From the Editor

At the end of medical school, I spent some time working with an attending psychiatrist who was keen on behavioural interventions. He asked me to see a patient with acrophobia, a fear of heights, and told me to take the patient for an elevator ride for a “real-world experience.” For the record, the patient declined. (Having had no background in behavioural interventions, I’m not sure who was more anxious about that possible elevator ride, the patient or me.)

For people with phobias, exposure can be helpful. And so, therapists have taken their patients on plane trips and to visit tall buildings, and encouraged them to sign up for public speaking classes. As technology advances, we can ask: could virtual reality, or VR, work?

In the first selection, we consider a new paper from JAMA Psychiatry. Vrije Universiteit Amsterdam’s Tara Donker and her co-authors use VR for acrophobia. They choose a very basic intervention – an app and cardboard google glasses. They find: “A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions.”


The future of psychiatry? Maybe – and certainly recyclable

In the second selection, we look at a new editorial from The Lancet Psychiatry. While the authors are keen on digital psychiatry – the sort of work that Donker and her team do – they also warn about potential problems.



Phobias and VR

“Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial”

Tara Donker, Ilja Cornelisz, Chris van Klaveren, Annemieke van Straten, Per Carlbring, Pim Cuijpers, Jean-Louis van Gelder

Access to evidence-based psychological treatment for mental health disorders is a global challenge because of high-treatment costs and the limited availability of mental health professionals. Treatment coverage is below 50% and usually substantially lower. Novel technologies may contribute to accessible and affordable treatment options in important ways.

Specific phobias rank among the most prevalent mental health disorders,of which acrophobia is the most prevalent of all subtypes. Worryingly, specific phobias may increase the risk of developing other anxiety disorders and major depression.

Several evidence-based therapies exist, most of which use cognitive behavior therapy (CBT), involving exposing individuals to their feared object or situation. An emergent form of exposure is virtual reality exposure therapy (VRET), in which immersive virtual environments replace real-life exposure settings. Meta-analyses indicate VRET is as effective as conventional exposure therapy with large effect sizes and similar dropout and deterioration rates. However, VRET has thus far required therapist involvement and uses high-end virtual reality (VR) equipment.

Recently, efforts toward reducing therapist involvement using VRET have been undertaken. A randomized clinical trial targeting acrophobia demonstrated a large effect size (d = 2.0) but still required expensive technology, and treatment was delivered in a clinic under the supervision of a therapist. Hence, the relative effect of the intervention itself remains unknown and costs are not reduced…

The present study tested the effectiveness and user friendliness of ZeroPhobia, a fully self-guided VR CBT for acrophobia symptoms that is delivered through a smartphone. To ensure scalability, the VR-CBT app relies on participants’ own smartphone and basic ($10) cardboard VR goggles, while the program can be followed at home. We hypothesized that the app would be associated with greater overall response at posttest compared with a wait-list control group and that the treatment gains would be maintained at 3-month follow-up. For robustness, we included a second questionnaire assessing acrophobia symptoms. Depressive symptoms were examined to assess whether the VR-CBT app could also influence depression levels. We also tested whether variation in perceived user friendliness, general anxiety, and cyber sickness when using the app affected acrophobia symptoms at posttest.

tara_donkerTara Donker

So begins a paper by Donker et al.

Here’s what they did:

  • In this single-blind randomized clinical trial, participants were recruited through magazines and the local media, as well as websites, drawing from the Dutch population.
  • Inclusion criteria included scoring more than 45 on Acrophobia Questionnaire (AQ)-Anxiety, and access to an Android smartphone. Participants were adults.
  • Exclusion criteria included current phobia treatment and severe depression.
  • Participants were randomized to the intervention or a wait-list control group.
  • The VR intervention: “Participants received 6 animated CBT-based modules using 2-dimensional animations and a voice-over provided by a virtual therapist. The modules took between 5 and 40 minutes to complete. Participants were asked to complete the entire intervention within 3 weeks. Aside from the psychoeducation and CBT techniques, the VR-CBT app included a gamified immersive VR environment and four 360° videos covering the entire exposure spectrum. The participants started using VR and 360° videos from module 3 onwards and navigated through the virtual environment using gaze control.” Participants also received weekly motivational emails.
  • The primary outcome: AQ.
  • Measurement was done post-test, and at 3 months post-intervention. Secondary outcomes included other scales (Beck Anxiety Inventory, PHQ-9, and more).
  • Statistical analyses were done on an intention-to-treat basis.

