Effectiveness of immersive VR therapy in reducing stress-associated symptoms in Ukraine

ABSTRACT

Background: The ongoing conflict in Ukraine has led to a rise in stress-related symptoms, including anxiety and depression, among veterans, necessitating accessible and effective mental health interventions. Traditional rehabilitation resources are often limited, prompting exploration into alternative therapies.

Objective: This paper aims to assess the effectiveness of immersive 360° video-based Virtual Reality (VR) therapy as an enhancement to standard rehabilitation programmes for Ukrainian veterans experiencing anxiety and depression.

Method: A randomised controlled trial (RCT) was conducted with 69 participants, who were randomly assigned to either the experimental group (n = 34), receiving daily VR sessions alongside standard rehabilitation, or the control group (n = 35), following standard rehabilitation alone. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS) both at baseline and post-intervention. Additionally, momentary changes in anxiety and mood were measured immediately before and after each VR session to evaluate the immediate effects. The VR intervention was designed with veteran and expert feedback to enhance emotional regulation and stress resilience, integrating evidence-based psychotherapeutic techniques.

Results: Results demonstrate significant rapid improvement in mood and reduction in anxiety following each session, along with significant reductions in anxiety (up to 14.5%) and depression (up to 12.3%) upon programme completion. Consistent results across all study iterations confirmed the reliability and scalability of 360-VR therapy as a short-term rehabilitation tool.

Conclusions: Immersive VR therapy presents an effective, accessible solution for managing the psychological impact of war, particularly within the limitations of Ukraine’s healthcare system.

HIGHLIGHTS

• Effective Therapy: Immersive 360° VR therapy demonstrates a rapid improvement in mood and reduction in anxiety following each session, and reduced anxiety by 14.5% and depression by 12.3% in Ukrainian veterans upon rehabilitation programme completion.

• User-Centered Development: The VR content was refined through ongoing feedback from veterans and clinicians to ensure a trauma-sensitive experience.

• Scalable Solution: VR therapy consistently proved reliable, offering an accessible mental health tool for short-term rehabilitation in conflict zones.

1. Introduction

Veterans returning from combat frequently experience stress-related mental health conditions, with anxiety and depression ranking among the most prevalent psychological concerns. These conditions often co-occur with post-traumatic stress disorder (PTSD) and contribute significantly to long-term distress and functional impairment (Lim et al., 2022). A systematic review and meta-analysis found that approximately 20% of veterans experience depression, emphasising the widespread nature of this issue (Moradi et al., 2021). Similarly, a large-scale UK military cohort study reported that 21.9% of service personnel exhibited symptoms of common mental disorders, including anxiety and depression, highlighting the substantial mental health burden in this population (Stevelink et al., 2018). While anxiety and depression can be standalone diagnoses, they frequently exacerbate PTSD symptoms, leading to greater functional impairment and reduced quality of life (Liu et al., 2019). Additionally, studies indicate that Generalised Anxiety Disorder (GAD) affects nearly 8% of veterans, a prevalence rate 2.5 times higher than in civilian populations (Macdonald-Gagnon et al., 2024). These findings underscore the interconnected nature of anxiety, depression, and PTSD in veterans, reinforcing the importance of effective and accessible mental health interventions.

In Ukraine, the prevalence of these mental health conditions has escalated dramatically in recent years due to the Russo-Ukrainian War (2014–present) (Karatzias et al., 2023). This crisis is further compounded by mass conscription, which has forced many untrained civilians into combat, exposing them to severe and prolonged psychological stress (Johnson et al., 2022). Unlike professional military personnel, many of these newly recruited soldiers lack prior combat experience, increasing their vulnerability to anxiety, depression, and PTSD (Patel & Erickson, 2022). Although comprehensive national data on Ukrainian veterans’ mental health remains limited, reports from the Ministry of Veterans Affairs of Ukraine indicate a rapid rise in depression rates. As of August 2023, 30% of surveyed veterans reported severe depression, with an additional 15% experiencing mild symptoms. By June 2024, these numbers surged, with 50% of veterans classified as severely depressed and the remainder experiencing moderate symptoms (Ministry of Veterans Affairs of Ukraine, 2024). These figures align with global trends in trauma-related mental health conditions and highlight an urgent need for scalable, evidence-based mental health interventions. Given the strained healthcare infrastructure and the sheer scale of affected individuals, there is a critical need for accessible therapeutic solutions that can be rapidly deployed to support Ukrainian veterans and conscripts suffering from combat-related psychological distress (Bai et al., 2022).

