anxiety [23]. Severe mental disorders behavioral therapy (CBT), are recreated within VR alongside were excluded; a number of studies on psychosis were identified; exposure techniques [19]. This exposure is particularly effective however, due to its neurological origins as a state of brain as the goal of VR is to produce an “illusion of reality” [5]; development rather than a disease, psychosis was excluded from however, for the patients, despite knowing that the computer the study [24]. Autism was also excluded due it its environment is not real—a computerized illusion—their brains neurodevelopmental origin. Finally, we excluded any perceive the images and sound as real stimuli [1]. The broad rehabilitation studies, typically on stroke [25]. reach of VR has enabled its use for treating schizophrenia, posttraumatic stress disorder (PTSD), social and generalized Search Strategy anxiety disorders, specific phobias, eating disorders, substance The search strategy implemented in this review was conducted abuse, attention-deficit/hyperactivity disorder, depression, pain in 5 stages. management, and psychological stress, as well as its use as part Key reviews in the area were identified; these contained of a wide range of poststroke rehabilitation. broad mental health VR reviews to more condition-specific reviews. Methods The results and reference lists of these reviews were scanned to make an initial list of suitable studies. Design Our own searchers were then carried out to identify any Narrative syntheses were conducted on VR studies that were missed and more recent studies. The terms searched were: pertinent to areas of mental health [20]. The literature was [“Virtual”] AND [“mental health” OR “well-being”]. This critically assessed within the parameters of our review aims. was followed with more condition-specific searches: Control and noncontrol studies were included, and studies varied [“Virtual”] AND [“Anxiety” OR “Social Anxiety” OR from theory and assessment to treatment. Studies were featured “Phobia” OR “Agoraphobia” OR “Arachnophobia” OR if they appeared in peer-reviewed journals. “Fear” OR “PTSD” OR “Depression” OR “Depress” OR Inclusion and Exclusion “Stress” OR “Abuse” OR “Addiction” OR “pain” OR “Substance” OR “Eating” OR “Disorder” OR “Sleep” OR We set an inclusion timeframe from January 2012 to July 2017. “Body Image” OR “Body” OR “sexual” OR A 5-year period was seen as sufficient enough to reflect the “Dysfunction”]. Searches were conducted within current state of the technology; this would allow us to assess “MEDLINE,” “Journal of Medical Internet Research,” studies that used both the new generation of HMDs and a range “PsychINFO,” “Google Scholar,” and “Science Direct.” of older HMDs that have been in academia for the past decade. Screening was carried out upon the completion of a In line with this, studies were only included if they used an comprehensive list of studies. At this stage, studies were HMD. This meant excluding studies that used Cave Automatic excluded based on publication date, condition type, and Virtual Environment, the Computer-Assisted Rehabilitation lack of immersive VR. Environment, and other projector systems without an HMD. As we focused on the systems used, if authors failed to disclose http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al The full texts of remaining articles were then assessed to increased level of effectiveness for VRCBT over traditional find further reason for exclusion; at this stage, studies were CBT. In addition, Malbos et al [42] found that when treating typically excluded for not using an HMD or failing to anxiety for agoraphobia, VRET was just as effective in reducing disclose the type of VR used. anxiety as VRET with CBT combined. VR has been proven to be a markedly effective tool to induce fear to stimuli [19], and A full list of identified studies can be found in Multimedia it is also able to predict future levels of PTSD severity [34] and Appendix 2. diagnose patients with the condition [43]. Results Pain Management VR has been used as a distraction tool for pain management. The Current State of Research Different forms of VR distractions have been used for burn wound pain [44-47], phantom limb pain [48,49], cold pressor Head-Mounted Displays pain [50,51], dental pain [52,53], neck pain [54,55], back pain The following findings have been compiled from 81 studies [56], and cystoscopy [57] as well as for the assessment of that used HMDs in interventions related to mental health; 18 analgesia [58-60] and kinesiophobia [56,61]. Distractions ranged HMDs appeared across six different areas of mental health. The from coastal walks [52] and target-aiming tasks [61] to a Sonic eMagin z800 (n=34) was the most commonly used form of the Hedgehog Nintendo video game [51]. Other treatments were HMD appearing 34 times (Table 1). At the time of the review, dictated by the pain they were treating; visual limb distractions the only quotable price for this product was US $1795, with no were used for phantom limb pain [48,49]. Bahat et al used VR stock available in the UK. The z800 operates with a screen to manage impairments in cervical kinematics, which is resolution of 800   600, a 40° diagonal FoV, and the standard commonplace for those with neck pain [54]. Two studies refresh rate of 60 FPS. The second most commonly used HMD reported VR distraction to be more effective at reducing was the nVisor sx60 (n=8), which despite a higher screen perceived pain than controls, which included passive 2D resolution compared with the z800, still features a relatively distractions [38,44]. In contrast, Sil et al reported that an low FoV compared with the consumer products used today. interactive video game without VR was equally as effective at Two successful embodiment studies made use of HMDs with reducing pain as the same game with VR [51]. Piskorz et al higher specifications: an nVisor sx111 with a resolution of 1280 focused on the varying levels of complexity within VR   1024 and a 111° diagonal FoV was used to provide compassion distraction tasks and concluded that more complex tasks were to crying baby avatars [26]. Keizer et al [27] used a more effective at reducing the levels of pain [50]. In total, we second-edition Oculus Rift Developers Kit (960   1080 screen identified 22 studies; VR delivered through HMDs was resolution and 100° nominal FoV) to reduce the level of body frequently seen as the most effective method to distract from size misestimation among anorexic patients. Interestingly, the pain and, at worst, was equally as effective as controls. Oculus Rift was used in 5 of 22 pain management studies but in none of the anxiety studies, which may reveal a preference Stress for certain specifications for certain medical conditions. Mobile Stress was the primary target and depression the secondary in phone VR was used once by Taskian et al who made use of Shah et al’s VR mood induction procedure study [62]. That Samsung’s Gear