Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses

Background: Automated delivery of psychological therapy using immersive technologies such as virtual reality (VR) might greatly increase the availability of effective help for patients. We aimed to evaluate the efficacy of an automated VR cognitive therapy (gameChange) to treat avoidance and distress in patients with psychosis, and to analyse how and in whom it might work. // Methods: We did a parallel-group, single-blind, randomised, controlled trial across nine National Health Service trusts in England. Eligible patients were aged 16 years or older, with a clinical diagnosis of a schizophrenia spectrum disorder or an affective diagnosis with psychotic symptoms, and had self-reported difficulties going outside due to anxiety. Patients were randomly assigned (1:1) to either gameChange VR therapy plus usual care or usual care alone, using a permuted blocks algorithm with randomly varying block size, stratified by study site and service type. gameChange VR therapy was provided in approximately six sessions over 6 weeks. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 6 (primary endpoint), and 26 weeks after randomisation. The primary outcome was avoidance of, and distress in, everyday situations, assessed using the self-reported Oxford Agoraphobic Avoidance Scale (O-AS). Outcome analyses were done in the intention-to-treat population (ie, all participants who were assigned to a study group for whom data were available). We performed planned mediation and moderation analyses to test the effects of gameChange VR therapy when added to usual care. This trial is registered with the ISRCTN registry, 17308399. // Findings: Between July 25, 2019, and May 7, 2021 (with a pause in recruitment from March 16, 2020, to Sept 14, 2020, due to COVID-19 pandemic restrictions), 551 patients were assessed for eligibility and 346 were enrolled. 231 (67%) patients were men and 111 (32%) were women, 294 (85%) were White, and the mean age was 37·2 years (SD 12·5). 174 patients were randomly assigned to the gameChange VR therapy group and 172 to the usual care alone group. Compared with the usual care alone group, the gameChange VR therapy group had significant reductions in agoraphobic avoidance (O-AS adjusted mean difference –0·47, 95% CI –0·88 to –0·06; n=320; Cohen's d –0·18; p=0·026) and distress (–4·33, –7·78 to –0·87; n=322; –0·26; p=0·014) at 6 weeks. Reductions in threat cognitions and within-situation defence behaviours mediated treatment outcomes. The greater the severity of anxious fears and avoidance, the greater the treatment benefits. There was no significant difference in the occurrence of serious adverse events between the gameChange VR therapy group (12 events in nine patients) and the usual care alone group (eight events in seven patients; p=0·37). // Interpretation: Automated VR therapy led to significant reductions in anxious avoidance of, and distress in, everyday situations compared with usual care alone. The mediation analysis indicated that the VR therapy worked in accordance with the cognitive model by reducing anxious thoughts and associated protective behaviours. The moderation analysis indicated that the VR therapy particularly benefited patients with severe agoraphobic avoidance, such as not being able to leave the home unaccompanied. gameChange VR therapy has the potential to increase the provision of effective psychological therapy for psychosis, particularly for patients who find it difficult to leave their home, visit local amenities, or use public transport. // Funding: National Institute of Health Research Invention for Innovation programme, National Institute of Health Research Oxford Health Biomedical Research Centre

The effectiveness of videoconference-based cognitive-behavioural therapy

The purpose of this research was to expand scientific understanding regarding the use of videoconferencing technology to administer psychological services. The primary study in this thesis is a randomised-controlled trial comparing in-person to videoconference-based Cognitive-Behavioural Therapy (CBT). This study is, to the author’s knowledge, the largest clinical trial investigating the effectiveness of CBT via videoconference that has been conducted on an adult population in Australia. Twenty-nine clients were recruited who had a primary DSM-IV diagnosis of anxiety and/or depression. Participants were randomly assigned to receive 12 sessions of either in-person or videoconference-based treatment. Participants in both conditions received treatment at a university clinic in Perth Western Australia.The intervention provided was based on CBT manualised treatments but individualised to suit the unique needs of each client. Primary symptomology and quality of life was measured pre, post and 6-weeks following treatment. Secondary outcome measures included working alliance, credibility of therapy and client satisfaction. Overall, retention in both treatment conditions was similar. Statistical analysis using multi-level linear modelling indicated a significant reduction in client symptoms across time but no significant differences between treatment conditions. There were also no significant differences between conditions on working alliance, credibility of therapy and client satisfaction ratings. The findings of study one suggest that CBT via videoconference can be effectively provided in a real-world clinical practice context.The second study in this thesis is an in-depth case study of a client with severe and complex obsessive-compulsive disorder who received forty sessions of psychotherapy administered through a mix of videoconference and text-chat. Session recordings, transcripts and therapists notes were analysed using thematic analysis to explore how the technology influenced client engagement. The results indicated that the mixture of videoconferencing and text-chat might have facilitated client engagement by helping to reduce interpersonal anxiety, thus allowing the client to continue disclosing and discussing issues that were espoused in shame, guilt and embarrassment. To the author’s knowledge, the methods of engaging the client via combined videoconference and text-chat reported in study two have not been reported in the literature before

