Abstract
The coronavirus disease 2019 (COVID-19) pandemic is a global health emergency requiring clinicians to be prepared to cope with the increase in the future incidence of trauma and stress-related psychopathological symptoms. The early detection of psychological distress and timely intervention are strongly recommended. Clinicians should also consider integrating new technologies such as virtual reality (VR) in the treatment of these trauma and stress-related psychopathological symptoms. Here we provide a brief overview of how VR can help to cope with the potential short-term and long-term mental health consequences related to this global emergency.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic is a global health emergency currently involving 188 countries with >8,480,000 infections confirmed and >450,000 deaths worldwide. 1 This calamity is dramatically affecting our everyday life with serious consequences from both the socioeconomic and mental health points of view. In particular, the current and future negative psychological impacts of this emergency should not be underestimated and neglected. 2 The adverse impact on mental health concerns not only medical staff, who are working incessantly in a high-stress and high-risk health environment,2,3 but also millions of people forced into isolation and/or quarantine.4,5
Specifically, the Chinese experience during both the COVID-19 and the severe acute respiratory syndrome (SARS) emergency showed that health care workers who were at high risk of contracting viruses reported significant levels of depression, anxiety, and chronic stress.2,3,6,7 Similarly, an online survey on people during the initial phase of the COVID-19 outbreak in China (i.e., January 31–February 2, 2020) reported a prevalence of 8.1 percent for moderate-to-severe stress levels, 16.5 percent for moderate-to-severe depressive symptoms, and 28.8 percent for moderate-to-severe anxiety symptoms. 8 These data are in accordance with a recent review showing that quarantine is related to several negative consequences on mental health, including post-traumatic stress symptoms, confusion, and anger. 4
Beyond the immediate impact, the attention of both researchers and clinicians should also be focused on the potential long-term mental health consequences related to the COVID-19 emergency, such as the increased incidence of trauma and stress-related disorders. These clinical pictures, such as adjustment disorders and post-traumatic stress disorder (PTSD), mainly present with heterogeneous psychopathological symptoms (e.g., anxiety, anhedonic, dysphoric, aggressive, and/or dissociative symptoms) after exposure to a traumatic or stressful event. 9 Although “a life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event,” 9 the sudden and catastrophic impact of COVID-19 on our life may redefine the concept of traumatic event, inherently controversial. 10
Independently from this theoretical debate, the COVID-19 pandemic is a global health emergency requiring clinicians to be prepared to cope with the increase in the future incidence of trauma and stress-related psychopathological symptoms.
The early detection of psychological distress and timely intervention are strongly recommended, using online psychological services, which are known to have a positive impact on mental health during the outbreak, not only for medical staff 3 but also for people forced into isolation and/or quarantine. 11 Despite this, little attention has been paid so far to the practical implementation of psychological interventions, 12 and, at the time of writing, few protocols have been proposed: a list of some of them is reported in Table 1. Clinicians can also consider integrating new technologies, such as virtual reality (VR), in these psychological interventions. Therefore, in this study we provide a brief overview of how VR can help to cope with the potential short-term and long-term mental health consequences related to this global emergency.13–22
Examples of Mental Health Protocols Developed to Face the Psychological Impact During the COVID-19 Outbreak
CBT, cognitive behavioral therapy; COVID-19, coronavirus disease 2019; MCI, mild cognitive impairment; PTSD, post-traumatic stress disorder; VR, virtual reality.
VR in the treatment of stress-related psychopathological symptoms
Several studies have shown that, among various therapeutic programs, VR represents a highly specialized and effective tool for the prevention and treatment of stress-related psychopathological symptoms23–25 and PTSD,26–28 with therapeutic benefits similar or even superior to those of traditional programs such as cognitive behavioral therapy (CBT) interventions (e.g., in vivo exposure and guided imagination).29,30
Past research has implemented this technology for Cyber-intervention (cyber-SIT)23–25 and for VR Exposure Treatment (VRET), which are programs based on the principles of CBT aimed at helping people to cope with stressful and traumatic events.31–33 Cyber-SIT and VRET have been used in the treatment of stress-related psychopathological symptoms and PTSD in soldiers,34–36 survivors of natural disasters, 37 accidents,38,39 or other events such as terrorist attacks and episodes of violence.40,41
Recently, a freely available 10-minute three-dimensional 360° video (4K resolution supported) called The Secret Garden has been developed to manage stress and counter the disappearance of places and communities generated by the coronavirus.22,42 This protocol (Table 1) has been translated in seven different languages (i.e., English, Italian, Spanish, Korean, Portuguese, Japanese, and French) and it is currently under clinical testing in Italy, Spain, and the United States. 22
Furthermore, we are developing the MIND-VR project, aimed at designing, developing, and testing an advanced solution based on the use of VR for the prevention and treatment of stress-related psychopathological symptoms and PTSD in hospital health care personnel involved in the COVID-19 emergency. In particular, the expected results of MIND-VR concern the creation of VR environments built to offer basic education on stress and anxiety and to promote relaxation through the use of virtual environments developed ad hoc.