HMD [28]. study did not have a control group, but the VR-based stress management program did show a decrease in the levels of Anxiety depression and stress. This result was achieved by face-to-face VR has been used as a form of exposure treatment (VRET). Its psychoeducation that centered on relaxation practice and on uses include the following conditions: social anxiety disorder how to manage stress; relaxation techniques were then practiced [29-31]; PTSD for military veterans [32] and for World Trade in VR. The Trier Social Stress Test (TSST), a paradigm used Center attack [33] and assault victims [34]; a range of specific for inducing psychosocial stress, was successfully implemented phobias, focusing on fear of flying [35] and fear of spiders in VR [63]. Designed to induce rather than reduce stress, [36-39]. Various forms of VRET are featured throughout the VR-TSST showed a marked increase in peripheral and anxiety literature. Some studies have compared the efficacy of subjective physiological reactions compared with in vivo TSST. VRET versus in vivo exposure [30], while others have Finally, VR-based mindfulness apps may also prove to have a incorporated VRET with CBT and compared it with traditional positive effect on stress [64]. CBT [29]. The contained exposure that VR provides has led to controlled studies where the effects of cycloserine and Depression alprazolam have been tested for the treatment of PTSD We identified only one intervention that had depression as the [32,33,40]. Similarly, VR environments have been used for primary target [36]. Patients delivered a compassionate message Theta burst stimulation [41] for those with spider phobia. The to a crying baby avatar and then received the same message literature review revealed that VR exposure showed positive while embodied as the baby. After three repetitions of the results on levels of anxiety and, generally, was at least as scenario, patients demonstrated a marked reduction in depression effective as in vivo exposure, although in some cases, the latter severity and self-criticism, with a substantial increase in was slightly more effective [30]. A similar trend was noted for self-compassion. VR and CBT studies, with Bouchard et al [29] finding an http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al Table 1. Head-mounted display (HMD) specifications. Type Resolution Hz Field of View Number of Studies eMagin z800 800 × 600 60 Hz 40° 34 nVisor SX60 1280 × 1024 60 Hz 60° 8 nVisor SX111 1280 × 1024 60 Hz 111° 4 nVisor ST50 1280 × 1024 60 Hz 50° 1 Sony HMZ-T1 1280 × 720 60 Hz 51.6° 1 5DT HMD 800 × 600 N/A 40° 3 VisuaStim 1280 × 1024 85 Hz 40° 1 Kaiser XL 50 1024 × 768 60 Hz 50° 1 VR1280 1280 × 1024 60 Hz 60° 1 Virtual Realities VR HMD pro 3D-42 800 × 600 N/A 42° 1 Pro 640 × 480 60 Hz 71.5° 2 Vuzix iWear VR920 640 × 480 N/A N/A 5 Vuzix VR1200 N/A N/A N/A 2 VFX3D 640 × 480 N/A 35° 1 Sensis Zsight 1280 × 1024 60 Hz 60° 2 V6 by Virtual Research Systems 640 × 480 60 Hz 60° 1 V8 by Virtual Research Systems 640 × 480 60 Hz 60 1 Oculus Rift DK1 640 × 800 60 Hz 110° 1 Oculus Rift DK2 960 × 1080 75 Hz 100° 6 ITV goggles ITG Wideview Xl edition N/A N/A N/A 1 Samsung Gear VR 2560 × 1440 60 Hz 96° 1 i-glasses 920HR N/A N/A 35° 1 Kaiser Optics SR80a N/A N/A N/A 1 Capable HMDs commonly sold on the market today HTC Vive 2160 × 1200 (combined) 90 Hz 110° N/A HTC Vive Pro 2880 × 1600 (combined) 90 Hz 110° N/A Oculus Go 1280 × 1440 (per eye) 72 Hz N/A N/A PlayStation VR 1920 × 1080 90 Hz (120 Hz in cinema 100° (approximately) N/A mode) Samsung Odyssey 1440 × 1600 per screen 90-60 Hz 110° N/A N/A: not applicable. Super AMOLED (active-matrix organic light-emitting diode) and dependent on mobile phone used. [27] created a full-body illusion treatment and concluded that Eating Disorders disturbed experiences of the body in patients with anorexia Studies on eating disorders included those on body image nervosa could be altered with VR. disturbance (BID) [65,66], anorexia, and bulimia nervosa Addiction and Substance Abuse [36,67]. Gutiérrez-Maldonado et al [67] compared this form of VR with a more immersive VR that used the Oculus Rift HMDs have been used to deliver exposure therapy to help treat Developers Kit 1. The study found immersive VR to be slightly tobacco addiction. Four studies investigated tobacco addiction more effective at reducing food cravings compared with [68-71]; one focused on relapse prevention of tobacco nonimmersive VR. Mountford et al [66] concluded that dieters consumption [72] and one on nicotine dependence [73]. The reported higher social evaluative concerns compared with remaining studies focused on gambling addiction [74,75] and nondieters. In addition, Purvis et al [65] found that women adolescent risk reduction [76]. Virtual reality cue exposure reported higher levels of body satisfaction in a VR environment therapy (VR-CET) was used to various degrees of success in than in control conditions. In an innovative study, Keizer et al the majority of studies. Pericot-Valverde et al [68] found http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al VR-CET to be as effective as traditional CET for smoking resources toward health. While nonimmersive virtual cessation and, in a later study [69], stated that VR-CET might environments were excluded from this review, it is worth noting be more beneficial toward certain individual variables, how health promotion became a prominent feature of the particularly age. Forms of CET were used in 6 out of 8 studies, computer program Second Life [81], as users were able to and VR-based cue reactivity assessment approach was used interact with bulletin boards, multimedia productions, power [73] to demonstrate the feasibility of cue exposure within VR points, health videos, and links to health-related Web pages. to treat nicotine dependence. Lister et al [74] did not test the These acted similar to psychoeducation in the sense that both efficacy of VR to treat gambling addiction but, nevertheless, information and education were offered [82]. Offering a more constructed a VR environment to demonstrate how goal setting immersive experience than Second Life, there is reason to within gambling can lead to a chasing behavior that can amount believe that similar health promotion tactics could succeed in to large financial losses for gamblers. Another study compared a VR environment. Further research is needed to determine the efficacy of CBT against VRET for preventing relapses in whether exposure to positive stimuli is as effective for mental nicotine dependence [58]. health as exposure to negative stimuli is for a psychological change. Discussion The success of VR in the treatment of anorexia- and depression-focused embodiment studies [27,36] highlights its This review confirms that HMDs have been used to treat mental effectiveness in treating conditions that can be “visual” for the health in different ways. VRET was one type of intervention sufferers. While there is no evidence to suggest