Treatment Effect of Psychoeducation and Training Program Using Virtual Reality Technique in the Patients with Depressive Symptoms

MinJea Kim; Sun-Woo Choi; SunYoung Moon; Hae-In Park; HeeKyung Hwang; Min-Kyeong Kim; Jeong-Ho Seok

doi:10.4306/jknpa.2020.59.1.51

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Kim, Choi, Moon, Park, Hwang, Kim, and Seok: Treatment Effect of Psychoeducation and Training Program Using Virtual Reality Technique in the Patients with Depressive Symptoms

Original Article

J Korean Neuropsychiatr Assoc 2020;59(1):51-60.

Published online: 17 January 2020

DOI: https://doi.org/10.4306/jknpa.2020.59.1.51

Treatment Effect of Psychoeducation and Training Program Using Virtual Reality Technique in the Patients with Depressive Symptoms

MinJea Kim, MD^1,², Sun-Woo Choi, MA², SunYoung Moon, MA², Hae-In Park, MA², HeeKyung Hwang, MA², Min-Kyeong Kim, MD, PhD^1,², Jeong-Ho Seok, MD, PhD^1,²

¹Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea

²Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea

Address for correspondence Jeong-Ho Seok, MD, PhD Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel +82-2-2019-3343 Fax +82-2-3462-4304 E-mail johnstein@yuhs.ac

Revised 24 September 201914 November 2019 Accepted 9 December 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives

To compare the clinical effectiveness of the virtual reality (VR) programs in assessing psychosocial problems, improving symptoms, and reducing suicide risk in depressive patients with those of pharmacotherapy.

Methods

Thirty-six patients were recruited with depression in the treatment group and 22 participants in the healthy control group through internet advertisements between November 2018 and March 2019. Participants in the treatment group were allocated randomly at a 1:1 ratio to either the VR group or pharmacotherapy group. At the baseline, all participants were assessed with a comprehensive battery for their psychological characteristics by structured scales using VR technologies. Assessments of patients in the treatment group were repeated four weeks after therapeutic intervention. The primary outcome measures were the Korean Version of Quick Inventory of Depressive Symptomatology-Self-Report and suicidality scales of the Korean Mini International Neuropsychiatric interview. The borderline personality (Personality Assessment Inventory–Border-line Features Scale) and resilience (Korean Resilience Questionnaire) were also evaluated.

Results

Twenty-four depressive patients completed the treatment, and the final assessment was conducted after four weeks of treatment. In the initial assessment, the patient group showed significantly higher depressive symptoms, suicidality, borderline personality trait, and lower resilience than healthy control group. After the four-week therapeutic interventions, the VR group showed significant improvement in depression, suicidality, borderline personality trait, and resilience. In addition, there was no significant difference in the treatment efficacy between the VR group and the pharmacotherapy group.

Conclusion

In this study, the VR treatment program has clear benefits for emotional distress and reducing suicidality in depressive patients. Evidence-based VR treatments may show new clinical potential for depressive disorder.

Keywords: Virtual reality, Psychotherapy, Depressive disorder, Suicidal ideation

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Fig. 1.

A screenshot sample of the psychological characteristic evaluation test in virtual reality program.

Fig. 2.

A screenshot sample of an psychoeducation session in virtual reality program.

Fig. 3.

A screenshot sample of a skill training session in virtual reality program.

Table 1.

The items of basic intellectual capacity screening test on reading comprehension and calculation for participation of virtual reality task

Number	Question	Answer
1	I had 20 towels at home. If I bought 5 more towels today, how many towels do I have in my house?	25
2	I used 41 minutes out of 60 minutes of free calls. How many minutes do I have left of the free call?	19
3	Twelve people got on a 25-seat bus. How many seats are left?	13
4	I took 14 candles out of a can of 32. How many candies are left in the can?	18
5	I picked apples from an orchard and put 25 apples each in 3 boxes, and have 7 left. How many apples did I pick?	82
6	It takes 15 minutes to get to the supermarket. If I went to the supermarket and took 22 minutes to shop, how much time did it take in total?	52
7	It takes 23 minutes to cook 2 portions of pork belly. How much time does it take to cook 8 portions?	92
	Total basic intelligence score : the number of corrective answers	7

Each item is modified from the calculation subtest items of the Korean Version of Wechsler Adult Intelligence Scale

Table 2.

Overview of VR education/training program

	Session	Topic	Objective
Psychoeducation	Common	The stigma of mental illness	Correct the misunderstanding and stigma of mental illn by explaining the mental health
		Causes and treatment of depression	Explain the various causes of depression and educate on how to promote mental health
Training	1	Concept and management of stress	Evaluate one's stress level through learning the concep of stress and social readjustment
		How to cope with stress	Address the effects of stress and how to deal with it, an practice coping skills with cases
	2	Concept of mentalization	After cognitive training on mentalization, apply the cas to real-life situations
		Attachment and mentalization	Explore the development of mentalization ability throug attachment relationships
		Mindfulness skills training	Be aware of thoughts and feelings through VR and practice how to focus on ‘here-now’
	3	Enduring a difficult moment	Embrace difficult moments and train methods of relaxation to endure painful situations
		Emotional awareness training	Understand what is in basic emotions and be aware of the flow of one's emotions
	4	Emotional control training 1	Identify the causes and consequences of emotions and the obstacles that make it difficult to recognize emotio
		Emotional control training 2	Recognize emotions and understand oneself more to change into a positive attitude
		Communication training	Practice proper self-assertion and effective communication methods with examples

VR : Virtual reality

Table 3.

