Table 1.
Characteristics of studies of virtual reality relaxation for people with mental health conditions
| Study | Country | Participants | N | Mean age (SD) | Equipment | Virtual Environment | Measures | Sessions | Intervention | Findings |
|---|---|---|---|---|---|---|---|---|---|---|
| Bossenbroek et al. [35] (2020) | The Netherlands | Outpatients at a specialist secondary school for adolescents with psychiatric and behavioral problems, including ADHD or ASD, with either ED, ODD, PD, RAD or SAD | 8 (1 female, 7 males); one group | 14.67 (1.83) | HTC VIVE HMD with headphones; DEEP VR biofeedback game; DEEP breathing belt with Arduino- FLORA wearable electronic platform for movement in virtual environment. Arduino Software | Underwater fantasy world. No other information provided | STAI, disruptive classroom behavior measured by teachers using Likert Scale | 6 (daily, for 12.41 min) | DEEP VR biofeedback game. Interactive intervention and facilitator-led | Participants showed reductions in state anxiety and disruptive behaviors |
| Gorini et al. [22] (2010) | Italy | Outpatients with Generalized Anxiety Disorder | 20 (no gender data reported); three groups: VR and mobile phone with biofeedback (N = 4), VR & mobile phone without biofeedback (N = 8), controls (N = 8) | Not reported | HMD with head tracking but no further information. 3DVIA Virtools 4.1 software; HTC Touch Pro | Tropical island with campfire, beach, waterfall, and gazebo (with words/images about stressful situations). Audio narrative of relaxation techniques such as muscle relaxation | BAI, HAM-A, PSWQ, STAI-Y, GSR/HR sensor module | 8 | VR/biofeedback group’s HR variations modified virtual environment e.g., changed fire intensity, movement of waterfall, etc. VR group without biofeedback experienced VR. Control group did not receive VR. Interactive intervention and facilitator-led sessions with self-led mobile phone element for use at home | Both VR groups decreased in anxiety. Biofeedback group decreased in state anxiety. Non-biofeedback group and control group decreased in worry |
| Habak et al. [32] (2021) | Australia | Outpatients with depression or suicidality | 79 (53 females, 23 males, 3 non-binary) | Most common age range: 25–34. Full Age Range: 18–65 + | Edge of the Present mixed reality environment software. No HMD information | Rainforest, tropical beaches, desert, with environmental effects to intensify sensory experience (e.g., a warm breeze) | BHS, PANAS, Sense of Presence, SWEMWBS, VR feedback | 1 (10 min) | Participants explored scenes freely. Interactive but does not state whether facilitator or self-led | Wellbeing and positive mood increased. Negative mood and hopelessness decreased. Sense of presence was very high |
| Kim et al. [28] (2021) | South Korea | Outpatients with high stress | 74 (37 females, 37 males); two groups: VR relaxation first (N = 36), biofeedback first (N = 38) | Mean and SD not reported. Median age = 39, Range = 19–59 | Samsung Gear VR, head tracking, stereo earphones, ProComp Infiniti Biofeedback system | Relaxing video: natural scenes on trekking course with relaxing soundtrack. Stress video: walking on a shaky (moving) path | PSS-10, STAI-X1, STAI-X2, NRS, PANAS, SDS, EQ-5D-5L, SSQ, HRV | 2 (1 for each relaxation type, approximately 28 min each) | All participants were presented with the stress video and then asked to perform a mathematical task. Then the VR relaxation first group watched the relaxing video and the biofeedback first group carried out relaxation techniques while viewing their own biofeedback data on a screen. The following day, the groups swapped exercises. Passive intervention and facilitator-led | Both VR and biofeedback interventions reduced stress. There were no significant differences between interventions |