that newer VR that was consistently used across different conditions. VRET systems—with higher screen resolution and FoV—are more interventions with and without CBT content have been clinically successful than older VR systems, HMDs with higher implemented for therapy of anxiety, PTSD, stress, eating specs may be better equipped to execute successful disorders, and substance addiction. VR excels in its advantage condition-focused interventions. For example, the Oculus Rift of being able to draw on both audio and interactive visual with its 110° FoV was not used in any of the anxiety studies stimuli, making the fearful stimuli appear as real as possible. but appeared in 5 of the 22 pain management studies. This could In addition, CBT delivered in VR has shown consistent positive be attributed to the preferences of the authors; however, it could results; the accurate adaption of relevant stimuli allows CBT be argued that the Rift with its larger FoV is more suitable for to pinpoint troublesome behaviors. The merging of VR and distraction interventions, whereas this increased FoV is not as mobile phones is a timely collaboration, and stress management crucial when trying to evoke a fearful reaction in someone with apps for mobile phones have been described as “incremental anxiety. It is also hard to determine whether VR HMDs are acquisitions” to cope with daily-life stresses [77]. The release being used to their full potential. The reporting of materials in of cost-effective HMDs, such as Google Cardboard, along with the reviewed literature was frequently limited, and we even mobile phone–compatible Samsung Gear VR is paving the way excluded studies for failing to specify the type of VR used; for an accessible form of health promotion that encompasses however, the specifications of PCs being used to power VR the mobile nature of mobile phones and the interactive exposure were even less frequently reported. All HMDs featured in Table of VR. However, this review revealed only one occasion when 1 allow images to be displayed at least 60 FPS, with newer a mobile HMD was used [38]. A rise in cryptocurrencies has models allowing for 90 FPS. Many computer systems are unable implied that the cost of personal computer (PC) graphics cards to reach this potential as the experience of VR being powered that power VR graphics is increasing rather than declining as by a 2GB Nvidia GeForce GTX 950 graphics card will be once expected [78]; moreover, added with the announcement different to a newer 11Gb GeForce GTX 1080Ti. This matters of Oculus Go [79], it highlights the need to demonstrate the because we know that frame rate judder caused by lower FPS clinical capabilities of mobile VR that does not rely on high-end can be a catalyst for motion sickness [83]. Thus, we recommend PCs. Future research should focus on testing a VR experience the use of FPS tools, as suggested [84], to provide more rigor that can be used at home; the cheaper alternatives discussed to material and method reporting. In the interest of making the would be an ideal starting location. research replicable, we also recommend the development of a Lindstrom [80] highlighted the work of Aaron Antonovsky’s framework for reporting technical specifications of VR. “Salutogenesis” in which he points to a method of “generating” The state of research suggests that VR cannot be a clinical tool health and emphasized an important difference between public itself and, instead, its success relies on the content it provides health and biomedical models: health promotion focuses on the a platform for. Complex VR systems backed by PCs with high resources toward health over the cautionary tales of risk and graphical and processing power to build detailed and adaptable disease. Early results in the treatment of stress suggest that VR environments allow the content of the intervention to be is an ideal platform to combine exposure to relaxation and complemented further. The most common HMD was the eMagin provide psychoeducation [62]. There is a need to investigate z800, which in the UK is not an accessible product. In public how the core features of VR can create exposure to positive health context, it is imperative that commonly sold HMDs are stimuli that help promote health. VR research into pain used with VR apps that can be used for self-help and to promote management has highlighted how positive VR experiences can health. This review points to VR as a useful method of provide a pain-relieving distraction. If exposure to pleasant modifying the behavior in an effort to enhance mental health; stimuli in relaxing environments is as successful as evoking the challenge now is to apply this to accessible products, which fear during deliberately troubling environments, VR could prove the public can use at home, work, and on the move. to be an important novel platform for providing people the http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al The results of this review suggest the potential efficacy of VR have been demonstrated. In addition, VR-induced distraction to provide a platform for improved mental health. VR has has proven to be a remarkable development in pain management. demonstrated some compatibility with proven psychological The lack of studies surrounding stress and depression, despite interventions, but combined, they illustrate a potential for a real positive initial outcomes, highlights VR’s infancy in some areas positive behavior change for a range of mental health conditions. of mental health. To help understand more about the relationship The current state of research does not illustrate VR’s ability to between VR systems and its efficacy as a mental health tool, improve mental health on its own; instead, it highlights the we recommend a thorough reporting of HMD and computer importance of the condition-oriented content within VR specifications. Finally, there is a need to design interventions interventions. that make the most of VR’s increasing mobility, as self-help VR tools could prove to be a valuable asset for mental health However, the specifications of HMDs and the computers that services. Thus, researchers must make the most of a rapidly power them are still important when trying to improve mental developing medium that is seeing advances in equipment; this health using VR. Although increases in FoV have brought us will act as a catalyst to develop increasingly detailed and novel closer to FoV of the human eye, an improved FPS may decrease interventions that push the boundaries of virtual presence. By the chances of motion sickness for some users. Currently, VR’s achieving this, VR has the potential to radically change the way strengths are being used for exposure therapy, as successful we modify problematic behaviors that affect our mental health. interventions in the treatment of anxiety, phobias, and PTSD Acknowledgments The authors acknowledge the contribution of NHS Highlands and the University of the Highlands and Islands whose funding supported this research. Conflicts of Interest None declared. Authors' Contributions The study was conceptualized by all four authors. Furthermore, data was curated, formal analysis was performed, and methodology was devised by all four authors. Project administration & critical supervision was performed by MG, MKB, and HvW. The original draft was prepared by SJ, and revisions and editing were performed by all four authors. Multimedia Appendix 1 Literature table. 