Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis

Effects of virtual reality technology on attention deficit in children with ADHD: A systematic review and Meta-analysis

BACKGROUND

Virtual reality (VR) technology is increasingly utilized in the medical field, including interventions for attention deficit hyperactivity disorder (ADHD) in children. However, evidence on the efficacy of VR-based interventions in improving attention remains limited and inconclusive.

OBJECTIVE

This systematic review synthesizes evidence from randomized controlled trials (RCTs) to evaluate the effectiveness of VR-based interventions in addressing attention deficits in children with ADHD and identifies key methodological insights.

METHODS

Six databases were searched for English-language RCTs involving children aged 6-12 years with ADHD receiving VR interventions. The Cochrane bias risk assessment tool was used to assess methodological quality. Statistical analyses included meta-analysis for effect size estimation and publication bias testing.

RESULTS

Eleven RCTs involving 640 participants were included. Meta-analysis revealed a moderate reduction in attention deficit symptoms (SMD = -0.33, 95%CI [-0.58, -0.09], p = 0.008). No significant publication bias was detected.

CONCLUSION

VR-based interventions show potential in alleviating attention deficits in children with ADHD. However, study heterogeneity and limited long-term data warrant caution. Future research should focus on large-scale, standardized trials with extended follow-ups to validate these findings.

Speech-Language Pathologists' Perspectives On Virtual Reality for Childhood Traumatic Brain Injury

PURPOSE

Although evidence supports virtual reality (VR) applications in rehabilitation and education, investigations into VR technology for children with traumatic brain injury (TBI) are still evolving and lack robust evidence related to design or effectiveness. The purpose of the present study was to understand the perspectives of speech-language pathologists (SLPs) for designing VR tools that are acceptable and feasible for clinical practice.

METHOD

Thirty-one SLPs completed a self-administered online survey related to their awareness and opinions on VR and its potential application to childhood TBI broadly and within a case study of a child with TBI. Data were analyzed descriptively and using a modified version of systematic text condensation.

RESULTS

Participants, on average, reported being "somewhat aware" of VR and "neither not aware or unaware" of the idea of VR as a clinical tool. Participants generally had positive ratings for the potential use of VR to childhood TBI generally and in response to a case study centered on cognitive-communication skills. Through open-ended questions, participants identified various (a) benefits (e.g., ability for VR to simulate functional tasks or contexts) or (b) hesitations or challenges (e.g., limitations related to client ability, lack of equipment access) for using VR with children with brain injury related to design and implementation.

CONCLUSION

Although further development and translation research is needed, the perspectives of SLPs included in the present study can be utilized to inform future development and implementation efforts to ensure VR design that is inclusive, participatory, and best fit to future SLP practice with children with TBI.

Evaluating the evidence: a systematic review of reviews of the effectiveness and safety of digital interventions for ADHD

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) impacts academics, work and social relationships. Digital interventions, such as virtual reality, games, app and other, offer accessible therapeutic options, yet understanding their efficacy and potential adverse effects is crucial for safe use. The objective of this study is to identify and analyze the efficacy and adverse effects reported in systematic reviews of digital interventions for ADHD.

METHODS

We conducted a systematic review of systematic reviews to assess the reported efficacy and safety of digital interventions for ADHD. We searched for relevant publications in Scopus, PubMed, PsycINFO and Cochrane Library. Both study selection and data extraction were performed in duplicate to ensure accuracy and reduce bias. This review followed PRISMA 2020 guidelines, PRISMA-harms checklist, and we used AMSTAR-2 to assess the quality and risk of bias of the included reviews.

RESULTS

A total of 26 systematic reviews on digital interventions for ADHD were included. These reviews collectively involved 34,442 participants, with the majority focusing on children and adolescents. The digital interventions analyzed included video games, computerized cognitive training, virtual reality, apps, and others. The outcomes reported various positive effects, such as improvements in inattention and executive function, though evidence was generally low quality. Adverse effects were reported in 8 of the 26 included reviews (30,1%), and included physical discomfort, emotional reactions, and behavioral issues, such as video game addiction.