| Maarsingh et al. [29] (2019) | The Netherlands | Outpatients who experience significant stress and healthy controls | 175; two groups: Patients (N = 64, 52% females, 48% males), healthy controls (N = 111, 62% female, 38% male) | No age data for total sample. Patients: 40.6 (11.5). Healthy controls: 43.0 (10.5) | HTC Vive HMD, controllers, computer. Stressjam game | Tropical jungle island with temples and other buildings | SMM-G, HRV | 3 (1 h) | Stressjam game challenged participants to overcome increasingly difficult obstacles (e.g., climbing a rope) by increasing or decreasing their stress levels. Interactive intervention and facilitator-led | Patients experienced stress in a more functional way post-intervention |
| Malbos et al. [21] (2020) | France | Outpatients with Generalized Anxiety Disorder | 27 (13 females, 14 males); two groups: VR relaxation therapy, mental imagery relaxation therapy. Number of participants in each group not reported | 48.40 (11.91) | Sensics zSight HMD and head tracker; remote control with a directional pad; CryEngine Sandbox (Crytek GmbH) software | Tropical beach, campfire in forest, polar ice fields, living room, journey across the solar system, mountain peak in clouds. Audio track of flowing water, birds, choices of music, etc. | BDI-II, PSQW, SF-12 Quality of Life Questionnaire, STAI Y-A, STAI Y-B, SUD, HR, PQ, SSQ | 6 (30 min weekly) | VR group selected virtual environment and music. Participants were able to explore the environments by walking, swimming, and interacting with 3D objects (e.g., opening doors). Sessions included relaxation techniques. Imagery group combined relaxation and mental imagery techniques. Interactive intervention and facilitator-led | Both groups decreased in anxiety, worry and depression, and increased in quality of life |
| Manzoni et al. [19] (2008) | Italy | Inpatients with emotional eating in the context of obesity | 60 (all females); three groups: VR, imaginative, controls (all N = 20) | No age data for total sample. VR group = 42.80 (11.44), imaginative group = 48.55 (7.96), control group = 39.65 (14.52) |
Sony Glasstron PLM S-700 HMD, position tracker, earphones, joystick, NeuroVR 1.5 software, Asus G2S laptop |
Relaxing environment: green valley with lake and mountain, relaxing narrative/ audio track, e.g., birds, water, etc. Stressful environments: kitchen, restaurant, supermarket, office, etc | BDI, WELSQ, STAI, relaxation VAS, HR | 12 (1 h, 4 per week, for 3 weeks) | Both VR and imaginative groups learned relaxation techniques. VR group then carried them out in VR in both relaxing and stressful environments. Imaginative group carried them out with relaxing audio track only and imagined both relaxing and stressful situations. Interactive intervention and facilitator-led. The control group received treatment as usual | VR and imaginative groups increased in relaxation and self-efficacy about eating control and decreased in depression, anxiety, and heart rate. All groups decreased in weight |
| Manzoni et al. [20] (2009) | Italy | Inpatients with emotional eating in the context of obesity | 36 (all females, follow-up subsample of Manzoni et al. 2008). Three groups: VR (N = 12), imaginative (N = 14), controls (N = 10) | Not reported |
Sony Glasstron PLM S-700 HMD, position tracker, earphones, joystick, NeuroVR 1.5 software, Asus G2S laptop |
Relaxing environment: green valley with lake and mountain, relaxing narrative/audio track, e.g., birds, water, etc. Stressful environments: kitchen, restaurant, supermarket, office, etc | STAI, EOQ, BDI, WELSQ three months after intervention | 12 (1 h, 4 per week, for 3 weeks) | Both VR and imaginative groups learned relaxation techniques. VR group then carried them out in VR in both relaxing and stressful environments. Imaginative group carried them out with relaxing audio track only and imagined both relaxing and stressful situations. Interactive intervention and facilitator-led. The control group received treatment as usual | VR and imaginative groups increased in self-efficacy about eating control and decreased in depression, anxiety, and emotional eating. VR group were significantly lower in emotional eating than imaginative group. All groups maintained or decreased in weight |