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How-To Geek. 4 Quick Ways to See a PC Game’s FPS (Frames Per Second) URL: https://www.howtogeek.com/ 209710/4-quick-ways-to-see-a-pc-game%E2%80%99s-fps-frames-per-second/[WebCite Cache ID 70C0VUqQ4] Abbreviations CBT: cognitive behavioral therapy FoV: field of view FPS: frames per second HD: high definition HMD: head-mounted display PTSD: posttraumatic stress disorder TSST: Trier Social Stress Test VR: virtual reality VRET: virtual reality exposure treatment Edited by G Eysenbach; submitted 20.10.17; peer-reviewed by D Gunasekeran, C Mather; comments to author 17.12.17; revised version received 11.02.18; accepted 03.04.18; published 06.07.18 Please cite as: Jerdan SW, Grindle M, van Woerden HC, Kamel Boulos MN JMIR Serious Games 2018;6(3):e14 URL: http://games.jmir.org/2018/3/e14/ doi: 10.2196/games.9226 PMID: 29980500 ©Shaun W Jerdan, Mark Grindle, Hugo C van Woerden, Maged N Kamel Boulos. Originally published in JMIR Serious Games (http://games.jmir.org), 06.07.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 12 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

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2291-9279
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Abstract

Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment. (JMIR Serious Games 2018;6(3):e14) doi: 10.2196/games.9226 KEYWORDS virtual reality; well-being; behavior change http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al crisper resolution over their competition [9]. This suggests a Introduction potential new wave of VR products, thus, bringing down the prices of even the more sophisticated forms of VR today and Development of Virtual Reality making it an even more appealing tool for the health industry. Virtual reality (VR) is emerging as one of the key new With this in mind, now is the time to review the recent VR technological tools in a digital revolution sweeping across the research, taking a view of what technology is being used and health care industry. Immersive VR allows users to interact with how it is being used. a computer-generated world, where the users natural sensory Aims of This Literature Review perceptions are replaced with a digital three-dimensional (3D) alternative [1]. To create an immersive VR system, a computer In this review, we aim to critically assess the current state of is used to generate an image, a display system is required to head-mounted VR research in relation to mental health. By project the image, and, finally, a tracker is required to update doing so, we look to determine which conditions are more the image based on users’ movements. Traditionally, VR has susceptible to VR interventions, which conditions need more been confined to laboratories as expensive and powerful attention, and in what form VR interventions are most effective. computer(s) are needed to power it. VR, as we know it today, Our secondary aim is to understand more about VR used over has been around for decades; the vision of VR was first realized the past 5 years and compare it to the new generation of VR in by Ivan Sutherland in 1968 with the “Sword of Damocles” terms of accessibility and specifications. As there are indications head-mounted display (HMD) and later by Morton Heilig with that VR HMDs can be used at home as a self-help resource to his multisensory Sensorama [2]. Failed attempts at VR systems provide a valuable tool for public health, in this review, we will by Nintendo (Virtual Boy) and Sega (Sega VR) in the 1990s assess head-mounted VR health research to date to determine and a further lack of development in the 2000s had many of its whether this has been tested. critics arguing that the technology was “dead” [3]. However, Key Concepts as noted by Olson et al [4], the video games industry has driven advances in graphics cards that are able to handle increasingly HMD specifications are categorized into FoV, image resolution, sophisticated 3D constructed environments. Furthermore, and refresh rate (Hz). FoV refers to the view or surroundings a simultaneous developments in mobile phones and HMDs have human can see without any eye movement. The human eye has made VR an accessible commodity for consumers. Lately, a rotating FoV of up to 270° [10]; newer HMDs are attempting HMDs have markedly improved: an increased field of view to create a FoV closer to that of the human eye. Currently, we (FoV), higher-resolution images, lightweight comfortable can expect the Oculus Rift and HTC Vive to give an FoV of design, and an appealing price have added to its attraction [5]. 110°, while some prototypes such as the Pimax 8k claim to offer Steed and Julier [6] described how they designed an immersive an FoV of 200° [11]. Image or screen resolution refers to how VR system around an Apple mobile phone (iPhone 4s), which clean and crisp the picture quality is; this is determined by the had the computing power to act as a controller for a VR system. number of pixels in an image area and is reported by the number The implementation of gyroscope technology in mobile phones, of pixels arranged horizontally and vertically [12]. For example, which tracks user movements, has allowed HMDs to house a screen resolution of 1280   720, which we refer to as 720p, is mobile phones that act as the VR system itself. An example of classified as high-definition (HD) ready. High-end HMDs today the capabilities of gyroscope is the highly successful app give a resolution between full HD (1080p) and QHD (1440p); “Pokemon Go” that tracks users’ movements as part of an again, both the Oculus Rift and HTC Vive offer a screen augmented reality experience [7]. Collectively, these resolution of 2160   1200, which equates to 2,592,000 pixels developments have brought VR back into the public domain. per image. This method of reporting resolution has been key to Furthermore, low costs, innovative apps, and an increasing selling televisions, which we see advertized as “full HD 1080p” accessibility have captured the imaginations of researchers who or “4k.” The investment that companies put into screen have proposed its use in the treatment and assessment of a wide resolution can be seen by HTC’s upgrade of the Vive to the range of health care issues. Vive Pro, the two HMDs are essentially very similar with exception of the Vive Pro’s increased 2880   1600 resolution. Building the Case for a Review The refresh rate reported as hertz is the number of times a screen Evidently, VR is