Anxiety and Related Disorders

Anxiety disorders are one of the most common psychiatric disorders worldwide and many aspects of anxiety can be observed. Anxious patients often consult primary care physicians for their treatment, but in most cases they do not accept the diagnosis of anxiety disorder. Anxiety is a symptom that could be seen in many organic disorders and can accompany almost any psychiatric disorder. Anxiety disorders are frequent and are associated with significant distress and dysfunction. Stigmatization is an important factor in insufficient diagnosis. The problems of anxiety cover all fields of life. This book intends to describe the epidemiological aspects and the main co-morbidities and consecutive diseases of the anxiety disorders

An evaluation of behavioural activation treatment for anxiety (BATA) when delivered In-person and via videoconferencing

Cognitive Behavioural Therapy (CBT), a form of psychotherapy, is the most empirically supported treatment for anxiety, but new research into psychological treatments for anxiety is warranted because clinical improvement is not achieved by between 20% and 80% of the clinical population receiving CBT or other empirically supported psychological treatments. One recently developed approach is Behavioural Activation Therapy for Anxiety (BATA), first reported in 2009 by Turner and Leach who identified that Behavioural Activation (BA), though recognised as an effective treatment for depression, had rarely been applied to anxiety despite functional similarities. BATA has been written as a structured protocol, based on setting goals and scheduling activities, that brings clients into contact with naturally occurring sources of positive reinforcement for “clinically healthier”, socially-valid behaviours. This study included nine single case recipients of BATA ranging in age from 19 to 52 years old who met DSM-IV criteria for a non-trauma anxiety condition, assigned to one of three groups according to residence and type of delivery: Metropolitan In-Person, Metropolitan Videoconferencing, and Regional/Remote Videoconferencing. In each case, following a baseline period, BATA was applied in 12 weekly, 60-minute individual therapy sessions. Treatment outcomes were evaluated using A-B-C phase change analysis with repeated measures. Eight out of nine participants showed significant reduction in self-reported anxiety symptoms. A corresponding significant decrease in anxiety symptoms overall across all the participant groups was shown by an omnibus/global analysis, replicating the original Turner and Leach findings that featured an older group of participants. No differences were found between the Metropolitan and Regional/Remote groups or between the Metropolitan and Videoconferencing groups which provided evidence that BATA can be delivered as effectively by videoconferencing as when delivered face-to-face in-person

Advances in psychological treatments: the use of new Communication and Information Technologies

Los tratamientos psicológicos han logrado avances importantes en los últimos años. Desde la puesta en marcha del movimiento de la psicología basada en la evidencia disponemos de un buen número de protocolos de tratamiento que han demostrado ser eficaces y eficientes. En este sentido, merece subrayarse el papel desempeñado por las nuevas tecnologías de la información y la comunicación (TICs). Nuestro grupo de investigación ha desarrollado y validado una serie de aplicaciones basadas en TICs que se comentan es este trabajo. En concreto, técnicas de Realidad Virtual, Realidad Aumentada y aplicaciones de Telepsicología basadas en internet. También se analizan algunas de las ventajas y limitaciones de estos procedimientos frente a los tratamientos tradicionales y se presentan datos acerca del grado de satisfacción manifestado por pacientes que recibieron un programa de tratamiento basado en TICs y se comentan algunas perspectivas de trabajo futuras.The psychological treatments have advanced notably in the last years. Since the beginning of the psychology movement based on evidence we have already available a high number of treatment protocols that have proved to be effective and efficient. In this sense, it should be highlighted the role played by the new communication and information technologies (CITs). Our research group has developed and validated a series of applications based on CITs that are presented in this work. Specifically, Virtual Reality, Augmented Reality techniques and Telepsychology applications based on the internet. The advantages that these new procedures have over the traditional treatments, as well as some limitations currently existent regarding the use of CITs are analysed. Finally, data about the level of satisfaction reported by patients who received a treatment program based on CITs are presented, and some future perspectives in the field are also analysed