| Mark et al. [33] (2021) | United Kingdom | Psychiatric Intensive Care Unit (PICU) inpatients with Psychosis | 17 (all males) | 35.8 (9.63) | Oculus Go HMD. No software information reported | Videos of forests, beach, swimming with dolphins or turtles, watching animals (e.g., elephant orphanage, African safari), climbing trees, space ride, hot air balloon ride | Qualitative observations of distress, mental state, risk, VR experience | 1 session (3–10 min) | Participants watched one or two videos of their choice. Passive intervention and facilitator-led | All participants found the VR acceptable and reported it was a positive experience. Sixteen participants reported they would use VR again. Two participants reported they did not trust/feared VR |
| Mistry et al. [27] (2020) | Canada | Outpatients with PTSD |
96 (54 females, 42 males). Clinical sample (N = 26) Eight groups with varying VR and non-VR meditations (all N = 12) |
Not reported | Dell Visor Windows Mixed Reality HMD, hand controllers, headphones, Microsoft Windows 10 computer and Mixed Reality functionality powered the VR Guided Meditation application. No software information reported | Tropical rainforest, hidden cave, island, underwater coral reef, foreign planet | LES, LEC-5, ACE, PCL-5, TRASC, mDES, BASS, MEQ, Satisfaction and Credibility Questionnaire, verbal feedback | 1 (2 guided meditations, each lasted approximately 5 min) | Participants completed VR and non-VR meditations in varying orders. In the non-VR meditation, participants watched the virtual environment on a screen or closed their eyes. Interactive intervention and facilitator-led | Participants who completed the VR meditation first reported greater positive affect. Most participants preferred VR meditation to non-VR meditation. Clinical sample reported increased distress in both VR and non-VR compared to healthy sample |
| Pallavicini et al. [23] (2009) | Italy | Outpatients with Generalized Anxiety Disorder |
12 (9 females, 3 males); three groups: VR and mobile phone with biofeedback (N = 4), VR and mobile phone without feedback (N = 4), controls (N = 4) |
No age data for total sample. VR/biofeedback group = 41.25 (13.24), VR without biofeedback group = 48.5 (12.662), controls = 51.25 (9.845) | Vuzix iWear HMD, Asus G2S computer, therapist’s netbook EEPC 100H – BK039X for controlling virtual environment, joystick, Virtools software, GSR/HR Sensor Module, HTC Touch Pro T7272 | Tropical island with campfire, beach, waterfall, and gazebo (with words/images about stressful situations). Audio narrative of relaxation techniques such as muscle relaxation | GAD-7, PSWQ, BAI, STAI-Y2, HAM-A, STAI Y-1, VAS measuring anxiety, GSR, HR | 8 | VR/biofeedback group’s HR variations modified virtual environment, e.g., changed fire intensity, movement of waterfall, etc. VR group without biofeedback experienced VR. Interactive intervention and facilitator-led sessions with self-led mobile phone element for use at home. Control group did not receive VR | Both VR groups had a greater decrease in heart rate, anxiety, and worry compared to controls |
| Repetto et al. [24] (2013) | Italy | Outpatients with Generalized Anxiety Disorder | 25 (16 females, 9 males); three groups: VR and mobile group with biofeedback (N = 7), VR and Mobile group without biofeedback (N = 9), controls (N = 8) | No age data for total sample. VR/biofeedback group = 45.25 (14.24), VR without biofeedback group = 48.5 (12.662), controls = 49.25 (9.845) | Vuzix iWear HMD, Asus G2S computer, therapist’s netbook EEPC 100H – BK039X for controlling virtual environment, joystick, Virtools software, GSR/HR Sensor Module, HTC Touch Pro T7272 | Tropical island with campfire, beach, waterfall, and gazebo (with words/images about stressful situations). Audio narrative of relaxation techniques such as muscle relaxation | BAI, STAI-Y2, HAM-A, STAI-Y1, HR, GSR | 8 | VR/biofeedback group’s HR variations modified virtual environment, e.g., changed fire intensity, movement of waterfall, etc. VR group without biofeedback experienced VR. Interactive intervention and facilitator-led sessions with self-led mobile phone element for use at home. Control group did not receive VR | Both VR groups decreased in heart rate and anxiety |