CONCLUSIONS

This systematic review of systematic reviews indicates that while digital interventions for ADHD show potential benefits, their effectiveness remains inconclusive due to low evidence quality. Adverse effects, particularly from video games, have been reported but are inconsistently documented. Future research should focus on rigorous safety assessments, standardized reporting, and long-term effectiveness.

TRIAL REGISTRATION

This systematic review is registered in Prospero: CRD42024521084.

The Role of Physical Activity in ADHD Management: Diagnostic, Digital and Non-Digital Interventions, and Lifespan Considerations

Background: Attention Deficit Hyperactivity Disorder (ADHD) has been described as a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity affecting cognitive, emotional, and social functioning. While pharmacological and behavioral treatments remain primary, physical activity (PA) (digital and non-digital versions) has emerged as a great complementary intervention due to its potential impact on executive functions, emotional regulation, and neurobiological markers. Objectives: This study aimed to assess the effects of PA on ADHD symptoms, executive function, and emotional regulation, exploring its potential impact and new practical applications in digital and non-digital treatment. Methods: This narrative review assessed 132 studies published between 1 January 2010 and January 2025, ensuring the inclusion of the most recent and relevant findings. The review was conducted in Scopus, PubMed, and Web of Science, using a predefined combination of terms related to ADHD, physical activity, executive function, neuroplasticity, and emotional regulation. Results: Regular PA improves executive functions, attention, inhibitory control, and cognitive flexibility in ADHD. Aerobic exercise enhances sustained attention, high-intensity training improves impulse control, and coordinative activities boost cognitive flexibility. Non-digital and digital innovations, such as exergaming and wearable fitness trackers, offer promising solutions to improve adherence to PA regimens, reinforcing their role as a key intervention in ADHD management. Conclusions: PA could be a valuable complementary intervention for ADHD through a hybrid approach that may improve cognitive and emotional functioning while addressing comorbidities.

The impact of extended reality cognitive behavioral therapy on mental disorders among children and youth: A systematic review and meta-analysis protocol

BACKGROUND

The prevalence of mental disorders among children and youth has significantly increased, with rising rates of anxiety, depression, and other psychological disorders globally. Despite the widespread adoption of cognitive behavioral therapy (CBT) as a standardized treatment for various mental disorders, its efficacy can be constrained due to limited patient engagement, lack of commitment, and stigma, all challenges pronounced among children and youth. In this context, extended reality (XR) technologies (including virtual, augmented, and mixed reality) have emerged as innovative therapeutic tools offering immersive and engaging environments to overcome the limitations of traditional CBT.

OBJECTIVES

This protocol aims to outline the methodology for conducting a systematic review and meta-analysis to evaluate the impact of XR-CBT on symptoms of mental disorders among children and youth.

METHODS

This systematic review and meta-analysis will follow PRISMA-P 2015 guidelines. A comprehensive search will be conducted in PsycINFO, PubMed, EMBASE, Scopus, and Web of Science to identify relevant studies published between January 2014 and June 2024. Eligible studies must involve children and youth (ages 24 years or younger) diagnosed with a mental disorder (e.g., anxiety, depression, ADHD, PTSD) and compare XR-CBT interventions (virtual, augmented, or mixed reality) with traditional therapy or control groups (e.g., no treatment). The primary outcome will be the change in symptoms of mental disorders, measured using standardized instruments (e.g., PHQ-9, GAD-7, PSS). Data will be extracted on post-intervention means, standard deviations, and 95% confidence intervals. Effect sizes, calculated using Hedges' g, will be pooled with a random-effects model. Moreover, an a priori meta-regression within a random-effects framework will be conducted to examine how study-level characteristics influence effect sizes and address heterogeneity across studies. Heterogeneity will be assessed using the I2 statistic and the Cochran's Q test. Risk of bias in individual studies will be evaluated using the Cochrane risk-of-bias tool.

CONCLUSIONS

This protocol establishes a structured approach for assessing the efficacy of XR-CBT interventions on mental disorders among children and youth. The results of the systematic review and meta-analysis will fill a gap in current research and inform future therapeutic applications for mental health interventions among children and youth.