Because traditional rehabilitation programmes often struggle to meet the growing demand for mental health support, Virtual Reality (VR) therapy has emerged as a promising solution by providing immersive experiences that aid in emotional regulation and stress reduction (Rothbaum et al., 2001). While VR Exposure Therapy (VRET) can be an effective approach towards PTSD treatment, its reliance on trauma re-experiencing makes it less suitable for broader stress management (Emmelkamp & Meyerbröker, 2021). Additionally, VRET requires trained therapists, which are currently scarce in Ukraine’s healthcare system (Hembree et al., 2007). In contrast, non-exposure-based VR interventions provide a scalable alternative that can address widespread stress-related conditions, including anxiety and depression (Ma et al., 2023). These interventions integrate mindfulness, cognitive restructuring, and emotional stabilisation techniques, offering a flexible and accessible therapeutic approach that does not require trauma exposure.

This paper explores immersive 360° video-based VR therapy as a non-exposure alternative designed to support veterans experiencing stress-related symptoms such as anxiety and depression. Unlike fully interactive VR environments, 360° video therapy enables cost-effective, scalable implementation while still maintaining a high level of immersion. By integrating immersive VR sessions into veteran rehabilitation programmes, this study aims to evaluate whether 360° video therapy effectively reduces anxiety and depression while improving psychological well-being. Specifically, we make the following contributions:

1. We describe the iterative development of 360° VR therapy tailored for Ukrainian veterans.

2. We evaluate its effectiveness through a randomised controlled trial (RCT).

Results demonstrate a rapid improvement in mood and reductions in anxiety and depression following each session. Upon programme completion, participants showed significant reductions in anxiety (up to 14.5%) and depression (up to 12.3%). Given the growing need for short-term, accessible mental health interventions, this study positions 360° VR therapy as a scalable and practical solution for veterans facing the psychological consequences of war.

The paper is structured as follows: Section 2 covers related works. Section 3 describes the methods, tools, data and participants relating to our RCT study. Section 4 describes the development process and pilot testing of the VR intervention. Section 5 presents the results of the RCT study. Sections 6 and 7 discuss these findings and conclude the paper.

2. Related works

2.1. Mental health crisis in conflict zones

War is a well-documented driver of psychological disorders, with PTSD, anxiety, and depression being prevalent among both military personnel and civilians (Summerfield, 2000). The Russo-Ukrainian war has significantly increased these issues, particularly among conscripted civilians experiencing trauma for the first time (Johnson et al., 2022). This crisis has strained Ukraine’s mental health system, underscoring the need for scalable interventions (Bai et al., 2022).

VR therapy has emerged as a promising solution by providing immersive environments for stress reduction and emotional stabilisation. While VRET has been effective for PTSD treatment, its reliance on trauma re-exposure, therapist supervision, and specialised infrastructure limits large-scale implementation, especially in resource-constrained settings like Ukraine. In contrast, non-exposure-based VR approaches, such as immersive 360° video therapy, focus on relaxation and emotional regulation, making them more accessible for veterans with stress-related symptoms beyond PTSD. 360° video therapy is also highly scalable, requiring minimal clinician involvement and lower technical demands.

To that end, the following subsections briefly review the evolution of VR therapy, from VRET (2.2) to immersive stress-reduction models (2.3), implementation challenges (2.4), the role of 360° video (2.5), and cultural considerations for Ukraine (2.6).

2.2. History and early development of VRET

In their recent review, Emmelkamp and Meyerbröker (2021) highlight VR therapy’s evolution from a niche tool to a mainstream mental health treatment, particularly for anxiety, phobias, and PTSD. Early studies demonstrated VRET’s effectiveness for phobias (Baños et al., 2002; Garcia-Palacios et al., 2002), leading to its application in PTSD treatment, especially for veterans. Indeed, Rothbaum et al. (2001) were among the first to show significant PTSD symptom reductions in Vietnam veterans, while McLay et al. (2010) later confirmed its effectiveness in combat zones.

Recent meta-analyses have demonstrated the potential effectiveness of VRET for PTSD treatment, though its superiority over traditional therapies remains a topic of debate. Deng et al. (2019) found PTSD symptom reductions averaging 22%, with some studies reporting up to 40%. However, as highlighted by Kothgassner et al. (2019), direct comparisons between VRET and traditional exposure therapies are complicated by variability in individual responses, gender differences in treatment outcomes, and the need for trained therapists to guide exposure-based sessions effectively. Additionally, the broader comparison of VR-based interventions is complex, as VRET relies on controlled exposure to trauma-related content, whereas other approaches, such as immersive 360° video therapy, focus on relaxation and emotional regulation rather than trauma processing.

2.3. Expansion from exposure-based to immersive stress reduction models

Beyond exposure therapy, VR is being increasingly used for mindfulness and stress reduction. Ma et al. (2023) showed that immersive VR-based mindfulness significantly enhances traditional practices, reducing anxiety, stress, and depression. Li et al. (2021) found that nature-simulating VR environments reduced anxiety by 25% and improved emotional well-being. Loucks et al. (2019) demonstrated that non-exposure VR environments for military sexual trauma stabilised emotions without direct trauma confrontation. Similarly, Pallavicini et al. (2021) found that VR-delivered mindfulness techniques reduced anxiety by 20% in healthcare workers during the COVID-19 pandemic.

