From the Editor

Asking for a coffee. Passing strangers on a bus. Making eye contact at a grocery store. These tasks don’t seem particularly daunting but for those with major mental illness, they can be deeply unsettling. Some are left homebound.

In this week’s first selection, we look at a new Lancet Psychiatry paper by Daniel Freeman (of Oxford University) and his co-authors; in it, they detail an intervention where participants work through several tasks, like the ones named above. The coolness factor? It’s done through virtual reality (or VR). They find: “Automated VR therapy led to significant reductions in anxious avoidance of, and distress in, everyday situations compared with usual care alone.” We consider the paper and the larger implications.

Passing strangers on a bus: one of several tasks in gameChange

In the second selection, we weigh prevention in mental health care. Ainslie Heasman (of the Center for Addiction and Mental Health) joins me for a Quick Takes podcast interview. We discuss Talking for Change, which aims to prevent child sexual abuse with evidence-based interventions focused on high-risk populations – that is, “moving prevention upstream” in the words of the psychologist.

Finally, in the third selection, Dr. Bruce M. Cohen (of Harvard University) and his co-authors consider psychiatric terms, noting that some are outdated. In a Lancet Psychiatry paper, they discuss schizophrenia and personality disorders. They write: “Any label can stigmatise, and there are no perfect terms, but that should not prevent changing to better ones. Words communicate how we conceptualise a disorder.”


Selection 1: “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”

Daniel Freeman, Sinéad Lambe, Thomas Kabir, et al.

The Lancet Psychiatry, 5 April 2022  Online First

Providing effective psychological therapy on a large scale to patients with psychosis is a recognised challenge. There is a limited number of therapists and there are issues of adherence and competence in the delivery of current evidence-based approaches. Internationally, clinical services are seldom organised to give therapists the time to carry out the direct active learning in real-world situations with patients that is often important for clinical improvement. Immersive virtual reality (VR) – interactive three-dimensional computer-generated worlds that produce the sensation of actually being in life-sized new environments – is a potentially powerful therapeutic tool that can overcome these barriers. Patients more readily partake and learn in simulations of anxiety-provoking situations because they know the recreations are not real. By automating delivery of therapy in VR, the reliance on trained therapists is removed. In automated delivery, techniques are implemented consistently and trial outcomes are highly likely to be replicated. Automated VR therapies are therefore scalable…

Everyday situations can be anxiety-provoking for many patients with psychosis. Patients might fear, for example, negative judgements, observation, embarrassment, failure, rejection, panicking, deliberate social or physical harm from others, or being unable to cope with verbal auditory hallucinations. The result is that patients avoid everyday situations, such as walking in the street, going to a local shop, or getting on a bus, or find these activities intensely distressing. This anxiety leads to withdrawal from everyday situations, which adversely affects both mental and physical health. Many patients find it difficult even to leave their home.

So begins a paper by Freeman et al

Here’s what they did:

  • “We did a parallel-group, single-blind, randomised, controlled trial across nine National Health Service trusts in England.”
  • Patients were those 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.” 
  • Exclusion criteria included a primary substance use disorder and a clinically significant learning disorder.
  • The intervention: “gameChange VR therapy was provided in approximately six sessions over 6 weeks.” 
  • The primary outcome: improvement on the Oxford Agoraphobic Avoidance Scale (O-AS).

Here’s what they found:

  • “551 patients were assessed for eligibility and 346 were enrolled.” 
  • Demographics. Most were men (67%), White (85%), and the mean age was 37.2; few were employed (just 10%).
  • The intervention. For the intervention group, most did the sessions (a mean of 5.6 VR sessions) with a mean total time spent in VR of 145.2 minutes.
  • Comparison. “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…) and distress (–4·33…) at 6 weeks.”
  • “The greater the severity of anxious fears and avoidance, the greater the treatment benefits.”

A few thoughts: 

1. This is an impressive study, published in a major journal.

2. A nine-word summary of the results: at six weeks, “the treatment effect sizes were small…” 

3. But a longer summary puts the results in more perspective. “Patients with severe avoidance at baseline showed large effect size benefits with VR therapy at the 6-month follow-up. On average, patients with severe avoidance at baseline were able to complete two more O-AS activities, such as walking down the street or going to a shopping centre on their own, 26 weeks after VR therapy.” In other words, the intervention worked well for those who more ill. The Guardian interviewed a patient who was able to visit his father’s grave after the VR therapy. “I’ve been able to put flowers down, spend a little bit of time there and get the bus back.”

4. The intervention involved VR, of course. But note the necessary human element: participants were guided by a therapist.