a rapidly emerging field of research. Since can change image. We refer to this refresh rate as frames per 2016, new HMDs from Oculus, HTC, HP, Acer, Dell, and Sony second (FPS); an increased FPS will give a more fluid motion and the arrival of a range of cheaper mobile phone alternatives of images. FPS is particularly important as we want movements have acted as a catalyst for a new wave of VR research. Despite to be realistic; an environment should act according to the user, recent investment in Oculus by Facebook, indicating VR is here which means the reduction of any lag between the users’ input to stay, its popularity among consumers is unlikely to affect the and the output of images. Furthermore, VR setups that operate quantity of research around it. VR research has been below 90 FPS are more likely to induce nausea and continuously expanding in a time where it has not been at the disorientation [13]. forefront of digital consumerism. Oculus’ chief scientist Michael We used a useful definition of mental health from a mental Abrash has suggested that in the next 5 years, we will see a new health foundation that defined it as: generation of VR products, which will operate with 4k screen resolution and with eye tracking that may allow for foveated A state of well-being in which the individual realises rendering [8]. This prediction would appear to be coming partly his or her own abilities, can cope with normal stresses true as companies race to produce HMDs with increasingly http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al of life, can work productively and fruitfully, and is the type of VR used, or stated they used an HMD but provided able to make a contribution to his or her community. no further information regarding its model or specifications, [14] the study was excluded. Studies involving the use of two-dimensional (2D) virtual environments such as those seen The World Health Organization acknowledges that positive in Second Life were excluded. Furthermore, augmented reality mental well-being is rooted within mental health; this state of studies were not included as although augmented images are well-being allows an individual to lead a fulfilling and computer generated, the environment itself is not. Future VR productive life [15]. In this review, we aim to look at conditions may well feature an augmented experience within it [21]; that offer a scope to deliver psychological change that can make however, at this time, the two technologies are separate, and a meaningful difference to one’s mental health. We excluded this is reflected in this study’s direction. severe mental illnesses that require a more complex approach to treatment. Mental health conditions were categorized as behavioral conditions that showed the potential to be modified upon Virtual Reality and Mental Health intervention. In accordance with the International Statistical Health care and VR first met in the 1990s as a simulation tool Classification of Diseases and Related Health Problems [22], for colonoscopy and upper gastrointestinal tract endoscopy we were primarily concerned with the areas of “Neurotic, simulation within medical education [16]. VR would have stress-related, and somatoform disorders,” “Behavioral remained as a simulation tool for physicians and surgeons, but syndromes associated with physiological disturbances and its interactive nature suggested it as an applicable tool for physical factors,” “Mood disorders,” and substance abuse. We psychological change. For example, in the therapy of phobias, included VR studies that featured any form of anxiety adaptability of virtual worlds means that contextually relevant (generalized anxiety disorders, social anxiety disorders or virtual worlds can be created that are used to enable systematic specific phobias, and PTSD), depression, eating disorder exposure to feared stimuli [17]. The ability to precisely control (anorexia and binge eating), sleep disorders, and substance stimuli has allowed VR ecological validity in its assessment of addiction or abuse. Pain management was also included as it behaviors, emotions, and cognitions [18]. As a result, established has profound psychological and emotional consequences that effective psychotherapeutic approaches, such as cognitive can lead to depression and anxiety [23]. Severe mental disorders behavioral therapy (CBT), are recreated within VR alongside were excluded; a number of studies on psychosis were identified; exposure techniques [19]. This exposure is particularly effective however, due to its neurological origins as a state of brain as the goal of VR is to produce an “illusion of reality” [5]; development rather than a disease, psychosis was excluded from however, for the patients, despite knowing that the computer the study [24]. Autism was also excluded due it its environment is not real—a computerized illusion—their brains neurodevelopmental origin. Finally, we excluded any perceive the images and sound as real stimuli [1]. The broad rehabilitation studies, typically on stroke [25]. reach of VR has enabled its use for treating schizophrenia, posttraumatic stress disorder (PTSD), social and generalized Search Strategy anxiety disorders, specific phobias, eating disorders, substance The search strategy implemented in this review was conducted abuse, attention-deficit/hyperactivity disorder, depression, pain in 5 stages. management, and psychological stress, as well as its use as part Key reviews in the area were identified; these contained of a wide range of poststroke rehabilitation. broad mental health VR reviews to more condition-specific reviews. Methods The results and reference lists of these reviews were scanned to make an initial list of suitable studies. Design Our own searchers were then carried out to identify any Narrative syntheses were conducted on VR studies that were missed and more recent studies. The terms searched were: pertinent to areas of mental health [20]. The literature was [“Virtual”] AND [“mental health” OR “well-being”]. This critically assessed within the parameters of our review aims. was followed with more condition-specific searches: Control and noncontrol studies were included, and studies varied [“Virtual”] AND [“Anxiety” OR “Social Anxiety” OR from theory and assessment to treatment. Studies were featured “Phobia” OR “Agoraphobia” OR “Arachnophobia” OR if they appeared in peer-reviewed journals. “Fear” OR “PTSD” OR “Depression” OR “Depress” OR Inclusion and Exclusion “Stress” OR “Abuse” OR “Addiction” OR “pain” OR “Substance” OR “Eating” OR “Disorder” OR “Sleep” OR We set an inclusion timeframe from January 2012 to July 2017. “Body Image” OR “Body” OR “sexual” OR A 5-year period was seen as sufficient enough to reflect the “Dysfunction”]. Searches were conducted within current state of the technology; this would allow us to assess “MEDLINE,” “Journal of Medical Internet Research,” studies that used both the new generation of HMDs and a range “PsychINFO,” “Google