There are several characteristics that make VR particularly interesting in the prevention and treatment of stress-related psychopathological symptoms and PTSD, especially during this historical moment linked to the COVID-19 crisis.
First of all, VR represents a very useful interactive tool in psychoeducation programs for learning the basic elements of stress and PTSD, including causes and effects, 43 with the aim of making the patient more competent and aware of his/her problem, with a view to individual empowerment.44,45 The greater effectiveness of this type of intervention compared with classic educational programs (e.g., classroom lessons or books) is mainly linked to the higher user involvement in the learning process.46–48
Second, VR can help people in acquiring coping skills useful for stress and anxiety management, including relaxation techniques49–53 and biofeedback training.54–56 This technology, in fact, has been shown to be effective in inducing relaxation, reducing stress, and improving positive emotions in users.49,50,57 Particularly, the visual presentation of a relaxing virtual scenario can facilitate patients' practice and consequent mastery of relaxation techniques, making the experience more vivid and real than through photos and video,58–60 or using their own imagination and memory.61,62
Third, through VR, it is possible to simulate stressful and traumatic experiences in a highly engaging and realistic way, with the aim of improving the person's response to them. Through virtual simulations, in fact, it is possible to expose individuals, gradually and within a controlled and safe environment to stressful scenarios, allowing the person to put into practice the resources acquired to manage stress-related psychopathological symptoms.25,59,63
Finally, but most importantly in relation with the actual COVID-19 emergency, VR can play a key role in providing psychological care through VR-based therapy. Currently, in fact, many people cannot access face-to-face counseling, and video conferences using programs such as Skype, Zoom, and Facetime are commonly adopted to deliver psychological care sessions remotely. As reported in a recent study, VR-based therapy results more effective than treatments through video conferences: individuals responded greatly in favor of VR than counseling through video sessions and reported higher level of engagement, reducing dropout rates for clients and producing positive clinical outcome. 64 Furthermore, it should be noted that novel technologies may contribute to accessible and affordable treatment options in a relatively user-friendly way. 65 For example, self-help methods using smartphone applications and low-cost VR are known to be associated with several clinical benefits significantly increasing the accessibility of psychological treatments.65–67 Therefore, VR could be easily included in most of the extant psychological intervention protocols (Table 1) developed to face COVID-19 emergency.
Conclusions and Future Directions
For all the mentioned reasons, VR represents a highly specialized technique that could be very useful in supporting, improving, and in some cases providing completely new tools in the treatment of stress-related psychopathological symptoms as well as trauma related to the impact of COVID-19 pandemic, both in the health care workers and in the general population.
However, there are some important challenges for VR to be adopted effectively and widespread for these purposes, which include the following:
Sanitation of VR device: strict disinfection procedures should be implemented to reduce the risk of the COVID-19 contagion spreading in both mental health professionals and clients. Discomfort or lack of trainings for therapists: although VR is now commercially widespread and accessible at a limited cost, some mental health experts may find it difficult to use due to a lack of knowledge of this technology and how it can be used in psychological support.23,68 Might not to be suitable for specific types of patients: for example, patients with a current psychiatric diagnosis such as schizophrenia or bipolar disorders (who have an impairment on reality testing) may have delusional thinking in the VR environment or they may become preoccupied and/or addicted to this technology.
69
To overcome the mentioned obstacles and to promote the adoption of VR, governments and other societal bodies (e.g., medical societies, medical schools, and residency training programs) should inform about VR (e.g., through training courses dedicated to mental health professionals), as well as they should offer clear guidelines for the correct use of this technology within mental health practice.
Future studies are needed to deeply explore how VR can help to cope with the potential short-term and long-term stress and trauma psychopathological symptoms related to the impact of COVID-19 crisis. In particular, future research will have to investigate possible uses of VR at home, hospitals, and clinics for stress and trauma support, and the methodologies and approaches that will promote access and adoption in these settings. In addition, in the future, it will be important to evaluate the effect of VR in the treatment of stress-related psychopathological symptoms and trauma, considering the specific characteristics of the various targets (e.g., frontline health care providers, COVID-19 survivors, and general population).
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This article was supported by a grant (2019–3396) from the Italian Cariplo Foundation, which had not any involvement in manuscript preparation, or decision to submit the article for publication.