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Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial
Open accessAbstract
Importance: Globally, access to evidence-based psychological treatment is limited. Innovative self-help methods using smartphone applications and low-cost virtual reality have the potential to significantly improve the accessibility and scalability of psychological treatments. Objective: To examine the effectiveness of ZeroPhobia, a fully self-guided app-based virtual reality cognitive behavior therapy (VR CBT) using low-cost (cardboard) virtual reality goggles compared with a wait-list control group and to determine its user friendliness. Design, Setting, and Participants: In a single-blind randomized clinical trial, participants were enrolled between March 24 and September 28, 2017, and randomly assigned (1:1) by an independent researcher to either VR CBT app or a wait-list control group. A total of 193 individuals aged 18 to 65 years from the Dutch general population with acrophobia symptoms and access to an Android smartphone participated. The 6 animated modules of the VR-CBT app and gamified virtual reality environments were delivered over a 3-week period in participants' natural environment. Assessments were completed at baseline, immediately after treatment, and at 3-month follow-up. Analysis began April 6, 2018, and was intention to treat. Intervention: Self-guided app-based VR CBT. Main Outcomes and Measures: The primary outcome measure was the Acrophobia Questionnaire. The hypothesis was formulated prior to data collection. Results: In total, 193 participants (129 women [66.84%]; mean [SD] age, 41.33 [13.64] years) were randomly assigned to intervention (n = 96) or a wait-list control group (n = 97). An intent-to-treat analysis showed a significant reduction of acrophobia symptoms at posttest at 3 months for the VR-CBT app compared with the controls (b = -26.73 [95% CI, -32.12 to -21.34]; P < .001; d = 1.14 [95% CI, 0.84 to 1.44]). The number needed to treat was 1.7. Sensitivity and robustness analysis confirmed these findings. Pretreatment attrition was 22 of 96 (23%) because of smartphone incompatibility. Of the 74 participants who started using the VR-CBT app, 57 (77%) completed the intervention fully. Conclusions and Relevance: A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions. To our knowledge, this study is the first to show that virtual reality acrophobia treatment can be done at home without the intervention of a therapist. Trial Registration: Trialregister.nl identifier: NTR6442.
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In the citing paper
“The use of consumer VRET to treat these phobias has been shown to be effective for acrophobia and claustrophobia, as well as demonstrating efficacy with the general treatment of specific and complex phobias [38].”
From SAFEvR MentalVeRse.app: Development of a Free Immersive Virtual Reality Exposure Therapy for Acrophobia and Claustrophobia (2024) · cites this paper as [38]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“the possibility to use VR technologies has been explored in order to give traditional CBT a more ecological and patient-friendly approach, while keeping the whole benefits and effectiveness of the therapy (Donker et al., 2019).”
From Virtual reality and psychedelics for the treatment of psychiatric disease: A systematic literature review (2020) · cites this paper as Donker et al., 2019
Experimental — accuracy not yet measuredIn the citing paper
“Interestingly enough, all three automated VR exposure applications mentioned above opted to include a virtual therapist of some sort (Donker et al. 2019;Freeman et al. 2018;Miloff et al. 2019), either voiceover or as an embodied agent.”
From Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy (2021) · cites this paper as Donker et al. 2019
In the citing paper
“All three trials report impressive symptom reductions”
From Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy (2021) · cites this paper as Donker et al. 2019
In the citing paper
“Three high-quality randomized trials have been published recently, featuring three different applications: two on acrophobia with comparison against waiting-list (Donker et al. 2019;Freeman et al. 2018) and one on spider phobia examining non-inferiority against gold-standard in vivo exposure (Miloff et al. 2019).”
From Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy (2021) · cites this paper as Donker et al. 2019
In the citing paper
“The advent of modern consumer VR has resolved most of the logistic barriers to running larger clinical trials (but see below), as reflected in the larger sample sizes found in recent studies (Donker et al. 2019;Freeman et al. 2018;Miloff et al. 2019).”
From Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy (2021) · cites this paper as Donker et al. 2019
In the citing paper
“To date, three automated VRET treatments have been tested in clinical trials: two for use with acrophobia [26,27] and one for use with spider phobia [28].”
In the citing paper
“none reported on any user experiences beyond providing quotes from four participants on treatment effects [17], system usability ratings and cybersickness scores [18], and common negative effects [19]”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [18]
In the citing paper
“Although all three studies reported large effect sizes in terms of symptom reduction”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [18]
In the citing paper
“To our knowledge, only three randomized clinical trials of automated VRET interventions have been published to date: two for fear of heights [17,18] and one for spider phobia [19]”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [18]
In the citing paper
“Interestingly, all three studies on automated VRET [17-19] have included a virtual therapist in some format.”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [18]
In the citing paper
“These qualitative findings thus complement previous quantitative research revealing the high efficacy of automated VRET [17-19] in showing that these interventions are also perceived as appealing.”
From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [18]
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Metadata
- Authors
- Donker, T., Cornelisz, I., van Klaveren, C., van Straten, A., Carlbring, P., Cuijpers, P., & van Gelder, J.-L.
- Affiliations
- Amsterdam Public Health (NL)
- Vrije Universiteit Amsterdam (NL)
- Department of Education Sciences, Section Methods and Statistics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Clinical, Neuro- and Developmental Psychology, Section Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Stockholm University (SE)
- Department of Psychology of Conflict, Risk and Safety, University of Twente, Enschede, Amsterdam, the Netherlands
- Corresponding author
- Donker, Tara
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2019-07-01
- Volume
- 76
- Issue
- 7
- Pages
- 682
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC6583672
- OpenAlex
- W2923961203
- Cited by
- 187
- References
- 55
- Citations by year
- 2026: 12 · 2025: 30 · 2024: 26 · 2023: 24 · 2022: 25 · 2021: 38 · 2020: 26 · 2019: 6
- FWCI
- 27.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- University of Twente Research Information (publishedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (acceptedVersion, other-oa)
- MPG.PuRe (Max Planck Society) (submittedVersion)
- University of Twente Research Information (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Physical Sciences › Computer Science › Human-Computer Interaction › Virtual Reality Applications and Impacts
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- acrophobia, self-guided treatment, mobile application, low-cost virtual reality, gamification, anxiety disorders, treatment accessibility, attrition, ease of use, waitlist control, treatment effect size, number needed to treat, sensitivity analysis, robustness analysis
- MeSH terms
- Smartphone, Virtual Reality, Adult, Female, Humans, Male, Middle Aged, Phobic Disorders, Cognitive Behavioral Therapy, Single-Blind Method, Treatment Outcome, Mobile Applications
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