The Multidimensional Dynamic Feedback Model: A Comprehensive Framework for Understanding and Managing Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity. These symptoms can significantly impact academic performance, social interactions, and daily activities, often creating cycles that worsen long-term challenges. This review introduces the Multidimensional Dynamic Feedback Model (MDFM), which aids in understanding ADHD's development and guiding intervention strategies. The model emphasizes the dynamic interactions among genetic, environmental, cognitive, and behavioral factors. The MDFM consists of three key aspects: (1) the interplay between genetic and environmental factors in shaping ADHD's biological basis, (2) the role of cognitive and neural processes in driving core symptoms, and (3) the influence of behavioral feedback loops that reinforce negative behaviors and hinder adaptation. The model highlights the importance of personalized interventions and effective feedback systems, including early prevention, supportive family and school environments, and the impact of social and cultural backgrounds on treatment outcomes. As a comprehensive framework, the MDFM offers a holistic perspective for clinicians, aiming to enhance long-term outcomes and promote the health and well-being of individuals with ADHD across the lifespan. By addressing implementation challenges, the model seeks to improve ADHD prevention and management, ultimately supporting individuals and their communities.

Current virtual reality-based rehabilitation interventions in neuro-developmental disorders at developmental ages

This mini-review examines the available papers about virtual reality (VR) as a tool for the diagnosis or therapy of neurodevelopmental disorders, focusing on Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), and Specific Learning Disorders (SLD). Through a search on literature, we selected 62 studies published between 1998 and 2024. After exclusion criteria, our synoptic table includes 32 studies on ADHD (17 were on diagnostic evaluation and 15 were on therapeutic interventions), 2 on pure ASD, and 2 on pure SLD. These cover a total of 8,139 participants with ADHD (ages 3-19), 458 with ASD (ages 4-19), and 162 with SLD (ages 7-11). Results show that VR offers high ecological validity and enables improvements in cognitive and social skills. Specifically, in individuals with ADHD, VR showed benefits in attention and executive function, with optimal results when combined with pharmacological treatments. For ASD kids, VR proved effective in enhancing social skills and emotional regulation through personalized virtual scenarios. However, the literature on SLD remains limited, suggesting an evolving area of research. Despite limitations related to small sample sizes and technology costs, VR presents a promising outlook for clinical intervention in neuro-developmental disorders, supporting enhanced skills in a safe and controlled environment. We conclude that both immersive and non-immersive VR represents a valuable supplement to traditional therapies, allowing for personalized approaches.

The effect of digital interventions on attention deficit hyperactivity disorder (ADHD): A meta-analysis of randomized controlled trials

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. Individuals with ADHD often encounter heightened emotional and behavioral challenges. This study aims to conduct a meta-analysis of the efficacy of digital interventions in improving symptoms of ADHD.

METHODS

This study searched 6 databases for English articles from database construction until December 4, 2023. Randomized controlled trials employing digital interventions for ADHD were gathered. Following the Cochrane Collaboration criteria, Review Manager 5.3 software was utilized to evaluate the risk of bias present in the included papers. Mean differences for post-intervention and follow-up data were standardized using Stata 18.0 software. Subgroup analysis was employed to investigate the sources of heterogeneity. The study adhered to the PRISMA guidelines and was registered on the PROSPERO platform (CRD42024504134).

RESULTS

This review included a total of 25 randomized controlled trials (RCTs). The combined study population comprised 1780 cases. In the digital intervention groups, there was a significant decrease in overall ADHD symptoms (SMD = -0.33; 95 % CI = [-0.51, -0.16]) compared to the control groups. Furthermore, there was a significant reduction in inattention symptoms (SMD = -0.31; 95 % CI = [-0.46, -0.15]) and hyperactivity/impulsivity symptoms (SMD = -0.15; 95 % CI = [-0.29, -0.02]) within the digital intervention groups.

CONCLUSION

The digital interventions proved beneficial for individuals with ADHD by alleviating symptoms of ADHD, inattention, and hyperactivity/impulsivity.

