Virtual reality-based treatment for anxiety disorders

In virtual reality-based treatment, the user moves and interacts within a simulated 3D environment. The technology is typically used when treating phobia and anxiety disorders through exposure therapy.

Reading time approx. 9 minutes Published: December 2, 2021 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: December 2, 2021 Report no: ut202128 Registration no: SBU 2020/590

Question

What systematic reviews are there on VR-based treatment in anxiety disorders?

Identified literature

Table 1. Systematic reviews with medium risk of bias
Included studies	Population/Intervention	Outcome and Results
Eshuis et al. 2020 [1] Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy
11 studies included in qualitative synthesis (10 RCT) 7 studies from US 1 study from either UK, Netherlands, Portugal and Spain 9 studies included in meta-analysis	Population: PTSD (N=438, in eleven studies) The majority of the studies 9/11) included participants who were either active-duty service members or combat veterans Intervention: Virtual reality exposure therapy (VRET) or augmented reality exposure therapy (ARET) Control: Waitlist control or psychotherapy control	Effect on PTSD symptoms VRET vs waitlist control, 4 studies: –0.64 (95% CI, –1.05 to –0.22) VRET vs psychotherapy control, 6 studies: –0.25 (95% CI, –0.77 to 0.27)
Authors' conclusion: “VRET was superior to waitlist control groups and as effective as other psychotherapies. However, the results showed considerable heterogeneity due to the low number of studies and variety of VRET methods. VRET may be an effective alternative to current treatments and shows promise for the treatment of PTSD patients that have not responded to previous treatment. Future research should focus on high quality RCTs, including information on side effects and adverse events, with sufficient numbers of participants. This study recognizes a research gap regarding the efficacy of ARET, while it may have potential for PTSD treatment.”
Horigome et al. 2020 [2] Virtual reality exposure therapy for social anxiety disorder: a systematic review and meta-analysis
22 studies included in meta-analysis, 11 RCTs 14 studies on Social Anxiety Disorder (SAD), 8 studies on Public Speaking Anxiety (PSA)	Population: Participants diagnosed with SAD or PSA, or with severe social anxiety or public speaking anxiety (N=586) Intervention: VRET or a combination of VRET and psychotherapy Control: Waitlist control or in vivo exposure therapy	Effect on SAD symptoms VRET vs. waiting list or TAU At post-intervention: (7 studies, 273 participants) Hedge’s g=–1.23 (95% CI, –1.70 to 0.76) Statistically significant in favour of VRET VRET vs. in vivo exposure At post-intervention: (10 studies, 355 participants) Hedge’s g=0.07 (95% CI, –0.41 to 0.55) No statistically significant difference 3 months post-intervention: (3 studies, 129 participants) Hedge’s g=0.81 (95% CI, 0.01 to 1.61) Statistically significant in favour of in vivo-exposure
Authors' conclusion: “VRET is an acceptable treatment for SAD patients that has significant, long-lasting efficacy, although it is possible that during long term follow-up, VRET efficacy lessens as compared to in vivo exposure.”
Fernández-Álvarez et al. 2019 [3] Deterioration rates in Virtual Reality Therapy: An individual patient data level meta-analysis
36 RCTs 15 of 36 studies included in IPD meta-analysis	Population: Adults diagnosed with an anxiety disorder (n=1965). In IPD-dataset (n=810) primary diagnoses included: SAD (n=230), specific phobia (n=225), agoraphobia and/or panic disorder (n=273) and PTSD (n=80). Intervention: VR-based psychotherapy Control: Waitlist or non-VR-based psychotherapy	Deterioration risk VR vs non-VR therapy: MH OR 1.68 (95% CI, 0.65 to 4.33) Not statistically significant
Authors' conclusion: “VR [-based treatments] seems to be a non-deleterious treatment for patients with anxiety disorders”

References

Eshuis LV, van Gelderen MJ, van Zuiden M, Nijdam MJ, Vermetten E, Olff M, et al. Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy. J Psychiatr Res. 2020. Available from: https://doi.org/10.1016/j.jpsychires.2020.11.030.
Horigome T, Kurokawa S, Sawada K, Kudo S, Shiga K, Mimura M, et al. Virtual reality exposure therapy for social anxiety disorder: A systematic review and meta-Analysis. Psychol Med. 2020;50(15):2487-97. Available from: https://doi.org/10.1017/S0033291720003785.
Fernández-Álvarez J, Rozental A, Carlbring P, Colombo D, Riva G, Anderson PL, et al. Deterioration rates in Virtual Reality Therapy: An individual patient data level meta-analysis. J Anxiety Disord. 2019;61:3-17. Available from: https://doi.org/10.1016/j.janxdis.2018.06.005.