Scholar,” and “Science Direct.” of older HMDs that have been in academia for the past decade. Screening was carried out upon the completion of a In line with this, studies were only included if they used an comprehensive list of studies. At this stage, studies were HMD. This meant excluding studies that used Cave Automatic excluded based on publication date, condition type, and Virtual Environment, the Computer-Assisted Rehabilitation lack of immersive VR. Environment, and other projector systems without an HMD. As we focused on the systems used, if authors failed to disclose http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al The full texts of remaining articles were then assessed to increased level of effectiveness for VRCBT over traditional find further reason for exclusion; at this stage, studies were CBT. In addition, Malbos et al [42] found that when treating typically excluded for not using an HMD or failing to anxiety for agoraphobia, VRET was just as effective in reducing disclose the type of VR used. anxiety as VRET with CBT combined. VR has been proven to be a markedly effective tool to induce fear to stimuli [19], and A full list of identified studies can be found in Multimedia it is also able to predict future levels of PTSD severity [34] and Appendix 2. diagnose patients with the condition [43]. Results Pain Management VR has been used as a distraction tool for pain management. The Current State of Research Different forms of VR distractions have been used for burn wound pain [44-47], phantom limb pain [48,49], cold pressor Head-Mounted Displays pain [50,51], dental pain [52,53], neck pain [54,55], back pain The following findings have been compiled from 81 studies [56], and cystoscopy [57] as well as for the assessment of that used HMDs in interventions related to mental health; 18 analgesia [58-60] and kinesiophobia [56,61]. Distractions ranged HMDs appeared across six different areas of mental health. The from coastal walks [52] and target-aiming tasks [61] to a Sonic eMagin z800 (n=34) was the most commonly used form of the Hedgehog Nintendo video game [51]. Other treatments were HMD appearing 34 times (Table 1). At the time of the review, dictated by the pain they were treating; visual limb distractions the only quotable price for this product was US $1795, with no were used for phantom limb pain [48,49]. Bahat et al used VR stock available in the UK. The z800 operates with a screen to manage impairments in cervical kinematics, which is resolution of 800   600, a 40° diagonal FoV, and the standard commonplace for those with neck pain [54]. Two studies refresh rate of 60 FPS. The second most commonly used HMD reported VR distraction to be more effective at reducing was the nVisor sx60 (n=8), which despite a higher screen perceived pain than controls, which included passive 2D resolution compared with the z800, still features a relatively distractions [38,44]. In contrast, Sil et al reported that an low FoV compared with the consumer products used today. interactive video game without VR was equally as effective at Two successful embodiment studies made use of HMDs with reducing pain as the same game with VR [51]. Piskorz et al higher specifications: an nVisor sx111 with a resolution of 1280 focused on the varying levels of complexity within VR   1024 and a 111° diagonal FoV was used to provide compassion distraction tasks and concluded that more complex tasks were to crying baby avatars [26]. Keizer et al [27] used a more effective at reducing the levels of pain [50]. In total, we second-edition Oculus Rift Developers Kit (960   1080 screen identified 22 studies; VR delivered through HMDs was resolution and 100° nominal FoV) to reduce the level of body frequently seen as the most effective method to distract from size misestimation among anorexic patients. Interestingly, the pain and, at worst, was equally as effective as controls. Oculus Rift was used in 5 of 22 pain management studies but in none of the anxiety studies, which may reveal a preference Stress for certain specifications for certain medical conditions. Mobile Stress was the primary target and depression the secondary in phone VR was used once by Taskian et al who made use of Shah et al’s VR mood induction procedure study [62]. That Samsung’s Gear HMD [28]. study did not have a control group, but the VR-based stress management program did show a decrease in the levels of Anxiety depression and stress. This result was achieved by face-to-face VR has been used as a form of exposure treatment (VRET). Its psychoeducation that centered on relaxation practice and on uses include the following conditions: social anxiety disorder how to manage stress; relaxation techniques were then practiced [29-31]; PTSD for military veterans [32] and for World Trade in VR. The Trier Social Stress Test (TSST), a paradigm used Center attack [33] and assault victims [34]; a range of specific for inducing psychosocial stress, was successfully implemented phobias, focusing on fear of flying [35] and fear of spiders in VR [63]. Designed to induce rather than reduce stress, [36-39]. Various forms of VRET are featured throughout the VR-TSST showed a marked increase in peripheral and anxiety literature. Some studies have compared the efficacy of subjective physiological reactions compared with in vivo TSST. VRET versus in vivo exposure [30], while others have Finally, VR-based mindfulness apps may also prove to have a incorporated VRET with CBT and compared it with traditional positive effect on stress [64]. CBT [29]. The contained exposure that VR provides has led to controlled studies where the effects of cycloserine and Depression alprazolam have been tested for the treatment of PTSD We identified only one intervention that had depression as the [32,33,40]. Similarly, VR environments have been used for primary target [36]. Patients delivered a compassionate message Theta burst stimulation [41] for those with spider phobia. The to a crying baby avatar and then received the same message literature review revealed that VR exposure showed positive while embodied as the baby. After three repetitions of the results on levels of anxiety and, generally, was at least as scenario, patients demonstrated a marked reduction in depression effective as in vivo exposure, although in some cases, the latter severity and self-criticism, with a substantial increase in was slightly more effective [30]. A similar trend was noted for self-compassion. VR and CBT studies, with Bouchard et al [29] finding an http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al Table 1. Head-mounted display (HMD) specifications. Type Resolution Hz Field of View Number of Studies eMagin z800 800 × 600 60 Hz 40° 34 nVisor SX60 1280 × 1024 60 Hz 60° 8 nVisor SX111 1280 × 1024 60 Hz 111° 4 nVisor ST50 1280 × 1024 60 Hz 50° 1 Sony HMZ-T1 1280 × 720 60 Hz 51.6° 1 5DT HMD 800 × 600 N/A 40° 3 VisuaStim 1280 × 1024 85 Hz 40° 1 Kaiser XL 50 1024 × 768 60 Hz 50° 1 