[Ethical challenges of telepsychiatry]

Telepsychiatry is shifting the focus of psychiatry and psychotherapy from personal interaction and relationship building to communication with technological mediators in the form of telecommunication, virtual reality (VR), social robots or artificial intelligence (AI). This article discusses the opportunities and risks of new technologies in psychiatric treatment, taking into account the principles of medical ethics. Telepsychiatric treatments can promote self-determination in the home environment as opposed to institutionalisation but carry the risk of uncontrolled data sharing. They harbour risks of potential harm such as social isolation, negative effects on the doctor-patient relationship and long-term changes in patient behaviour through, for example, VR. In terms of justice, demographic and psychopathological factors could result in unequal access to telepsychiatry, with questionable sustainability effects. The anonymity of telepsychiatry threatens alienation, while moral considerations cannot be replaced by AI for the time being. It is obligatory to carefully weigh up the benefits and risks of telepsychiatry, but especially in rural areas they could optimise care.Precisely because of ethical concerns, further intensive research is necessary to weigh up the risks and benefits. The development of telepsychiatric systems requires transdisciplinary co-operation. At a societal level, the significance of technologies as a supplement or replacement for the doctor-patient relationship needs to be discussed.

Empowering Social Growth Through Virtual Reality-Based Intervention for Children With Attention-Deficit/Hyperactivity Disorder: 3-Arm Randomized Controlled Trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) usually begins in childhood and is often accompanied by impairments in social functioning. Virtual reality (VR) has emerged as an adjunctive tool to embed in social skills training to enhance the social skills of children with ADHD, but its effectiveness requires further investigation.

OBJECTIVE

This study aims to enhance the social skills of children with ADHD by examining the feasibility and effectiveness of VR-based training in comparison to traditional social skills training.

METHODS

A 3-arm randomized controlled trial was conducted with 90 children with ADHD aged 6-12 years. Participants were randomly assigned to 3 weeks of 12-session VR-based social skills training, traditional social skills training, or a waitlist control group of equivalent duration. Outcome measures included assessments by a clinical psychologist who was blinded to group assignments, the Social Skills Improvement System Rating Scale, the Behavior Rating Inventory of Executive Function, and the Simulator Sickness Questionnaire, conducted at baseline and after the intervention.

RESULTS

The preliminary results support the feasibility and acceptability of VR training for children with ADHD aged 6-12 years. Analysis showed that the VR and traditional social skills training groups experienced a statistically significant improvement in the clinical psychologist assessment of social skills and parent-rated self-control, initiative, and emotional control after the intervention compared with baseline. The VR group performed significantly better than the traditional social skills group on social skills assessed by clinical psychologists (F2,85=76.77; P<.001) and on parent-rated self-control (F2,85=18.77; P<.001), initiative (F2,85=11.93; P<.001), and emotional control (F2,85=17.27; P<.001). No significant between-group differences were found for parent-rated cooperation and inhibition (all P>.05).

CONCLUSIONS

The findings provide preliminary evidence supporting the feasibility and superior effectiveness of VR-based social skills training compared to traditional approaches for enhancing social skills and related executive functions in children with ADHD. These results suggest that VR may be a valuable tool to embed within social skills interventions for this population. Further research is warranted to explore the long-term impacts and generalizability of these benefits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/48208.

Exploring Immersive Multimodal Virtual Reality Training, Affective States, and Ecological Validity in Healthy Firefighters: Quasi-Experimental Study

BACKGROUND

Firefighters face stressful life-threatening events requiring fast decision-making. To better prepare for those situations, training is paramount, but errors in real-life training can be harmful. Virtual reality (VR) simulations provide the desired realism while enabling practice in a secure and controlled environment. Firefighters' affective states are also crucial as they are a higher-risk group.

OBJECTIVE

To assess the impact on affective states of 2 simulated immersive experiences in a sample of healthy firefighters (before, during, and after the simulation), we pursued a multivariate approach comprising cognitive performance, situational awareness, depression, anxiety, stress, number of previous adverse events experienced, posttraumatic stress disorder (PTSD) severity, and emotions. The efficacy and ecological validity of an innovative VR haptic system were also tested, exploring its impact on performance.