| Riva et al. [30] (2008) | Italy | Outpatients with high anxiety in the context of obesity and history of emotional eating | 40 (all females); three groups: VR stress management (N = 15), DVD stress management (N = 11), no treatment (N = 14) | Not reported | Not reported |
Tropical island with different zones e.g., watching waves, barrier reef. Audio narrative of relaxation techniques |
ITC-SOPI, PANAS, STAI, VAS of emotional states | 2 (1 h, on consecutive days) | Stress management protocol included imagery, relaxation and different cognitive behavioral approaches. Identical script and exercises both for VR and DVD but different imagery. Passive intervention and facilitator-led | VR group had a significantly greater reduction in anxiety compared to other groups. Anxiety reduction and increase in positive emotion were associated with presence |
| Shah et al. [31] (2015) | Singapore | Inpatients with a diagnosis of Major Depressive Disorder and Bipolar Disorder (with depressive episode) | 22 (16 females, 6 males) | Mean and SD not reported. Range: 21–60 | ITG-PCX3 HMD, VR DE-STRESS program | Beach, auditory instructions, relaxing music | DASS-21, PRS, KSSMQ, BP, HR, ST, feedback form | 3 (1 h, for 3 days) | Psychoeducation on causes, symptoms and management of stress; mood disorders, and the relationship with stress. VR with relaxation techniques. Interactive intervention and facilitator-led | Post-VR, participants reported significantly lower stress, depression and anxiety, and greater relaxation and knowledge. Participants reported the intervention was beneficial as it allowed them to think positively, learn to relax and manage stress |
| Tan et al. [36] (2021) | Singapore | In-patients with mild or moderate mental disorder e.g., schizophrenia, bipolar disorder, mood disorders | 40 (24 females, 16 males); two groups: VR (N = 19) and controls (N = 21) | No age data reported | iTVGoggles Wide View 3D. No software information reported | Bhutan scenery, e.g., mountains, forests, skies, rivers. Japanese scenery. Hot air balloons accompanied with soothing music | NSRS, HR, BP, ST, Perceived Relaxation Scale, PSS-10, KSMM, participant feedback | 2 (40 min) | Psychoeducation on stress. VR with breathing and muscle relaxation. Passive intervention and facilitator-led | Post-VR, VR group reported significantly greater relaxation and reduced stress |
| Tarrant et al. [25] (2018) | United States of America | Outpatients with moderate level of Generalized Anxiety Disorder | 26 (20 females, 6 males); two groups: VR (N = 14) and controls (N = 12) | No age data for total sample. VR group = 46.21 (10.77), controls = 48.17 (20.11) | Gear VR HMD powered by Samsung S7, Mindfulness in nature experience, by StoryUp VR | Mountain landscape, rocks, blue skies, with soft music and female voice to guide mindfulness exercises | GAD-7, EEG, STAI | 1 (75 min) | All groups rested. Then the VR group experienced VR. Control group experienced further rest. Passive intervention and facilitator-led | Both VR and control groups decreased in state anxiety. VR group showed significant electrophysiological markers demonstrating lower anxiety |