VR1280 1280 × 1024 60 Hz 60° 1 Virtual Realities VR HMD pro 3D-42 800 × 600 N/A 42° 1 Pro 640 × 480 60 Hz 71.5° 2 Vuzix iWear VR920 640 × 480 N/A N/A 5 Vuzix VR1200 N/A N/A N/A 2 VFX3D 640 × 480 N/A 35° 1 Sensis Zsight 1280 × 1024 60 Hz 60° 2 V6 by Virtual Research Systems 640 × 480 60 Hz 60° 1 V8 by Virtual Research Systems 640 × 480 60 Hz 60 1 Oculus Rift DK1 640 × 800 60 Hz 110° 1 Oculus Rift DK2 960 × 1080 75 Hz 100° 6 ITV goggles ITG Wideview Xl edition N/A N/A N/A 1 Samsung Gear VR 2560 × 1440 60 Hz 96° 1 i-glasses 920HR N/A N/A 35° 1 Kaiser Optics SR80a N/A N/A N/A 1 Capable HMDs commonly sold on the market today HTC Vive 2160 × 1200 (combined) 90 Hz 110° N/A HTC Vive Pro 2880 × 1600 (combined) 90 Hz 110° N/A Oculus Go 1280 × 1440 (per eye) 72 Hz N/A N/A PlayStation VR 1920 × 1080 90 Hz (120 Hz in cinema 100° (approximately) N/A mode) Samsung Odyssey 1440 × 1600 per screen 90-60 Hz 110° N/A N/A: not applicable. Super AMOLED (active-matrix organic light-emitting diode) and dependent on mobile phone used. [27] created a full-body illusion treatment and concluded that Eating Disorders disturbed experiences of the body in patients with anorexia Studies on eating disorders included those on body image nervosa could be altered with VR. disturbance (BID) [65,66], anorexia, and bulimia nervosa Addiction and Substance Abuse [36,67]. Gutiérrez-Maldonado et al [67] compared this form of VR with a more immersive VR that used the Oculus Rift HMDs have been used to deliver exposure therapy to help treat Developers Kit 1. The study found immersive VR to be slightly tobacco addiction. Four studies investigated tobacco addiction more effective at reducing food cravings compared with [68-71]; one focused on relapse prevention of tobacco nonimmersive VR. Mountford et al [66] concluded that dieters consumption [72] and one on nicotine dependence [73]. The reported higher social evaluative concerns compared with remaining studies focused on gambling addiction [74,75] and nondieters. In addition, Purvis et al [65] found that women adolescent risk reduction [76]. Virtual reality cue exposure reported higher levels of body satisfaction in a VR environment therapy (VR-CET) was used to various degrees of success in than in control conditions. In an innovative study, Keizer et al the majority of studies. Pericot-Valverde et al [68] found http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al VR-CET to be as effective as traditional CET for smoking resources toward health. While nonimmersive virtual cessation and, in a later study [69], stated that VR-CET might environments were excluded from this review, it is worth noting be more beneficial toward certain individual variables, how health promotion became a prominent feature of the particularly age. Forms of CET were used in 6 out of 8 studies, computer program Second Life [81], as users were able to and VR-based cue reactivity assessment approach was used interact with bulletin boards, multimedia productions, power [73] to demonstrate the feasibility of cue exposure within VR points, health videos, and links to health-related Web pages. to treat nicotine dependence. Lister et al [74] did not test the These acted similar to psychoeducation in the sense that both efficacy of VR to treat gambling addiction but, nevertheless, information and education were offered [82]. Offering a more constructed a VR environment to demonstrate how goal setting immersive experience than Second Life, there is reason to within gambling can lead to a chasing behavior that can amount believe that similar health promotion tactics could succeed in to large financial losses for gamblers. Another study compared a VR environment. Further research is needed to determine the efficacy of CBT against VRET for preventing relapses in whether exposure to positive stimuli is as effective for mental nicotine dependence [58]. health as exposure to negative stimuli is for a psychological change. Discussion The success of VR in the treatment of anorexia- and depression-focused embodiment studies [27,36] highlights its This review confirms that HMDs have been used to treat mental effectiveness in treating conditions that can be “visual” for the health in different ways. VRET was one type of intervention sufferers. While there is no evidence to suggest that newer VR that was consistently used across different conditions. VRET systems—with higher screen resolution and FoV—are more interventions with and without CBT content have been clinically successful than older VR systems, HMDs with higher implemented for therapy of anxiety, PTSD, stress, eating specs may be better equipped to execute successful disorders, and substance addiction. VR excels in its advantage condition-focused interventions. For example, the Oculus Rift of being able to draw on both audio and interactive visual with its 110° FoV was not used in any of the anxiety studies stimuli, making the fearful stimuli appear as real as possible. but appeared in 5 of the 22 pain management studies. This could In addition, CBT delivered in VR has shown consistent positive be attributed to the preferences of the authors; however, it could results; the accurate adaption of relevant stimuli allows CBT be argued that the Rift with its larger FoV is more suitable for to pinpoint troublesome behaviors. The merging of VR and distraction interventions, whereas this increased FoV is not as mobile phones is a timely collaboration, and stress management crucial when trying to evoke a fearful reaction in someone with apps for mobile phones have been described as “incremental anxiety. It is also hard to determine whether VR HMDs are acquisitions” to cope with daily-life stresses [77]. The release being used to their full potential. The reporting of materials in of cost-effective HMDs, such as Google Cardboard, along with the reviewed literature was frequently limited, and we even mobile phone–compatible Samsung Gear VR is paving the way excluded studies for failing to specify the type of VR used; for an accessible form of health promotion that encompasses however, the specifications of PCs being used to power VR the mobile nature of mobile phones and the interactive exposure were even less frequently reported. All HMDs featured in Table of VR. However, this review revealed only one occasion when 1 allow images to be displayed at least 60 FPS, with newer a mobile HMD was used [38]. A rise in cryptocurrencies has models allowing for 90 FPS. Many computer systems are unable implied that the cost of personal computer (PC) graphics cards to reach this potential as the experience of VR being powered that power VR graphics is increasing rather than declining as by a 2GB Nvidia GeForce GTX 950 graphics card will be once expected [78]; moreover, added with the announcement different to a newer 11Gb GeForce GTX 1080Ti. This matters of Oculus Go [79], it highlights the need to demonstrate the because we know that frame rate judder caused by lower FPS clinical