While the short-term efficacy of VR therapy is clear, its long-term sustainability remains under study. Zhai et al. (2021) and White et al. (2018) showed that continued exposure to calming VR environments led to lasting reductions in anxiety and depression over several months.

2.4. Challenges in implementing VR therapy in conflict zones

Despite its potential, VR therapy (exposure and non-exposure based) faces logistical and ethical challenges in conflict zones. Glegg and Levac (2018) identified key barriers like the lack of robust infrastructure and specialised equipment, which are often unavailable in war-torn regions. Additionally, scaling VR interventions requires trained personnel, adding complexity. Boeldt et al. (2019) emphasised that the availability of technology and expertise is crucial for successful integration in clinical settings. Kenwright (2018) warned about the risk of retraumatization and the need for culturally sensitive approaches, while Shivayogi (2013) stressed the importance of safeguarding vulnerable populations when introducing new technologies. Levac et al. (2013) raised concerns about clearly defining VR therapy’s boundaries and distinguishing it from entertainment or educational uses.

However, the long-term success of VR therapy in conflict zones hinges on scalability and integration into healthcare systems. Rahman et al. (2022) suggested that AI and machine learning could aid and enhance VR therapy by providing personalised, real-time emotional monitoring, and improving accessibility for larger populations. Quero et al. (2019) demonstrated the effectiveness of adaptive VR systems for treating adjustment disorder and grief, highlighting that personalised therapy offers more sustained symptom reduction compared to standardised approaches.

2.5. 360° videos for immersive mental health interventions

360° immersive VR videos proposed in the early 2000s have recently gained renewed research attention as a valuable tool for mental health interventions due to their cost-effectiveness and accessibility compared to fully computer-generated VR environments. For instance, Metsis et al. (2019) discussed the prototyping process for developing VR interventions, noting that 360° video content provides an immersive experience that closely mimics real-life environments, making it suitable for therapeutic applications. This approach facilitates high levels of presence and engagement, essential for effective mental health treatments. In their comprehensive review of this topic, Ionescu et al. (2021) further highlight the utility of 360° videos for promoting mindfulness, relaxation, and exposure therapy, emphasising their potential to deliver impactful interventions with fewer technical and financial barriers compared to traditional VR. Engaging with immersive 360° videos fosters a sense of presence or the feeling of ‘being there,’ which can influence users’ attitudes and behaviours, potentially carrying over into their real-life experiences (Slater & Sanchez-Vives, 2016).

Nason (2020) conducted a comparative study of 360° video therapy and 3D VR treatments for veterans with social anxiety and PTSD, showing that while 360° videos offer less interactivity, they still provide significant therapeutic benefits. The study found that 360° video interventions were effective in reducing symptoms and were well-received by participants, with lower rates of motion sickness and higher overall comfort. This underscores the potential for 360° videos to be incorporated into broader mental health strategies, especially in resource-constrained environments where complex VR systems may not be feasible.

2.6. Cultural and psychological factors specific to Ukraine’s trauma population

Ultimately, the success of VR therapy in Ukraine will depend on overcoming not just logistical barriers but also cultural and psychological factors specific to the region. In post-Soviet contexts, where mental health care is often stigmatised, adopting VR therapy will require efforts to educate the population on its benefits and build trust in it as a valid treatment option. Kamińska et al. (2024) and Glybchenko (2024) explored VR therapy for Ukrainian war refugees, finding that while effective in reducing acute stress, cultural factors like trust in mental health interventions were key to its acceptance.

3. Methods

This section outlines our study's methodology, which evaluated the effectiveness of immersive 360° video-based VR therapy as an enhancement to a rehabilitation programme for Ukrainian veterans and conscripts. This involved 49 participants during development and pilot testing phases, followed by a randomised controlled trial with 34 participants in the experimental group receiving daily VR sessions and 35 in the control group following standard rehabilitation.

3.1. Study design

The study was conducted in three iterations at the Veterans Mental Health and Rehabilitation Center, Kyiv, in Ukraine during January-June 2023. See also Table 1 for further details.

Table 1.

Summary of development phases and study timelines.

The study participants were Ukrainian veterans attending a 21-day short-term in-patient rehabilitation programme, selected based on the presence of stress-associated symptoms such as anxiety and depression.

The first iteration was a development phase involving 9 patients and 10 psychotherapists, designed to assess the feasibility and initial effectiveness of the developed VR therapy programme.

Following feedback from the 9 patients and the centre’s psychologists, we revised the VR experience content and conducted a pilot study with 40 new participants (not included in the previous iteration). This study helped us test and confirm the safety and robustness of our protocols. While we collected qualitative feedback on the 360° video experience, no quantitative data was recorded, as the focus was on assessing feasibility rather than measuring clinical outcomes.