Literature search

Multi-database searching: PsycINFO, Psychology and Behavioral Sciences Collection via EBSCO 27 Aug 2021

Title: VR-based treatment for anxiety disorders
AB = Abstract; AU = Author; DE = Term from the thesaurus; MH= Exact Subject Heading from CINAHL Subject Headings; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; N = Near Operator (N) finds the words if they are a maximum of x words apart from one another, regardless of the order in which they appear.; W = Within Operator (W) finds the words if they are within x words of one another, in the order in which you entered them.
Search terms		Items found
Population: Anxiety disorders
1.	TI ( ( anxiety OR phobi* OR panic OR distress OR posttraumatic OR trauma* ptsd OR ocd OR obsessi) ) OR AB ( ( anxiety OR phobi OR panic OR distress OR posttraumatic OR trauma* ptsd OR ocd OR obsessi) ) OR SU ( ( anxiety OR phobi OR panic OR distress OR posttraumatic OR trauma* ptsd OR ocd OR obsessi*) )	420 628
Intervention: Virtual reality-based treatment
2.	TI ( "virtual reality" OR "VR" OR immersive ) OR AB ( "virtual reality" OR "VR" OR immersive ) OR SU ( "virtual reality" OR "VR" OR immersive )	15 881
Study types: Systematic reviews
3.	TI ( ( (systematic N2 review) OR "meta analys" OR metaanalys ) ) OR AB ( ( (systematic N2 review) OR "meta analys" OR metaanalys ) ) OR SU ( ( (systematic N2 review) OR "meta analys" OR metaanalys ) )
Combined sets:
4.	1 AND 2	1 675
5.	3 AND 4	81
Final result
6.		81

Embase via Elsevier 24 September 2019

Title: VR-based treatment for anxiety disorders
/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ' ' = Citation Marks; searches for an exact phrase; NEAR/n = Requests terms that are within 'n' words of each other in either direction; NEXT/n = Requests terms that are within 'n' words of each other in the order specified
Search terms		Items found
Population: Anxiety disorders
1.	‘anxiety disorder’/exp OR ‘anxiety’/de	471 154
2.	(anxiety OR phobi* OR panic OR distress OR posttraumatic OR trauma* OR PTSD OR OCD OR obsessi*):ti,ab,kw	1 029 567
3.	1 OR 2	1 156 336
Intervention: Virtual reality-based treatment
4.	‘virtual reality’/exp OR ‘virtual reality exposure therapy’/exp OR ‘virtual reality system’/exp	21 706
5.	'virtual reality':ti,ab,kw OR vr:ti,ab,kw OR immersive:ti,ab,kw	25 536
6.	4 OR 5	34 863
Study types: Systematic reviews
7.	'systematic review'/exp OR 'meta analysis'/exp OR ((systematic NEAR/3 review):ti,ab,kw) OR metaanalys:ti,ab,kw OR 'meta analys':ti,ab,kw
Combined sets
8.	3 AND 6	3 194
9.	7 AND 8	207
Final result
10.		207

Medline via OvidSP 24 September 2019

Title: VR-based treatment for anxiety disorders
Search terms		Items found
.ab. = Abstract; .ab,ti. = Abstract or title; .af. = All fields; Exp = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; .sh. = Term from the Medline controlled vocabulary; .ti. = Title; / = Term from the Medline controlled vocabulary, but does not include terms found below this term in the MeSH hierarchy; * = Focus (if found in front of a MeSH-term); * or $ = Truncation (if found at the end of a free text term); .mp = Text, heading word, subject area node, title; “ “ = Citation Marks; searches for an exact phrase; *ADJn* = Positional operator that lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
Population: Anxiety disorders
1.	exp Anxiety Disorders/	83 214
2.	exp Stress Disorders, Traumatic/	39 867
3.	(anxiety or phobi* or panic or distress or trauma* or posttraumatic or ptsd or ocd or obsessi*).ab,kw,ti.	745 811
4.	1 OR 2 OR 3	780 321
Intervention: VR-based treatment
5.	Virtual Reality/	3 258
6.	Virtual Reality Exposure Therapy/	720
7.	(virtual reality or vr or immersive):ab, kw.ti	18 494
8.	5 OR 6 OR 7	19 354
Study types: systematic reviews and meta-analysis
9.	Systematic Review.pt. OR Meta-Analysis.pt. OR Cochrane Database Syst Rev.ja. OR ((systematic adj3 review) OR "meta analys" OR metaanalys).ti,ab.
Combined sets
10.	4 AND 8	1 799
11.	9 AND 10	130
Final result
12.		130

Scopus via Elsevier 26 Aug 2021

Title: VR-based treatment for anxiety disorders
Search terms		Items found
TITLE-ABS-KEY = Title or abstract or keywords; ALL = All fields; PRE/n = "precedes by". The first term in the search must precede the second by a specified number of terms (n).; W/n = "Within". The terms in the search must be within a specified number of terms (n) in any order.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; LIMIT-TO (SRCTYPE, "j" = Limit to source type journal; LIMIT-TO (DOCTYPE, "ar" = Limit to document type article; LIMIT-TO (DOCTYPE, "re" = Limit to document type review
Population: Anxiety disorders
1.	TITLE-ABS-KEY ( anxiety OR phobi* OR panic OR distress OR trauma* OR posttraumatic OR PTSD OR OCD OR obsessi* )	1 284 058
Intervention: Virtual reality-based treatment
2.	TITLE-ABS-KEY(“virtual reality” OR VR OR immersive)	162 513
Study types: Systematic reviews
3.	( ( TITLE-ABS-KEY ( ( ( systematic W/2 review ) OR "meta analys" OR metaanalys ) ) OR ( SRCTITLE ( cochrane ) AND DOCTYPE ( re ) ) ) )
Combined sets
4.	1 AND 2	4 199
5.	3 AND 4	229
Final result
6.		229

Page published December 2, 2021

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