Virtual Reality Shows Promise in Patients With SMI

While pharmacotherapy can help to alleviate some of the symptoms of serious mental illness (SMI), vocational rehabilitation and related social programs are critical for helping people with SMI to re-enter the community. While there are more patients than there are programs to support them, recent studies suggest that virtual reality–based interventions might be able to fill some of this gap.

Daniel Freeman, Ph.D., a professor of clinical psychology at Oxford University, is a big proponent of using virtual reality (VR) to encourage social engagement among people with psychosis. One of his first patients was completely homebound because the patient experienced severe terrors whenever thinking about going outside, he told Psychiatric News.

Oxford VR

That patient was not an outlier, he noted. Freeman recently conducted a survey of patients with psychosis in the United Kingdom and found that 65% met the clinical criteria for agoraphobia (fear of crowded spaces). “Even if their [psychosis] symptoms are managed, many patients have these residual fears that leave them housebound,” including fear that others will judge them of negatively.

Freeman’s experiences with such patients led him to develop a VR program called gameChange. The program places users into virtual locations such as a café or clinic waiting room and asks them to perform such tasks as making eye contact with people and placing an order. Each location has multiple difficulty levels that increase the number of people present and social interactions required. The program does not require a therapist to be present; instead, a virtual coach guides and encourages the participant through the exercises.

“The users can advance at their own comfort level in a safe space,” said Freeman, who spun out his VR research into a company called Oxford VR (he is the chief scientific officer). Just as pilots train on flight simulators, patients can use VR to train for navigating social settings, he said.

Earlier this year, Freeman’s group published data from a study that compared outcomes in a group of patients with psychosis and agoraphobia who completed weekly gameChange sessions with those who did not participate in the VR sessions. Three hundred and fifty participants with psychosis received either six weekly sessions of gameChange in addition to usual care or their usual care alone (which included antipsychotic medications and regular visits with a community mental health worker). The gameChange sessions were done in a clinic but required only the assistance of a technician for set up and monitoring purposes.

At the end of six weeks, the patients who received gameChange reported significantly less avoidance of social situations and less distress when out in public compared with the patients who received usual care. Freeman noted that these differences were seen even as the COVID-19 pandemic emerged.

“It was disconcerting that we were helping patients reconnect with society and halfway through they were getting the opposite message [from public health agencies],” he told Psychiatric News. “By the same token, many patients might have benefited from public spaces being much less crowded than usual.”

Now that most COVID-related social restrictions have been lifted, Freeman hopes to conduct studies of gameChange in both the United Kingdom and United States to see if the program can be effectively implemented in routine clinical settings. He is also looking to expand the capabilities of gameChange to help address paranoia and feelings of persecution.

Practice Makes Perfect

One key milestone on the road to recovery is obtaining gainful employment, a process that can be stressful for anyone, let alone someone dealing with the challenges of schizophrenia, said Matthew Smith, Ph.D., M.S.W., a professor of social work at the University of Michigan.

While supported employment services help people with mental illness find jobs, the staff may not have the resources to offer in-depth interview training. To help patients prepare for a job interview, Smith developed a virtual reality interview training program informally known as Molly (the name of the virtual hiring manager). Like gameChange, Molly creates a space in which users can practice their interviewing skills and receive automated feedback without any real-world repercussions.

Numerous clinical studies have shown people with a variety of mental illnesses, including SMI or autism spectrum disorders, become more confident and gain employment faster after using Molly than people who don’t use the program.

Recently, Smith worked with Thresholds—a nonprofit community organization in Chicago that provides comprehensive mental health services—to test Molly in a real-world setting. As part of its programs, Thresholds offers the patients it serves individual placement and support (IPS), considered the industry standard in vocational rehabilitation.

The study included 90 job-seeking adults with a serious mental illness who randomly received regular IPS services or IPS augmented with about nine Molly interviews. Smith had hoped to recruit more people for the study, but the COVID-19 pandemic forced him to end recruitment early. While the results showed that 43% of adults who received the virtual training combined with IPS obtained a job within nine months compared with 28% of the adults who received only IPS, the differences in employment between the two groups were not statistically significant.

When Smith took a closer look at the data, he discovered that the Molly program worked especially well for adults who had been enrolled in IPS for at least three months prior to the study and still had not found a job—a group he referred to as “IPS nonresponders.” Over half of nonresponders who trained with Molly subsequently found a job, compared with 19% of nonresponders who trained with regular IPS services.

“We also followed up with some in-depth interviews and learned that many nonresponders had never interviewed for a job or avoided job interviews due to being anxious about the interview process,” Smith said. “This study validated how the ability to practice something that is feared can make a difference.”

Smith is aiming to launch a larger real-world trial focused specifically on IPS nonresponders that will involve community organizations across multiple states. In addition to testing the scalability of Molly, he hopes to compare the effectiveness of offering the patients VR support from traditional employment specialists versus trained peer support specialists. He told Psychiatric News the results should be interesting in light of the post-COVID shift to having more virtual job interviews. “Interviewing with Molly is a great representation of how online job interviews are currently playing out, so it could make trainees become even more skilled and confident.”

Even as both Freeman and Smith begin to test their products in office settings, they are thinking of the possibilities ahead. “These tools are getting to the point of being fully remote,” said Smith. Outside of an introductory orientation to the program, in-person assistance isn’t really needed, he said.

“I’m still impressed how far VR has come over these past few years, to the point we have headsets that don’t even need a computer connection anymore,” Freeman added. As standalone VR units become cheaper, Freeman can see patients receiving take-home VR kits filled with a suite of training and skill-building programs that they can use when and where they need. ■