Finally, the third and final iteration was a randomised controlled trial (RCT) involving 69 new participants (not included in the previous iterations). The following subsections describe the methods relating to the RCT study.

3.2. Participant inclusion criteria and allocation

A total of 98 participants were assessed for eligibility, with 29 excluded for not meeting inclusion criteria. The remaining 69 participants were randomly assigned to either the experimental group (n = 34), which received VR therapy + standard rehabilitation, or the control group (n = 35), which received standard rehabilitation only.

Inclusion & Exclusion Criteria: Participants were required to have anxiety and depression-related symptoms, confirmed through standardised assessments, including the Hospital Anxiety and Depression Scale (HADS) and the PTSD Checklist for DSM-5 (PCL-5). Only individuals for whom anxiety and depression were the predominant symptoms were included, as determined by clinical evaluation and psychologist recommendations. Exclusion criteria included severe mental health conditions, acute mild traumatic brain injuries (mTBI), acoustic barotrauma, and PTSD as the dominant diagnosis.

Participant Characteristics: The RCT included only male Ukrainian veterans of the Russo-Ukrainian War, as no women in the rehabilitation centre met the inclusion criteria at the time. Participants had been demobilised due to mental and neurological injuries sustained in combat, with a demobilisation period of under one year. Most participants were civilian volunteers with service durations of up to one year, while eight participants were former professional military personnel.

Randomisation & Group Allocation: To ensure balanced age distribution, we used block randomisation with stratification by age. Participants were assigned to three predefined age subgroups: 24–30 years (n = 34), 31–40 years (n = 24) and 40–45 years (n = 11). Within each block, participants were randomly allocated to either the experimental or control group using a fixed block size of four participants, preventing allocation imbalances. Randomisation was computer-generated and conducted by an independent researcher uninvolved in participant recruitment or outcome assessment to minimise selection bias.

Blinding & Statistical Considerations: Baseline anxiety and depression levels showed no significant differences between groups (p > .05; df = 67) based on independent samples t-tests. To reduce bias, outcome assessors were blinded to group assignments, and participants were instructed not to disclose their treatment condition during follow-ups. Statistical analyses were conducted by an independent researcher unaware of group allocations.

Consent: All participants were fully informed of the study and provided their signed consent.

See Figure 1 for the flow diagram of the progress through the phases of a randomised trial control trial.

Figure 1.

CONSORT Flow Diagram of the progress through the phases of a randomised control trial.

3.3. Dropout rates and retention

In the experimental group (34 participants), the dropout rate was under 10%, with 2 participants voluntarily leaving the programme. In the control group (35 participants), the dropout rate was under 10% (2 participants) too. All participants withdrew due to early discharge or personal reasons, maintaining a balanced retention rate across groups. Given that dropout was predominantly due to logistical factors rather than intervention-related issues, a per-protocol analysis (PP) was conducted instead of an intention-to-treat (ITT) analysis.

3.4. Equipment

The study was conducted in a designated room at the Veterans Mental Health and Rehabilitation Center, Kyiv, in Ukraine, where rotating office chairs were used, allowing participants to watch the video while seated and rotate 360 degrees. Meta Quest 2 headsets were used for viewing, with a pre-installed application launched by an assistant in advance. No controllers were used during the session. The assistant launched and managed the headset (see Figure 2(c)).

Figure 2.

(a) Spring Carpathians Mountains. (b) Jellyfish museum. (c) Participant going through the session in a typical setting. (d) Filming process of (a).

3.5. Intervention: treatment as usual

Treatment as Usual (TAU) consisted of a structured short-term psychotherapeutic programme targeting symptoms of anxiety and depression. The TAU intervention included psychoeducation, training in psychological stabilisation techniques (such as breathing exercises, grounding, attentional shifting, and cognitive distancing), and structured approaches for working with anxiety-related experiences. These approaches incorporated differentiating between adaptive and maladaptive anxiety, problem-solving frameworks (e.g. decision tree analysis), and responsibility reattribution techniques (e.g. responsibility pie chart method).

3.6. Intervention: VR therapy programme

In the experimental group, VR therapy was implemented as an adjunctive intervention to enhance the effects of TAU. While the control group received TAU alone, the experimental group underwent TAU + VR therapy, where immersive 360° video VR sessions served as a complementary tool designed to reinforce and support the psychotherapeutic process rather than function as a standalone treatment.

The VR therapy programme consisted of a series of seven sessions, conducted daily as part of the participants’ rehabilitation programme. During each session, the client watched a video lasting 5–8 minutes. Each session also included a brief introductory conversation and a discussion of impressions after the viewing. The total duration of each session was up to 30 minutes. The intervention involved immersive videos designed to create calming and engaging environments. The four immersive video experiences included an immersive journey to the Jellyfish Museum (in Kyiv), the Spring Carpathians, the Oceanarium (in Kyiv), and a cozy room with a fireplace (see Figure 2). These videos were accompanied by audio psychoeducation (described below) focusing on key mindfulness skills such as breath control, observation, labelling thoughts, mindful action, and being present at the moment. The content was tailored to provide both an immersive distraction effect and a virtual transfer to a safe space, while also integrating practical psychoeducational components that participants could apply in their daily lives. The videos had been previously piloted during the development process (described further in Section 4) and were found to be appropriate.