Demographic data of the subjects

Variables	VR group (n=15)	Drug group (n=14)	Healthy control (n=20)	p-value
Age (years)	33.07±9.74	31.86±7.35	32.05±8.01	0.909
Gender				0.130
M	1 (6.7)	4 (28.6)	1 (5.0)
F	14 (93.3)	10 (71.4)	19 (95.0)
Education (years)	16.71±1.86	15.86±1.23	17.22±2.07	0.057

Data are presented as a mean±standard deviation or number (%). VR : Virtual reality

Table 4.

Comparison of baseline assessment among three groups

Variables	Group I (n=15)	Group II (n=14)	Group III (n=20)	ANOVA p-value	Post hoc test (p-value)
Variables	Group I (n=15)	Group II (n=14)	Group III (n=20)	ANOVA p-value	I vs. II	I vs. III	II vs. III
Basic intelligence screening score	6.80 (0.17)	6.50 (1.19)	6.67 (0.58)	0.130∗	-	-	-
K-QIDS-SR	16.73 (5.57)	13.93 (4.38)	3.50 (2.78)	＜0.001	0.123	＜0.001	＜0.001
Suicidality	2.80(3.19)	2.93 (3.29)	0.60 (1.47)	0.009	0.983	0.017	0.025
PAI-BOR	28.87 (9.33)	31.07 (6.67)	18.20 (4.82)	＜0.001	0.674	＜0.001	＜0.001
KRQ-53
Total	164.73 (18.79)	169.57 (26.47)	198.90 (23.94)	＜0.001	0.842	＜0.001	0.002
POS	52.00 (7.67)	52.29 (10.45)	63.00 (10.54)	0.002	0.997	0.005	0.008
SELF	55.73 (10.60)	55.50 (8.21)	66.05 (7.75)	0.001	0.996	0.004	0.004
INT	57.00 (8.04)	61.79 (11.22)	69.85 (8.86)	0.001	0.362	0.001	0.045

Data are presented as a mean (standard deviation). Group I : VR group, Group II : Drug group, Group III : Healthy control. ∗ : O the basis of Kruskal-Wallis test. K-QIDS-SR : Korean Version of Quick Inventory of Depressive Symptomatology-Self-Report, PAI-BOR Personality Assessment Inventory–Borderline Features Scale, KRQ-53 : Korean Resilience Questionnaire-53, POS : Positivity, SELF Self-regulation ability, INT : Interpersonal relationship ability, ANOVA : Analysis of variance

Table 5.

Changes in scores for psychological assessment of the VR and drug group

Variables	VR group (n=14)					Drug group (n=10)			p-value∗
Variables	Baseline	4 weeks f/u	t/z	p-value	Baseline	4 weeks f/u	t/z	p-value	p-value∗
K-QIDS-SR	16.79 (5.78)	9.21 (4.87)	3.98	0.002	13.10 (4.46)	5.80 (4.21)	3.52	0.006	0.925
Suicidality	2.93 (3.27)	1.17 (2.21)	-2.04^†	0.041	3.20 (2.94)	2.80 (4.37)	0.27	0.793	0.752
PAI-BOR	29.21 (9.58)	26.21 (8.10)	3.86	0.002	31.10 (5.86)	25.10 (8.14)	2.88	0.018	0.203
KRQ-53
Total	163.29 (18.62)	175.79 (20.23)	-3.61	0.003	176.40 (25.61)	186.50 (26.39)	-3.03	0.014	0.634
POS	52.00 (7.96)	57.86 (10.82)	-3.89	0.002	53.20 (10.85)	56.40 (10.96)	-2.08	0.068	0.243
SELF	54.86 (10.42)	58.64 (9.60)	-3.11	0.008	58.20 (6.80)	61.70 (7.73)	-1.70^‡	0.090	0.666
INT	56.43 (8.03)	59.29 (7.17)	-1.71	0.112	65.00 (10.68)	68.40 (9.64)	-2.44	0.037	0.816

Data are presented as a mean (standard deviation). ∗ : p value from independent t-test or Mann-whitney test comparing the differences of initial assessment and 4 weeks later between the VR and drug group,

^† : On the basis of positive rank in Wilcoxon signed-rank test,

^‡ : On the basis of negative rank in Wilcoxon signed-rank test. K-QIDS-SR : Korean Version of Quick Inventory of Depressive Symptomatology-Self-Report, PAI-BOR : Personality Assessment Inventory–Borderline Features Scale, KRQ-53 : Korean Resilience Questionnaire-53, POS : Positivity, SELF : Self-regulation ability, INT : Interpersonal relationship ability, VR : Virtual reality, f/u : Follow up

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