| Veling et al. [34] (2021) | The Netherlands | Outpatients with a diagnosis of anxiety, psychotic, depressive or bipolar disorder | 50 (33 females, 17 males); two groups: VR relaxation (N = 25), standard relaxation exercises (N = 25) | 41.6 (14.2) | Samsung Galaxy S6 or S7 smartphone, connected to the Samsung Gear VR HMD, VRelax software | Beaches, coral reef with tropical fish, swimming with dolphins, mountain meadow with animals, drone flight over river landscape, sea view from cliff, mountain scenery in the Alps, beach session of Tibetan singing bowl therapy | BAI, GPTS, IDS, PSS-10, SSQ, VAS on positive and negative affective state | 20 (minimum of 10 min, 10 consecutive days per intervention) | The VR group was able to freely explore and select VR scenes. Standard relaxation was audio tracks of guided meditation and progressive relaxation techniques. Interactive intervention and self-led in participants homes | Both groups reported significant improvements in positive affective states and significant reductions of negative affective states. VR group had a significantly greater reduction of negative affective states, including anxiety, compared to standard relaxation. There were no significant differences with stress and symptoms |
| Wang et al. [26] (2020) | Taiwan | Outpatients with Generalized Anxiety Disorder | 77 (38 females, 39 males); two groups: virtual nature (N = 40), virtual abstract painting (N = 37) | No age data for total sample. Virtual nature group = 58.43 (7.37), virtual abstract painting group = 59.87 (6.99) | Two projectors, curved screen with 3D environment, static bike used to ‘cycle’ through virtual environments. No software information provided | Virtual nature: forests, parks, rivers, woodlands. Virtual abstract painting: colors such as blue, green, yellow | GAD-7, MMSE, EEG, HR, perceived stress, restorative quality, satisfaction scale | 1 (20 min) | All participants cycle at a moderate intensity. Virtual nature groups cycle through landscapes. Virtual abstract painting group cycle through abstract paintings. Interactive intervention and facilitator-led | Both groups displayed significant improvements in restorative quality, satisfaction, and relaxation. Virtual nature group had significantly higher levels of restorative quality and satisfaction post-VR compared to the virtual abstract painting group. Only the virtual nature group had significantly reduced stress |
ACE adverse childhood experiences, ADHD attention deficit hyperactivity disorder, ASD autism spectrum disorder, BAI Beck anxiety inventory, BASS Buddhist affective states, BDI Beck’s depression inventory, BHS Beck hopelessness scale, DASS-21 21-item depression anxiety stress scale, ED eating disorder, EOQ emotional overeating questionnaire, EQ-5D-5L five-level version of the EQ-5D (measuring quality of life, EuroQoL Group), GAD-7 generalized anxiety disorder 7-item scale, GPTS green paranoid thoughts scale, HAM-A Hamilton anxiety rating scale, HMD head mounted display, IDS inventory of depressive symptomatology, ITC-SOPI ITC- sense of presence inventory, KSMMQ knowledge on stress and medication management questionnaire, LEC-5 life events checklist for DSM-5, LES life events survey, mDES modified differential emotions scale, mDES-NA negative affect, mDES-PA positive affect, MEQ normative meditative experiences, MMSE mini mental state examination, NRS numeric rating scale, NSRS numeric stress rating scale, ODD oppositional defiant disorder, PANAS positive and negative affect schedule, PCL-5 posttraumatic stress disorder checklist for DSM-5, PD personality disorder, PII personal involvement inventory, PQ presence questionnaire, PRS perceived relaxation scale, PSS perceived stress scale, PSS-10 10 item version of perceived stress scale, PSWQ Penn state worry questionnaire, RAD reactive attachment disorder, SAD social anxiety disorder, SDS Sheehan’s disability scale, SMM-G stress mindset measure, SSQ simulation sickness questionnaire, SUS system usability scale, SWEMWBS short Warwick–Edinburgh mental well-being scale, STAI-Y state–trait anxiety inventory, SUD subjective units of discomfort, TRASC trauma-related altered states of consciousness, VAS visual analog scales, WELSQ weight efficacy life-style questionnaire
BP blood pressure, EEG electroencephalogram, GSR galvanic stress response, HR heart rate, HRV heart rate variability, IM imaginative, N Number of, SD standard deviation, ST skin temperature, TAU treatment as usual, VR virtual reality, Wl waiting list