3.7. Assessment tools

The effectiveness of the VR therapy was assessed using the following two standardised measures:

1. Hospital Anxiety and Depression Scale (HADS): A validated 14-item self-report questionnaire designed to assess symptoms of anxiety and depression in clinical and non-clinical populations. It consists of two subscales:

   • HADS-Anxiety (HADS-A): Measures anxiety symptoms (7 items).
   • HADS-Depression (HADS-D): Measures depressive symptoms (7 items).
     Each item is rated on a 4-point Likert scale (0–3), with total scores ranging from 0 to 21 for each subscale. Higher scores indicate greater symptom severity. HADS is widely used in rehabilitation settings due to its ease of administration and strong psychometric properties.

2. Mood and Anxiety Express Assessment Scale (MAEAS): Participants provided pre- and post-session ratings of their mood and anxiety levels using a simple five-point scale (ranging from 1 = very low to 5 = very high). This scale allowed for immediate, session-specific assessments of emotional changes, capturing short-term effects of the VR therapy.

These tools were selected to assess general stress-related symptoms, focusing on anxiety and depression, rather than PTSD-specific symptom clusters. This aligns with the study’s goal of evaluating short-term stabilisation within a rehabilitation setting.

3.8. Data collection

Data was collected at multiple points throughout the study, both before and after the VR sessions. Participants provided self-reports on their anxiety and depression levels using HADS and the MAEAS. Data on the number of sessions completed, the specific VR experience chosen, and session duration were logged for each participant. All participant data was anonymized using unique identifiers to protect their privacy and ensure confidentiality throughout the study.

3.9. Statistical analysis

To analyse the data collected in this RCT study, we employed a range of statistical methods to ensure a comprehensive understanding of the observed effects.

Descriptive statistics were used to summarise the central tendency and variability of the data, providing an overview of participants’ scores on depression and anxiety measures before and after the intervention. Measures such as means, standard deviations, and ranges were calculated for both experimental and control groups.

The Shapiro–Wilk test confirmed that HADS anxiety and depression scores followed a normal distribution (p > .05), justifying the use of parametric tests. However, express effect assessment scores did not meet normality assumptions (p < .05), requiring non-parametric tests for pre- and post-session comparisons.

The Wilcoxon signed-rank test was used to assess immediate VR therapy effects, comparing pre- and post-session scores within the experimental group, accounting for non-normal data distribution.

A two-way repeated measures ANOVA was conducted to assess intervention effects on anxiety and depression, with time (pre- and post-intervention) as a within-subject factor and group (experimental vs. control) as a between-subject factor. This analysis examined main effects of time and group and their interaction. ANOVA was justified by the normal distribution of HADS scores (Shapiro–Wilk, p > .05) and homogeneity of variances (Levene’s test, p > .05).

Cohen’s d was calculated to assess within-group changes in anxiety and depression from pre- to post-intervention and between-group differences in post-intervention scores. Effect sizes followed Cohen’s guidelines: small (d = 0.20), medium (d = 0.50), and large (d = 0.80).

Lehr’s Rule was used to estimate the sample size needed for 80% power. Preliminary calculations suggested that larger samples may be required, especially for detecting smaller effects, such as those observed for depression.

These statistical methods were applied using SPSS software (version 27), and a significance level of p < .05 was adopted to determine the statistical significance of all results.

Completer/non-completer analysis: A per-protocol (PP) analysis was used due to design constraints and the limited assessment points (baseline and post-intervention). Standard imputation methods, such as LOCF and Multiple Imputation (MI), were not feasible given the low missing data rate (6.2%) and lack of repeated measures. Since dropout was mainly due to early discharge, not intervention-related factors, and retention remained high (94%), PP analysis was deemed the most appropriate for evaluating VR therapy’s effects.

3.10. Ethics

The study was approved by the clinic's ethics committee, and the study itself monitored compliance with the research protocol and the quality of the recording of results.

4. VR intervention development process

The development of our immersive 360° video-based VR therapy experiences followed a structured, iterative process aimed at ensuring both therapeutic effectiveness and user engagement. Our goal was to create calming and immersive environments tailored to veterans with trauma-related symptoms such as PTSD, anxiety, and depression. This process was guided by the Design Thinking framework, involving five key phases: Empathise, Define, Ideate, Prototype, and Test, followed by a pilot study involving 40 patients from the clinic. A summary of these is given in Table 1.

