Effect of Virtual Reality on Sleep-Deprived Individuals

Abstract

Background:

Sleep deprivation (SD) refers to getting less than the required amount of sleep, which for adults ranges from 7 to 9 h of sleep per night and can be caused by social and biological factors. College students experience SD, which can affect their academic performance, health, and mood. Virtual Reality Therapy (VRT), an upcoming method of intervention, has been used in other psychological conditions with positive outcomes. The purpose of this study was to determine the effect of VRT on individuals with SD.

Methods:

This quasi-experimental study recruited 28 individuals based on the scores of the Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale, and Beck’s Depression Inventory, which were used as the inclusion and exclusion criteria. VRT sessions of 20 min were given twice a week for 2 weeks. PSQI was also used as an outcome measure, immediately and 2 weeks after the intervention

Results:

A significant difference was found between the baseline and post-intervention PSQI scores (p = 0.001, effect size = 1.2). There was not much difference between the PSQI scores immediately and 2 weeks after the intervention.

Conclusion:

VRT was effective in improving sleep in individuals with SD.

Key Messages:

Poor quality sleep in college students can affect their academic performance, immune system, cognitive functioning, mood, fatigue, and their confusion level. Virtual reality therapy (VRT) was found to be effective in improving sleep in sleep deprivation (SD).

The study was registered prospectively in the Clinical Trial Registry-India of the Indian Council of Medical Research (CTRI/2022/02/040288).

Sleep deprivation (SD) refers to getting less than the required amount of sleep, which for adults ranges from 7 to 9 h of sleep per night. ¹ SD can be due to social and biological factors; the common causes include sleep apnea, insomnia, parasomnias, mood disturbances, stress, and other psychiatric and medical conditions. ² SD may result in excessive daytime sleepiness. ³

An estimated 83.6 million adults in the United States have poor sleep quality. ⁴ Around 64% of India’s urban population wakes up before 7 a.m., and 61% sleeps <7 h a day. ⁵ Low-quality sleep can affect academic performance, autonomic function, the immune system, cognitive functioning, mood, fatigue, and confusion levels.^3,6,7 College students experience many sleep problems that can affect their academic performance, health, and mood. ³ Among students, 62.6% have poor sleep quality, ⁸ while 56.6% reported sleep problems during the lockdown period. ⁹

Treatment for SD includes behavioral modification and improving sleep hygiene, treating the cause in the case of a medical or psychiatric condition, and pharmacotherapy. ² Physical activity and stretching exercises also help induce sleep.^10,11

Virtual Reality Therapy (VRT) exposes people to stimuli that mimic real-world experiences by immersing them in a computer-generated virtual environment. It helps health practitioners in the therapy of a client by implementing a cognitive behavioral exposure therapy approach in a virtual context. As these situations are simulated by a computer, it allows the therapist to choose the intensity and duration of the provided experiences. ¹² Studies using virtual reality (VR) alone or in combination with other methods have shown positive outcomes in psychiatric disorders like anxiety, Post Traumatic Stress Disorder (PTSD), and smoking addiction. ¹³ However, only a few studies have been done to find out the effect of VRT on college students with SD. Therefore, we intended to find out the effect of VRT on college students with SD.

Materials and Methods

Design and Participants

This quasi-experimental study was conducted from December 2021 to March 2022 in apparently healthy individuals from health science institutions, aged 18 to 30 years ⁶ of both sexes, who were chosen using the convenient sampling method based on the inclusion and exclusion criteria, through a Google Form containing the inclusion criteria that was circulated among the participants. The sample size was determined based on the prevalence found in previous studies among health science students ⁶ using the power of test analysis (α = 5%, β = 90%), and effect size (d = 3.5), and was found to be 28. Written informed consent was obtained from all the participants. Participants with a score of ≥5 on the Pittsburgh Sleep Quality Index (PSQI) scale, ⁸ ≤6 on the Athens Insomnia Scale, and 0–17 on the Beck’s Depression Inventory were included. The exclusion criteria included individuals being on medications like benzodiazepines, sedatives, and hypnotics that induced sleep and identifying biological causes of sleep problems like restless leg syndrome, narcolepsy, periodic limb movement disorder, pregnancy, ¹⁴ and history of an acute injury or illness. The Research and Ethics Committee approved this study.

Intervention

Participants were briefed about the intervention and were each given a VR headset (Procus ONE X VR headset). ¹⁵ The intervention comprised a combination of three relaxation videos, which were nature based, along with audio that was played on the headset. The participants were instructed to use the headset with the intervention for 20 min before going to sleep for 2 weeks, twice a week. ¹⁶ The two days of the intervention during the week were selected by the therapist for systematic handling of all the participants. The participants were asked to maintain a sleep journal, and routine calls on specified days were made to ensure that they watched the video on that day. For the intervention days and the rest of the week, the participants were instructed to follow these instructions: No alcohol and caffeine within 4 h of bedtime; non-specific relaxation behavior before bedtime like deep breathing, music, and reading; and limited usage of cellphones or any other electronic devices 1 h before bed. ¹⁷

Outcome Measure

PSQI scale, which is widely used to evaluate the consistency and quality of sleep in adults, served as the primary outcome measure. By evaluating seven factors, such as subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the previous month, it can distinguish between “poor” and “good” sleep quality. A score of ≥5 indicates poor sleep quality. It has an ICC value of 0.979.^18,19 PSQI scores assessed at baseline, immediately after the intervention, that is, after 2 weeks, and during a follow-up 2 weeks later.