capabilities of mobile VR that does not rely on high-end can be a catalyst for motion sickness [83]. Thus, we recommend PCs. Future research should focus on testing a VR experience the use of FPS tools, as suggested [84], to provide more rigor that can be used at home; the cheaper alternatives discussed to material and method reporting. In the interest of making the would be an ideal starting location. research replicable, we also recommend the development of a Lindstrom [80] highlighted the work of Aaron Antonovsky’s framework for reporting technical specifications of VR. “Salutogenesis” in which he points to a method of “generating” The state of research suggests that VR cannot be a clinical tool health and emphasized an important difference between public itself and, instead, its success relies on the content it provides health and biomedical models: health promotion focuses on the a platform for. Complex VR systems backed by PCs with high resources toward health over the cautionary tales of risk and graphical and processing power to build detailed and adaptable disease. Early results in the treatment of stress suggest that VR environments allow the content of the intervention to be is an ideal platform to combine exposure to relaxation and complemented further. The most common HMD was the eMagin provide psychoeducation [62]. There is a need to investigate z800, which in the UK is not an accessible product. In public how the core features of VR can create exposure to positive health context, it is imperative that commonly sold HMDs are stimuli that help promote health. VR research into pain used with VR apps that can be used for self-help and to promote management has highlighted how positive VR experiences can health. This review points to VR as a useful method of provide a pain-relieving distraction. If exposure to pleasant modifying the behavior in an effort to enhance mental health; stimuli in relaxing environments is as successful as evoking the challenge now is to apply this to accessible products, which fear during deliberately troubling environments, VR could prove the public can use at home, work, and on the move. to be an important novel platform for providing people the http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al The results of this review suggest the potential efficacy of VR have been demonstrated. In addition, VR-induced distraction to provide a platform for improved mental health. VR has has proven to be a remarkable development in pain management. demonstrated some compatibility with proven psychological The lack of studies surrounding stress and depression, despite interventions, but combined, they illustrate a potential for a real positive initial outcomes, highlights VR’s infancy in some areas positive behavior change for a range of mental health conditions. of mental health. To help understand more about the relationship The current state of research does not illustrate VR’s ability to between VR systems and its efficacy as a mental health tool, improve mental health on its own; instead, it highlights the we recommend a thorough reporting of HMD and computer importance of the condition-oriented content within VR specifications. Finally, there is a need to design interventions interventions. that make the most of VR’s increasing mobility, as self-help VR tools could prove to be a valuable asset for mental health However, the specifications of HMDs and the computers that services. Thus, researchers must make the most of a rapidly power them are still important when trying to improve mental developing medium that is seeing advances in equipment; this health using VR. Although increases in FoV have brought us will act as a catalyst to develop increasingly detailed and novel closer to FoV of the human eye, an improved FPS may decrease interventions that push the boundaries of virtual presence. By the chances of motion sickness for some users. Currently, VR’s achieving this, VR has the potential to radically change the way strengths are being used for exposure therapy, as successful we modify problematic behaviors that affect our mental health. interventions in the treatment of anxiety, phobias, and PTSD Acknowledgments The authors acknowledge the contribution of NHS Highlands and the University of the Highlands and Islands whose funding supported this research. Conflicts of Interest None declared. Authors' Contributions The study was conceptualized by all four authors. Furthermore, data was curated, formal analysis was performed, and methodology was devised by all four authors. Project administration & critical supervision was performed by MG, MKB, and HvW. The original draft was prepared by SJ, and revisions and editing were performed by all four authors. Multimedia Appendix 1 Literature table. [PDF File (Adobe PDF File), 210KB-Multimedia Appendix 1] Multimedia Appendix 2 Head-mounted display (HMD) virtual reality (VR) use as reported in literature 2012-2017 (n=81). [PDF File (Adobe PDF File), 83KB-Multimedia Appendix 2] References 1. Freeman D, Reeve S, Robinson A, Ehlers A, Clark D, Spanlang B, et al. Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychol Med 2017 Oct;47(14):2393-2400. [doi: 10.1017/S003329171700040X] [Medline: 28325167] 2. Slater M, Sanchez-Vives MV. Enhancing our lives with immersive virtual reality. Front Robot AI 2016 Dec 19;3. [doi: 10.3389/frobt.2016.00074] 3. Mims C. MIT Technology Review. Whatever Happened to ... Virtual Reality? URL: https://www.technologyreview.com/ s/421293/whatever-happened-to-virtual-reality/[WebCite Cache ID 70AX5IDCz] 4. Olson J. 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How-To Geek. 4 Quick Ways to See a PC Game’s FPS (Frames Per Second) URL: https://www.howtogeek.com/ 209710/4-quick-ways-to-see-a-pc-game%E2%80%99s-fps-frames-per-second/[WebCite Cache ID 70C0VUqQ4] Abbreviations CBT: cognitive behavioral therapy FoV: field of view FPS: frames per second HD: high definition HMD: head-mounted display PTSD: posttraumatic stress disorder TSST: Trier Social Stress Test VR: virtual reality VRET: virtual reality exposure treatment Edited by G Eysenbach; submitted 20.10.17; peer-reviewed by D Gunasekeran, C Mather; comments to author 17.12.17; revised version received 11.02.18; accepted 03.04.18; published 06.07.18 Please cite as: Jerdan SW, Grindle M, van Woerden HC, Kamel Boulos MN JMIR Serious Games 2018;6(3):e14 URL: http://games.jmir.org/2018/3/e14/ doi: 10.2196/games.9226 PMID: 29980500 ©Shaun W Jerdan, Mark Grindle, Hugo C van Woerden, Maged N Kamel Boulos. Originally published in JMIR Serious Games (http://games.jmir.org), 06.07.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jerdan et al information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/3/e14/ JMIR Serious Games 2018 | vol. 6 | iss. 3 | e14 | p. 12 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jul 6, 2018

Keywords: virtual reality; well-being; behavior change

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