4.1. Empathise: understanding user needs

During the Empathise phase, we consulted 10 psychotherapists working with veterans to identify key therapeutic needs and cognitive limitations, including undiagnosed mTBI, acoustic barotrauma, cognitive decline, and heightened vigilance due to combat exposure. Ukrainian veterans also exhibit chronic stress responses, increased reactivity, and persistent anxiety and depression (Karatzias et al., 2023).

Our approach was guided by the Allostatic Load Model (ALM), which explains how prolonged stress leads to physiological wear and dysregulation, increasing vulnerability to anxiety, depression, and cognitive impairment (McEwen, 2013). This informed our focus on stabilising autonomic and neuroendocrine systems to support emotional regulation. Additionally, the Transactional Model of Stress and Coping (TMSC) provided insights into maladaptive coping mechanisms like avoidance behaviours, shaping strategies to address both physiological dysregulation and cognitive distortions (Biggs et al., 2017). Specifically, we considered the following aspects:

• Post-traumatic symptoms: Chronic activation of defensive stress responses (ALM) and negative appraisals of safety (TMSC) required interventions that fostered calm and reassured participants of their ability to cope.

• Sensory sensitivities: Conditions like mTBI and acoustic trauma heightened sensory reactivity, necessitating careful design of light and sound stimuli to avoid overstimulation (ALM).

• Attention and perception biases: Stress-related cognitive impairments, such as narrowed focus and avoidance tendencies, underscored the need for external stimuli that gently redirected attention (TMSC).

• Reduced motivation and avoidance behaviours: Chronic fatigue and negative appraisals led to diminished engagement, highlighting the need for VR experiences that were simple, accessible, and non-threatening (TMSC).

• Heightened sense of danger and hypervigilance: The veterans’ prolonged defensive states require environments that evoked feelings of safety and predictability (ALM).

4.2. Define: establishing requirements

Based on this understanding, we moved into the Define phase, where we outlined clear requirements for the VR environments:

• Visual and auditory sensitivity: We avoided bright lights, sudden flashes, pulsating effects, and flickering stimuli, opting for smooth scene transitions. Sounds were carefully selected to be slow-paced, with a pleasant and non-intrusive voice for guidance.

• Simplicity of metaphors and instructions: All content was designed to be easily understood, with metaphors that avoided triggering associations.

• Avoidance of triggering imagery: We excluded certain scenes like enclosed forest clearings and winter forests, based on initial participant feedback.

• High-quality immersive experience: We emphasised realism and quality in the environments to evoke a sense of safety and calm. This included settings like a cozy room with a fireplace and serene natural landscapes.

• Duration of videos: Each video was designed to last 5–8 minutes to prevent overstimulation and fatigue.

We also set technical requirements for VR usability, including the use of a rotating chair to accommodate participants with limited mobility and ensuring that trained assistants could easily facilitate the experience.

4.3. Ideate: concept development

During the ideation phase, we developed 10 foundational scenarios, including natural landscapes and enclosed spaces. However, based on user feedback and technical constraints, some were excluded – such as the winter forest, which evoked combat associations. The final six videos were selected to meet therapeutic requirements.

At this stage, we also developed and tested audio instructions, using metaphors linked to video content to enhance skill-building. For example, clouds represented shifting emotions, while fish and jellyfish symbolised different thought patterns. Observing fire encouraged present-moment focus, and two videos included stabilisation breathing training with guided pauses for practice. Scripts were 1–1.5 min long within 5–8 min videos, ensuring a structured yet flexible experience. Each session concluded with guidance on applying skills in daily life.

4.4. Prototype: pilot testing

We developed six prototype videos, filmed in 4 K resolution using the Insta360 Titan camera. These videos were piloted with a small group of 9 veterans during the trial phase, selected based on mental health professionals’ recommendations to ensure participants were stable and without contraindications like severe mTBI or acoustic trauma.

During these pilots, we collected feedback on:

• Overall impressions of the VR experience.

• Ease of use of the headset and controls.

• Perception of the environment (whether participants felt safe and calm).

• Perception of psychoeducational instructions, their clarity, and ease of practicing by the user.

We also collaborated with three psychologists to refine the VR scenarios, removing environments like the Autumn Carpathians, as open spaces were often associated with combat zones. A key technical challenge emerged from heightened attention shifts in VR, making typically unnoticed details more apparent. To address this, we carefully framed each 360° video to optimise visual appeal. Each video consisted of 4–5 long takes, allowing users ample time to immerse themselves while following psychological instructions.

4.5. Test: refinement and finalisation

In the Test phase, we refined the VR experiences based on prior feedback. The final set included four videos that best met the criteria of safety, comfort, and therapeutic benefit:

• A spring mountain landscape that evoked calm without triggering combat associations.

• A room with a fireplace that fostered feelings of safety and warmth.

• A greenhouse representing a semi-enclosed space that was well-received in earlier stages.

• A unique jellyfish museum to offer a virtual journey that felt serene and engaging.