Statistical Methods

The statistical analysis was done using SPSS software, version 23. The Kolmogorov-Smirnov test was used to assess normality, and the paired Wilcoxon test was applied for within-group analysis. p-Values of 0.05 or lower were deemed significant at a level of 5% significance.

Results

A total of 62 participants were screened for eligibility. Thirty were excluded based on the eligibility criteria, and four declined to participate in the study. Hence, a final number of 28 participants was included (Table 1). The baseline assessment was done using the PSQI, and the VR intervention was given.

Table 1.

Demographic Details of the Participants.

Variable		Mean ± SD/n
Age (years)		23.60 ± 1.16
Height (cm)		159.75 ± 8.74
Weight (kg)		62.25 ± 13.15
BMI (kg/m2)		24.27 ± 3.92
Sex (females/males)		23/5
Living status	At home	4
	Outside home  Roommates	21
	No roommates	3
Educational status	Below graduation	Nil
	Undergraduates	11
	Postgraduates	17
Smoking		5
Alcohol use		6
Caffeine use		3

The paired Wilcoxon test was used to compare the pre-intervention PSQI scores with post-intervention scores and scores obtained after 2 weeks of intervention (Table 2). Lower values were recorded at the two post-treatment assessments, and the differences were statistically significant (p = 0.001), justifying improvements in sleep quality following the intervention.

Table 2.

Pre-Intervention, Post-Intervention, and Post Two Weeks Intervention Pittsburgh Sleep Quality Index Scale Scores.

	Mean	SD	Effect Size	Z-Value	p-Value
Pre	8.21	2.67	1.24	6.58	0.001*
Post	5.18	1.83
Pre	8.21	2.67	1.21	6.43	0.001*
Post 2 weeks intervention	4.46	1.53

*Level of significance set at 5%.

Discussion

The main goal of this study was to find out the effect of VR therapy in individuals with SD. Results favored VR in terms of PSQI scores taken post-intervention and after 2 weeks of the intervention. The sleep-deprived participants were apparently healthy, as they only had poor sleep quality, which did not affect their daily functioning or health, based on the inclusion criteria (PSQI, Athens Insomnia Scale, and Beck’s Depression Inventory). VR works by diverting attention and immersing individuals in relaxing simulations intended to trigger and regulate various physiological and psychological changes that may help promote sleep, ¹⁹ as was evident with our results in terms of the PSQI scores.

VR presentations of cognitive stimuli like peaceful landscapes or soothing music have been shown to stabilize vital signs. ²⁰ Nature-based environments can activate particular psychophysiological parasympathetic patterns and elicit strong emotions, leading to the release of GABA, which is necessary for inducing sleep.^21,22 In sleep-deprived individuals, the relaxing environments created through VR could have elicited a state of calmness, inducing a relaxed state, which in turn could have helped reduce negative emotions ¹⁹ and initiate sleep.

The relaxing effect evoked by immersive nature videos can be aligned with the Stress Reduction Theory,^21,23 which proposes that exposure to such surroundings has a restorative effect that can reduce physiological stress responses and improve well-being. Ulrich et al. explored stress recovery in natural and urban environments and observed a more significant reduction in heart rate, blood pressure, and muscle tension in natural than urban environments. This suggested that the parasympathetic nervous system may play a significant role in how people respond to nature. ²³ Similar results were found by Young et al., where VRT was given to ICU patients via a head-mounted device once, and a positive effect was observed in terms of improvement in sleep quality. ¹⁵

Anxiety and stress are most commonly seen in college students and are two major causes of SD. ²⁴ Prior work has established VR as an effective tool for lowering psychological problems like stress and anxiety. A systematic review concluded that VR was an effective means of treating anxiety and other phobias as well as stress disorders by enhancing parasympathetic activity on the parameters of blood pressure and heart rate.^25,26

This study also aimed to determine if there was a carryover effect of the VR intervention, and the data showed positive results. As the individuals had better sleep quality during the intervention period, they may have visualized a similar environmental landscape in their minds before going to bed, thus putting the stress reduction theory into effect. This is similar to a case report about a post COVID-19 patient, which found that a 20-min session for 3 weeks of guided imagery and pulmonary rehabilitation via telerehabilitation showed a decrease in anxiety, an increase in sleep quality, and an enhanced quality of life. ²⁷

This study has three limitations. Better monitoring methods could have been used to ensure the implementation of the instructions given to the participants. Environmental factors such as temperature, noise, light, and bed comfort, which could have led to disturbances in the quality of sleep, were not considered. The study did not ascertain whether the results obtained were due to VR or the protocol of instructions given, due to the lack of a control group, which was beyond the scope of the objective of this study.

Conclusion

This study supports the use of VR to improve the quality of sleep in sleep- deprived individuals. It also establishes a possible carryover effect of VR in these individuals, and further studies can be conducted to assess its long-term effects. As our findings were preliminary, a randomized controlled trial can be carried out in the future to confirm them.