September 13, 2019


Michelle Craske is asking patients to dive into coral reefs, ride on bullet trains rushing past pine trees, and cheer on soccer teams from the stands — at least virtually — in a bid to tackle a symptom long sidelined in depression treatment.


The University of California, Los Angeles, psychiatry researcher and her colleagues are testing whether virtual reality can curb anhedonia, a symptom of depression and other serious mental health conditions that’s marked by a lack of interest or ability to feel pleasure. They’re putting patients into pleasant scenarios — like a stroll through a sun-soaked forest while piano music plays — and coaching them to pay close attention to the positive parts.The idea is to help patients learn to plan positive activities, take part in them, and soak up the good feelings in the process.


It’s an unconventional strategy — not just for its use of virtual reality, but also for how it approaches a patient’s symptoms. Treatments for depression and other serious mental health conditions primarily target negative symptoms, like hopelessness, sadness, and anxiety — but they often don’t help with the lack of positive feelings that some patients experience.


“Most treatments, up until now, have done an OK job at reducing negative [symptoms of depression], but a very poor job at helping patients become more positive,” said Craske.


There aren’t data yet to determine whether virtual reality treatment can make a meaningful difference in anhedonia. But the technology is increasingly popular in mental health care. Other studies have suggested virtual reality can be useful in easing certain phobias, helping people with psychotic disorders experience less paranoia and anxiety in public settings, and reducing social anxiety.


“It goes to the heart of the very best of psychological therapy — going into environments that cause difficulties and learning different ways of thinking, feeling, and behaving,” said Dr. Daniel Freeman, a University of Oxford psychologist who is studying whether it’s possible to use virtual reality to automate therapy for certain conditions, such as a fear of heights. Researchers elsewhere are using virtual reality for everything from treating PTSD in people who’ve experienced sexual trauma to equipping service members with coping skills they’ll need in combat zones.


“Mental health and the environment are inseparable,” said Freeman. “The brilliant thing about virtual reality is that you can provide simulations in the environment and have people repeatedly go into them,” he added.


Anhedonia has proven to be a particularly stubborn symptom to treat. Even when a patient’s other symptoms improve with treatment, anhedonia often doesn’t.


“It’s only one part of many symptoms, but it’s a symptom that’s especially impairing,” said Dr. Erika Forbes, a University of Pittsburgh psychologist who studies anhedonia. Research suggests people who have anhedonia are more likely to have longer, more difficult to treat cases of depression.


Scientists don’t know the exact biology behind the symptom, but believe that it’s tied to problems with the brain’s reward circuitry. There aren’t treatments that specifically target the symptom, but a handful of research groups are working on possible interventions.


The foundation of Craske’s approach is an intervention developed by Craske and her colleagues known as positive affect therapy. The gist: put a person into a situation that might be pleasurable, talk to them about it in painstaking detail, repeat. That might look like going to a museum, taking in the art, and then talking with a therapist about everything from the vivid shades of red in a painting to the feeling of their shoulders relaxing while standing in front of it.


In a paper accepted earlier this year by the Journal of Consulting and Clinical Psychology, Craske’s team found the treatment was more effective than cognitive behavioral therapy at boosting people’s positive feelings. Participants who went through the positive affect treatment also reported lower levels of depression, anxiety, and other negative symptoms than their peers in the standard treatment group.


But for some patients with severe anhedonia, depression, or other limitations, getting out into settings like museums or social gatherings isn’t a realistic first step. That’s where the virtual reality comes in.


“You bring the world to them,” Forbes said.


Craske is running two virtual reality studies on anhedonia. The first was a small pilot study of six patients with severe cases. The patients ventured into new environments using virtual reality, going through weeks of therapy designed to drill into positive emotions. The researchers also used functional MRI scans of the brain to see if the practice produced any changes in the brain, though they haven’t analyzed those scans yet.


Now, the researchers are running a larger study with dozens of patients with anxiety and depression who have anhedonia. In a bid to make virtual reality treatment easier and more accessible, patients are equipped with VR gear that they can use with their smartphones at home. Over 13 virtual reality sessions, patients are immersed in a series of scenarios, such as gliding through the canals in Venice. They’re encouraged to observe their thoughts, feelings, and physical reactions, then jot those down in an online diary after each session. They’ll also hear a guided mindfulness recording after each session that’s intended to reinforce the idea that certain activities can be rewarding.


After each session, participants rate their mood on a scale. Their results will be compared to a control group of peers who aren’t receiving the virtual reality treatment, but will be offered the option to do it once the trial wraps up.


“It sounds like a creative and promising way to address [anhedonia],” Forbes said.


If the studies support the virtual reality treatment, there are still kinks to be worked out in the system, including giving the virtual reality scenarios an upgrade. Craske and her colleagues are planning to work with a virtual reality company to design an interactive program that adapts to a patient’s responses. If, for example, a patient smiles at a VR character who waves and says hello, that character might walk over and strike up a friendly conversation.


“That’s where I want to go with this — make it much more interactive,” she said.


Moving virtual reality into mental health care will take a collaborative effort. Freeman said that having a well-designed program and good hardware are critical for using VR in health care — and key to making sure it doesn’t cause any unpleasant side effects that some people experience with VR, like nausea.


As the technology is refined and studied, experts say it could become a useful tool in treating psychiatric conditions and other health issues. But researchers still need to pinpoint which conditions and patient groups might benefit from virtual reality, and which won’t.


“Mental health is complex. There is no one solution,” said Freeman. “There won’t be one tech solution either.”