Additional feedback from the same set of 9 participants confirmed improvements in mood, concentration, and a sense of emotional safety during and after the sessions. Based on these positive responses, the final set of videos was integrated into the second and third iterations of the study design, ensuring that the VR environments were both user-centered and therapeutically effective.

4.6. Pilot study

Following the initial development phase, we conducted a pilot study with 40 participants from the clinic to evaluate the VR therapy’s feasibility, safety, and protocol robustness. Participants engaged in the developed immersive 360° video-based VR sessions, after which they provided qualitative feedback on their experiences. The primary focus of this pilot study was to assess user engagement, comfort, and potential adverse effects, rather than to measure clinical outcomes. All participants were fully informed of the study, and provided their signed consent.

The pilot study confirmed that the VR intervention was well-tolerated, with no reported adverse effects such as cybersickness or heightened distress. Participants generally found the experience engaging and calming, aligning with the therapeutic goals of stress reduction and emotional regulation. These findings validated the safety and acceptability of the intervention, allowing us to proceed with the randomised controlled trial (RCT).

5. Results of RCT study

Descriptive Statistics: Baseline assessments using the HADS indicated varying levels of anxiety and depression across participants. In both groups, the condition of the subjects ranged from mild to clinically pronounced anxiety and depression according to the HADS scale. In the experimental group, anxiety scores ranged from 2 to 20 (mean = 9.03, SD = 3.1) and depression scores from 0 to 17 (mean = 8.13, SD = 3.76), while in the control group, anxiety scores ranged from 2 to 23 (mean = 10.3, SD = 3.1) and depression scores from 1 to 19 (mean = 8.94, SD = 3.72).

Main Findings: The VR therapy demonstrated a reduced anxiety and improved mood among the participants. Immediately after each VR session, there was a significant reduction in anxiety levels, with an average decrease of 25.8%, as measured by the MAEAS scale. Additionally, mood scores improved by an average of 7.3% following the sessions. The statistical significance of the obtained results was confirmed by comparing pre  – and post-intervention scores using the Wilcoxon signed-rank test. A significant reduction in anxiety levels was observed (W = 485, p = .027), alongside a significant improvement in mood (W = 391, p = .039). These results are consistent with the trends seen in the literature (Deng et al., 2019; Emmelkamp & Meyerbröker, 2021; Eshuis et al., 2021).

Effects of the VR Intervention on Anxiety and Depression: A two-way repeated measures ANOVA assessed the effects of the intervention on anxiety and depression, with time (pre  – and post-intervention) as a within-subject factor and group (experimental vs. control) as a between-subject factor. The analysis examined main effects of time and group, as well as their interaction. Mean pre- and post-intervention scores for both groups are presented in Tables 2 and 3, with visual representations in Figures 3 and 4.

Table 2.

Results of the experimental group (HADS).

Metric	Mean	SD	Δ change
Pre-Intervention (Anxiety Score)	9.03	3.1	–
Post-Intervention (Anxiety Score)	7.71	3.01	−1.32
Pre-Intervention (Depression Score)	8.13	3.76	–
Post-Intervention (Depression Score)	7.13	3.08	−1.0

Table 3.

Results of the control group (HADS).

Metric	Mean	SD	Δ change
Pre-Intervention (Anxiety Score)	10.30	3.1	–
Post-Intervention (Anxiety Score)	9.97	5.54	−0.33
Pre-Intervention (Depression Score)	8.94	3.72	–
Post-Intervention (Depression Score)	9.00	4.03	+0.06

Figure 3.

HADS box plots of experimental group.

Figure 4.

HADS box plots of control group.

A significant main effect of the group was observed, F(1, 63) = 5.03, p = .027, indicating lower anxiety levels in the experimental group compared to the control. However, the main effect of time was not significant, F(1, 63) = 1.08, p = .301, suggesting no substantial overall change over time. The time × group interaction was also non-significant, F(1, 63) = 0.39, p = .534, indicating similar temporal patterns in both groups. These findings suggest that VR therapy effectively maintained lower anxiety levels independently of time-related changes.

Similarly, a significant main effect of the group was found, F(1, 63) = 4.36, p = .039, with the experimental group exhibiting lower depression scores than the control. The main effect of time, F(1, 63) = 0.51, p = .475, and the interaction effect, F(1, 63) = 0.68, p = .412, were not significant. This suggests that while overall depression levels remained stable, the VR intervention resulted in consistently lower symptom severity relative to TAU.

These results demonstrate the effectiveness of VR intervention in reducing anxiety and depression. Future analyses may explore individual response variability and potential moderators of treatment effects to further elucidate intervention mechanisms.

