Mindset XR Module 9: Case studies

When highlighting the clinical need for a XR solution, it is important to understand how and why that need is not currently being met.

At the start of a study, it is important to identify gaps in the literature. For this study, it was found there were no first-hand accounts of anhedonia across depression and psychosis.

Most of the existing tools:

• Are measuring pleasure in the lab;

• Use standardised images on a computer screen;

• Are developed in Western countries;

• Are based on data samples that is lacking in diversity.

• Inconsistent findings across different studies;

• No consensus on what stops people experiencing pleasure;

• Little progress in this field of study.

To address these gaps, especially the lack of first-hand accounts, a qualitative interview study was undertaken to explore experiences of anhedonia.

• Identify themes across people;

• Prioritise themes in research and clinical work;

• Help us understand how to measure pleasure;

• Show us where we might want to look to identity the mechanisms that contribute to the lack of pleasure.

To overcome the limits of existing tools, a VR scenario needs to be developed which can reliably evoke pleasure.

The new VR tool informed by lived experienced accounts, means the field can move forward because:

• We can answer research questions more reliably through better assessments;

• We can understand the impact of the interventions;

• We can understand differences and similarities between groups of people;

• This can help move from measuring symptoms to improving symptoms.

This pilot trial study looks to use XR for people with psychosis, a severe mental health condition. It can emerge in early adulthood and for most people it has lifelong implications.

• Daily activities
• Physical health
• Socialising
• Vocational attainment
• Educational attainment
• Healthcare

We wanted to use VR as we believe this medium could:

• Improve engagement compared to traditional talking therapies as the gamification element may make the experience more enjoyable;

• Be tailored so the individual can be exposed to what they feel is tolerable;

• Provide a better therapy structure.

We created a therapy package called V-neST. This VR prototype went through different waves of usability testing by people with lived experience.

It was agreed that there would be one session a week for 12 weeks lasting one hour.

Five environments were created, each targeting one or more hypothesised mechanisms affecting motivation and pleasure difficulties including elements targeting:

• Loss of pleasure;

• How individuals process feedback;

• Motivation and social interaction challenges;

• The ability to formulate a plan;

• The ability to formulate a plan.

• Games room;

• Factory with tasks;

• Neutral environment with music but with no demands;

• TV room;

• Social space where they were asked to interact with two others avatars.

The pilot trial was a single blind randomised control trial testing v-neST on 30 people with psychosis with poor motivation and loss of pleasure of daily activities.

• We could recruit enough eligible people;

• People would adhere to the treatment regiment;

• People would stay in trial.

Then we evaluated acceptability through qualitative interviews asking for feedback.

• We recruited to our target;

• 100% of the recruits completed the baseline research;

• We only lost 4 at the follow-up stage so couldn’t complete the three-month assessment for those individuals;

• We monitored two serious adverse events but none of those were connected to the study;

• An average of 9.7 session sessions were attended by the group.

After completed the therapy, we interviewed participants and recorded interviews to analyse the results qualitatively. This is an important step to make changes to the therapy and the research procedures.

• Positive experience with therapy goals;

• The impact of the pandemic;

• Whether the participants found the symptoms disabling;

• The relevance of VR;

• Feedback on therapy procedures;

• Suggestion for improvements.

This is a pilot trial not powered to assess the efficacy of an intervention. However, it is good practice to estimate the effects of an intervention to see if they are going in the expected direction.

Avatar therapy is designed for people who experience distressing voices in the context of psychosis. In this therapy, the person is supported to create an avatar who embodies the main distressing voice. They can customise how the avatar looks and sounds. They engage in series of face-to-face dialogues with the avatar facilitated by a therapist using voice-conversion technology.

The trial was developed on laptop screens but there is ongoing intern work looking at the impact of conducting the therapy in fully immersive VR environments.

The primary outcome was a reduction in voice-related distress at the therapy follow-up session at 12 weeks.

• Been undertaken in only a single NHS setting with a small, experienced group of therapists
• Suggested ways the therapy could be improved

The next steps will focus on the deployment of Avatar 2 within the NHS to gain real-world evidence.

• Whether Avatar therapy is effective and cost effective when delivered in routine care
• The main barriers and facilitators across diverse routine care settings
  

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The results could include:

• Quantitative data such as uptake
• Qualitative data such as interviews across all stakeholders