METHODS

In collaboration with the Portuguese National Fire Service School, we exposed 22 healthy firefighters to 2 immersive scenarios using the FLAIM Trainer VR system (neutral and arousing scenarios) while recording physiological data in a quasi-experimental study. Baseline cognitive performance, depression, anxiety, stress, number of adverse events, and severity of PTSD symptoms were evaluated. Positive and negative affective states were measured before, between, and after each scenario. Situational awareness, sense of presence, ecological validity, engagement, and negative effects resulting from VR immersion were tested.

RESULTS

Baseline positive affect score was high (mean 32.4, SD 7.2) and increased after the VR tasks (partial η2=0.52; Greenhouse-Geisser F1.82,32.78=19.73; P<.001). Contrarily, mean negative affect score remained low (range 11.0-11.9) throughout the study (partial η2=0.02; Greenhouse-Geisser F2.13,38.4=0.39; P=.69). Participants' feedback on the VR sense of presence was also positive, reporting a high sense of physical space (mean score 3.9, SD 0.8), ecological validity (mean score 3.8, SD 0.6), and engagement (mean score 3.8, SD 0.6). Engagement was related to the number of previously experienced adverse events (r=0.49; P=.02) and positive affect (after the last VR task; r=0.55; P=.02). Conversely, participants reported few negative effects (mean score 1.7, SD 0.6). The negative effects correlated positively with negative affect (after the last VR task; r=0.53; P=.03); and avoidance (r=0.73; P<.001), a PTSD symptom, controlling for relevant baseline variables. Performance related to situational awareness was positive (mean 46.4, SD 34.5), although no relation was found to metacognitively perceived situational awareness (r=-0.12; P=.59).

CONCLUSIONS

We show that VR is an effective alternative to in-person training as it was considered ecologically valid and engaging while promoting positive emotions, with few negative repercussions. This corroborates the use of VR to test firefighters' performance and situational awareness. Further research is needed to ascertain that firefighters with PTSD symptomatology are not negatively affected by VR. This study favors the use of VR training and provides new insights on its emotional and cognitive impact on the trainee.

Fluctuations of Attention During Self-paced Naturalistic Goal-Directed Behavior in Attention-Deficit/Hyperactivity Disorder

Objective

Temporal fluctuations of attention detected with strictly controlled neuropsychological tests is an important objective behavioral marker for attention-deficit/hyperactivity disorder (ADHD). This study examined whether intraindividual variability in response latencies is also detectable in more realistic open-ended virtual contexts where the participants can freely interact with the surroundings when performing instructed everyday tasks from memory.

Method

Three ex-Gaussian parameters, μ, σ, and τ, were derived from response latencies in 2 tasks obtained from 2 datasets comprising 9- to 13-year-old children (72 with ADHD and 71 typically developing controls). In the Executive Performance in Everyday LIving (EPELI) task, participants performed instructed household chores in a virtual apartment. In the other task, a continuous performance test (CPT), was used to examine whether previous findings were replicated in this sample.

Results

Children with ADHD had shorter response latencies than controls in the EPELI task, while group differences in τ reflecting occasional sluggish responses depended on whether the trials were task-relevant (smaller τ in children with ADHD) or task-irrelevant (larger τ in children with ADHD). CPT results replicated previous observations of longer response latencies and larger τ in children with ADHD compared with control children. Intraindividual variability in the naturalistic EPELI task, however, explained more of the symptom variability than the CPT.

Conclusion

This study demonstrates that task context and stimulus relevance considerably influence how intraindividual variability in attention is manifested in children with ADHD. Virtual reality tasks provide a promising avenue for ecologically relevant quantification of this common cognitive deficit in neuropsychiatric disorders.

Technologies for Supporting Individuals and Caregivers Living With Fetal Alcohol Spectrum Disorder: Scoping Review

Background

Fetal alcohol spectrum disorder (FASD) is a common developmental disability that requires lifelong and ongoing support but is often difficult to find due to the lack of trained professionals, funding, and support available. Technology could provide cost-effective, accessible, and effective support to those living with FASD and their caregivers.

Objective

In this review, we aimed to explore the use of technology available for supporting people living with FASD and their caregivers.