Within- and Between-Group Effect Sizes: To assess the impact of the immersive VR intervention, Cohen’s d was calculated for within-group and between-group effect sizes. Within the experimental group, anxiety (d = 0.43) and depression (d = 0.28) scores showed small to medium improvements, while the control group showed negligible changes (anxiety: d = 0.06; depression: d = −0.01). Between groups, the intervention produced a small to medium effect for anxiety (d = 0.39) and a small effect for depression (d = 0.27). These results highlight the effectiveness of immersive VR therapy in reducing stress-associated symptoms, particularly anxiety, and align with prior research on VR-based mental health interventions.

However, preliminary estimates using Lehr’s Rule indicate that a much larger sample size might be beneficial (n = 105 for anxiety, and n = 220 for depression per group), particularly for detecting smaller effects like those observed for depression.

6. Discussion

This study demonstrates the potential of immersive 360° VR therapy to reduce anxiety and depression among veterans with stress-related symptoms. Significant between-group differences (anxiety: p = .027; depression: p = .039) highlight the effectiveness of VR therapy beyond standard rehabilitation, even within a short intervention period.

While no significant time or time × group interaction effects were found, this is expected in short-term rehabilitation, where between-group differences are often a more meaningful indicator of intervention efficacy. These findings align with research supporting VR’s role in emotional regulation and stress reduction.

The minimal effect size in the control group underscores the limitations of standard rehabilitation in addressing stress-related symptoms within a 21-day period, suggesting longer interventions may be needed. In contrast, the small-to-medium effect sizes in the experimental group indicate that 360° VR therapy provides additional measurable benefits within the same timeframe, making it a practical solution in Ukraine’s resource-limited healthcare system.

Short-term rehabilitation primarily aims to stabilise veterans and lay the foundation for long-term recovery. The absence of symptom worsening and moderate improvements in the control group suggest that the rehabilitation programme had a positive impact, though VR therapy enhanced outcomes within the same period.

Strengths and Limitations: A key strength of this study was the use of immersive 360° videos, providing personalised, calming environments that enhance therapeutic impact and flexibility in rehabilitation (Rizzo et al., 2006). The psychoeducational component further strengthened the intervention by equipping participants with mindfulness and stress management techniques for continued use beyond VR sessions (Pallavicini et al., 2021).

Conducting this study during an active war posed challenges in recruitment and retention, particularly given veterans’ avoidance symptoms. Implementation within a rehabilitation facility added organisational complexities, yet the study's successful completion underscores its practical relevance and feasibility in conflict settings.

The controlled clinical environment provided validity but may limit generalizability to the broader veteran population. Reliance on self-reported measures (HADS, MAEAS) introduces potential subjective bias, though the use of concise, validated instruments was necessary to encourage participation.

The lack of long-term follow-up and modest sample size may also limit findings. However, homogeneous samples can enhance statistical power and consistency in intervention studies (Asano & Hirakawa, 2020; Lei et al., 2019). Small sample sizes are common in VR mental health research, with studies such as Szczepańska-Gieracha et al. (2021) demonstrating significant psychological improvements with just 30 participants. Future studies should expand sample diversity and include long-term follow-ups to assess VR therapy’s sustained impact.

Finally, participant engagement may have been influenced by the novelty of 360° VR therapy, potentially amplifying its effects. While this highlights VR’s capacity to enhance emotional recovery, further research is needed to isolate these effects and evaluate long-term benefits.

Clinical Implications: This study suggests that 360° immersive video VR therapy can rapidly reduce anxiety and depression symptoms, making it a valuable addition to short-term rehabilitation programmes in Ukraine. With short session durations (5–8 minutes) and flexible integration, this type of VR therapy requires minimal additional resources. The positive outcomes support its broader adoption as a standard mental health treatment for veterans and other high-stress populations, particularly in conflict-affected regions.

Future Research: While this study shows promising results, further research with larger, more diverse populations is needed to enhance generalizability. Long-term follow-up studies are essential to assess the lasting effects of 360° video VR therapy and the need for ongoing sessions. Future research should also investigate individual factors like demographics and trauma histories to personalise interventions. Additionally, incorporating advanced features such as biofeedback and AI could further improve the therapeutic potential of VR.

7. Conclusion

This paper highlights the significant potential of immersive 360° video VR therapy as an effective enhancement to rehabilitation programmes for veterans with stress-related symptoms, including anxiety and depression, particularly within Ukraine's unique challenges. Over multiple iterations, immersive 360° video VR therapy consistently produced statistically significant reductions in anxiety and depression, while also improving mood.

The development process of the 360° video VR experiences followed the Design Thinking framework, emphasising research, prototyping, and iterative feedback from both experts and participants. This approach ensured that the immersive environments were trauma-sensitive and tailored to the specific needs of Ukrainian veterans. The iterative refinement of the VR therapy contributed to its reliability and repeatability across study iterations, demonstrating its value as a component of short-term rehabilitation programmes.

Funding Statement

This work was supported by the Aspichi Charity Foundation. Orestis Georgiou was supported by the EU Horizon 2020 research and innovation programme under grant agreement No 101017746, Touchless.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.