Here’s what they found:

  • Of 631 people who signed up, 291 were ineligible. Of the 193 remaining, 96 were assigned to the intervention group and 97 to wait-list control.
  • Demographically: participants were, on average in their early 40s, female more than male (66%, intervention, and 63%, control), and overwhelmingly had postsecondary education. They also tended to be quite symptomatic (AQ scores were 85.16, intervention group, and 84.18, control).
  • 59% in the intervention group completed the post-test compared to 91% for the waitlist control.
  • “The intervention condition showed a significant reduction in acrophobia symptoms compared with the control on the AQ in the ITT analysis at posttest… with an effect size of d = 1.14… The number needed to treat was 1.7.”
  • In terms of secondary outcomes: “results demonstrated a significant intervention effect compared with the controls on acrophobia symptoms…” That was true for several measures, like the Beck Anxiety Inventory, but there was no statistical change in the depressive symptoms.
  • “The VR-CBT app was rated as user friendly… and can be interpreted as a good and usable system.”
  • 24 participants reported 1 or more symptoms of transient cyber sickness.


They conclude:

In sum, our findings support the hypothesis that a fully self-guided app-based VR-CBT, which can be done at home at a fraction of the cost of existing evidence-based treatment options, strongly reduces acrophobia symptoms.

A few thoughts:

  1. This is a good study.
  1. The intervention was an app (cost: $13.99) and cardboard google glasses (cost: $10). By way of comparison, patients would pay about that amount for the downtown parking in a big city to see a private psychologist, never mind the hourly fee of the psychologist.
  1. And it worked.
  1. But who exactly did this work for? I note that patients were self-selecting. It’s not exactly surprising, then, that they were demographically different from the general population (that is, in the educational background).
  1. The authors compare the intervention to a wait-list control. Given the lack of access to basic mental health services, is that a reasonable comparison? Or have they simply established that the app is better than nothing?


Digital Psychiatry and Potential

“Digital health: the good, the bad, and the abandoned”

The Lancet Psychiatry, April 2019

In 1961 a robotic arm called the Unimate #001 was deployed for some spot-welding at a small plant owned by General Motors in Trenton, New Jersey, USA. A vision was brought to life: automation was about to change the face of car manufacturing. Within a few years, General Motors redesigned entire factories across the USA with armies of increasingly sophisticated robots that greatly increased the degree of automation and pace of output. For both bosses and consumers automation was a success story.

In the decades since, the push for automation has moved well beyond manufacturing and into the rest of the world—including medicine. But rather than robotic arms, it’s terabytes of digital data and algorithms that seem poised to change how clinicians diagnose and treat their patients, in the hopes of making the process faster and more accurate.

image_21_portraitNiall Boyce, Editor of The Lancet Psychiatry

So begins an editorial from The Lancet Psychiatry.

The authors make three comments:

  • “[S]uccess for any new drug, method, or technology in health care should be judged by patient care and outcomes, and these are delivered not by individual doctors or staff, but by health-care systems.” The authors note the challenges of implementation, and they explain that they have “a healthy dose of skepticism.”
  • “Even as digital tools like EMR become more widespread in hospitals, they still suffer from the same constraints and hurdles that have plagued implementation of new technology in health systems for decades: failure to adapt to real-world complexity and insufficient integration.”
  • And they worry about patient privacy. “It’s never been easier to collect relevant (or potentially relevant) data for mental health, whether it’s sleeping habits, exercise, typing trends, or screen time. It’s also never been easier to monetise and abuse digital data, as compounding news reports continue to show.”

They close with a big question: “Will automation help patients attain positive and long-term changes in their mental health, or will quick gains ultimately succumb to and be reversed by the same old barriers of inadequate resources inside and outside our hospitals and clinics?”

A few points:

  1. This editorial is thoughtful.
  1. Digital psychiatry is red-hot right now – I note that The Lancet Psychiatry has published many papers in this area in recent months, as an example.
  1. It’s difficult not to be enthusiastic. That said, the editors raise good points. Patient privacy would strike me as particularly challenging – we worry about the security of patients’ charts, but in the not-to-distant future, our patients may be putting very personal information into their apps or discussing the most intimate details of their life virtually with a therapist. A recent BMJ paper looked at 24 health apps, finding that 79% shared user data with first and third parties. (The paper can be found here:


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