Methods

We conducted a scoping review to identify studies that included technology for people with FASD or their caregivers; focused on FASD; used an empirical study design; were published since 2005; and used technology for assessment, diagnosis, monitoring, or support for people with FASD. We searched MEDLINE, Web of Science, Scopus, Embase, APA PsycINFO, ACM Digital Library, JMIR Publications journals, the Cochrane Library, EBSCOhost, IEEE, study references, and gray literature to find studies. Searches were conducted in November 2022 and updated in January 2024. Two reviewers (CZC and HW) independently completed study selection and data extraction.

Results

In total, 17 studies exploring technology available for people with FASD showed that technology could be effective at teaching skills, supporting caregivers, and helping people with FASD develop skills.

Conclusions

Technology could provide support for people affected by FASD; however, currently there is limited technology available, and the potential benefits are largely unexplored.

Virtual reality in functional neurological disorder: a theoretical framework and research agenda for use in the real world

Functional neurological disorder (FND) is a common and disabling condition at the intersection of neurology and psychiatry. Despite remarkable progress over recent decades, the mechanisms of FND are still poorly understood and there are limited diagnostic tools and effective treatments. One potentially promising treatment modality for FND is virtual reality (VR), which has been increasingly applied to a broad range of conditions, including neuropsychiatric disorders. FND has unique features, many of which suggest the particular relevance for, and potential efficacy of, VR in both better understanding and managing the disorder. In this review, we describe how VR might be leveraged in the treatment and diagnosis of FND (with a primary focus on motor FND and persistent perceptual-postural dizziness given their prominence in the literature), as well as the elucidation of neurocognitive mechanisms and symptom phenomenology. First, we review what has been published to date on the applications of VR in FND and related neuropsychiatric disorders. We then discuss the hypothesised mechanism(s) underlying FND, focusing on the features that are most relevant to VR applications. Finally, we discuss the potential of VR in (1) advancing mechanistic understanding, focusing specifically on sense of agency, attention and suggestibility, (2) overcoming diagnostic challenges and (3) developing novel treatment modalities. This review aims to develop a theoretical foundation and research agenda for the use of VR in FND that might be applicable or adaptable to other related disorders.

Examining the Use of VR as a Study Aid for University Students with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by patterns of inattention and impulsivity, which lead to difficulties maintaining concentration and motivation while completing academic tasks. University settings, characterized by a high student-to-staff ratio, make treatments relying on human monitoring challenging. One potential replacement is Virtual Reality (VR) technology, which has shown potential to enhance learning outcomes and promote flow experience. In this study, we investigate the usage of VR with 27 university students with ADHD in an effort to improve their performance in ctableompleting homework, including an exploration of automated feedback via a technology probe. Quantitative results show significant increases in concentration, motivation, and effort levels during these VR sessions and qualitative data offers insight into considerations like comfort and deployment. Together, the results suggest that VR can be a valuable tool in leveling the playing field for university students with ADHD.

Measuring attention of ADHD patients by means of a computer game featuring biometrical data gathering

ADHD is a neurodevelopmental disorder diagnosed mainly in children, marked by inattention and hyperactivity-impulsivity. The symptoms are highly variable, such as different ages of onset and potential comorbidities, contributing to frequent misdiagnoses. Professionals note a gap in modern diagnostic tools, making accurate identification challenging. To address this, recent studies recommend gamification for better ADHD diagnosis and treatment, though further research is essential to confirm its efficacy. This work aims to create a serious game, namely "Attention Slackline", to assess attention levels. The game, designed with expert input, requires players to concentrate on a specific point to recognize specific patterns while managing distractions. A controlled experiment tested its precision, and results were compared with established attention tests by a correlation analysis. Statistical analysis confirmed the game's validity, especially in tracking attention through correct responses and errors. Preliminary evidence suggests that "Attention Slackline" may serve as a credible instrument for the assessment of attentional capacities in individuals with ADHD, given that its outcomes have been empirically shown to correlate with those derived from a well-established attention assessment methodology.

Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial

BACKGROUND

Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology.

OBJECTIVE

We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations.

METHODS

This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition.

RESULTS

This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023.

CONCLUSIONS

This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45100.