5. Like all studies, there are limitations. Here’s a big one: there is no data beyond 6 months.

6. Could this be scaled? Some did the VR therapy from home; the equipment is just a few hundred dollars. The results are compelling; the potential, exciting.

7. For more on technology (including VR) and mental health care, a past Reading considered a podcast interview with Dr. John Torous (of Harvard University), which can be found here:

The full Lancet Psychiatry paper can be found here:

Selection 2: “Prevention and Child Sexual Abuse”

Ainslie Heasman

Quick Takes, April 2022

Let’s be blunt: with the pandemic dragging on, everyone is feeling a bit exhausted. That’s why we are launching a new series within the Quick Takes series, featuring innovation in mental health (read: good news stories). 

I highlight from the first podcast.

The interview 

Ainsley Heasman, a psychologist with the Centre for Addiction and Mental Health. 

The program 

“Our program is called Talking for Change and it’s really one of the first of its kind in Canada.” 

The goal 

“Our focus: preventing child sexual abuse before it happens – so moving prevention upstream, much further than has typically been the case, and providing a range of services (anonymous and non-anonymous) to individuals who identify having a sexual interest in children and are concerned about offending sexually against a child or are concerned about using or their potential use of child sexual exploitation material.” 

The big surprise 

“No matter which agency I talk to – whether it’s police, child protection, politicians, other social service agencies, or even social media companies – everyone is supportive… 

“There’s this unanimous sense: how could something like this not exist? It seems so logical and beneficial, and we’re all working towards the same goal. We all want to protect children and prevent child abuse and child sexual abuse.” 

The above answers have been edited for length.

The podcast can be found here, and is 10 minutes long:

Selection 3: “Past due: improving the naming of psychiatric disorders”

Bruce M Cohen, Dost Öngür, Peter Q Harris

The Lancet Psychiatry, April 2022

One of the finest qualities of medicine is its drive to discover new information and communicate that information among experts and to the public, including patients. Despite those efforts, absent dramatic discoveries, some concepts and terms get frozen for generations.

Diagnostic designations are of particular concern. They are key to all communications among clinicians, investigators, patients, and the press and lay public. Misunderstandings can have unfortunate medical and public policy consequences. And terms can wound. The term ‘substance abuse disorders’ was replaced by ‘substance use disorders’, to reduce harm. Other terms currently being debated include ‘schizophrenia’ and various ‘personality disorders’…

So begins a paper by Cohen et al.

Initially, they focus on schizophrenia. 

“The term ‘schizophrenia’ is antiquated, being 100 years old, has modest agreement among clinicians, and is confusing to the public, who often identify it as describing multiple personalities. Furthermore, over the century in which it has been in use, it has not had a consistent meaning. Proposed as a group of disorders with features of alogia, autism, ambivalence, and affective blunting, it became a term for dementia praecox, then for most psychoses, and is now predominantly a diagnosis for chronic non-affective psychosis. For the public, the term incorrectly evokes a potential for violence and loss of hope for a meaningful life.”

They note that several Asian countries have renamed schizophrenia:

  • “Because key features of the diagnosis were related to cognitive processing, the term ‘integration disorder’ was chosen in Japan.”
  • “In Korea, ‘attunement disorder’ was chosen.
  • “‘Disorder of thought and perception’ was chosen in Hong Kong.”

They observe that these terms can be confusing, and that it is too early to gauge the impact on stigma. 

They weigh other options. “A better alternative might be to call all cases with prominent symptoms of psychosis ‘psychotic disorder’, which can be further specified as chronic, recurrent, or single episode, with predominantly positive or negative symptoms and with or without mood features.”

“We suggest considering replacing ‘personality disorder’ with the less critical ‘relational disorder’ or ‘relational difficulty’. It could be subcategorised as in the ICD, or it could be subcategorised as predominantly self-focused or other focused. That covers those who have issues in self-identification (internalising) and those who have problems treating others properly (externalising).”

Further –

“More alternatives include eponyms (Alzheimer’s disease for dementias) or acronyms (OCD for obsessive compulsive disorders). However, eponyms provide no description, and acronyms require a full technical name for which the acronym stands.”

They make the case for name changes – but they also argue that more needs to be done. They write: “Outreach and education campaigns must accompany improved names. Other word choices in psychiatry also matter. Those discussed here are among the most prominent, problematic, and addressable. The time to address them seems past due.”

A few thoughts:

1. This paper is well argued.

2. Why haven’t we formally renamed disorders? Or, in some ways, have we started? Increasingly, we speak to patients about psychosis, instead of schizophrenia, for example. 

3. The last point made by the authors is a good one: renaming is just one task.

4. To play the Devil’s advocate: renaming is easy but acceptance may be more challenging.

The full Lancet Psychiatry paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.