Immersive Psychiatry Brandon Birckhead, MD, MHDS

This episode provides thoughts on how we could implement custom virtual reality therapy programs for each patient using artificial intelligence, specifically using natural language processing. If you are interested in studying questions related to this, just reach out to me or Brian Dolan on Linkedin.

Outline

Part 1: Precision Medicine

The Future of Psychiatric Epidemiology - Great intro to the topic. 

On the Road to Personalized Psychotherapy: A Research Agenda Based on Cognitive Behavior Therapy for Depression - Why we won't have "Precision VR Therapy" for several years. 

Part 2: What is Psychiatric Formulation (2 types discussed)

Biopsychosocial Model and Case Formulation 

Beyond the DSM: The Perspectives of Psychiatry Approach to Patients

The Perspectives of Psychiatry 

Part 3: When VR Therapy Might Need AI-assisted Development + Kinds of Programs Related To It. 

Medical Virtual Asset Management System (An NLP based assembly program)

Generating human avatars based on external media

Realistic virtual humans (MetaHumans by Unreal) 

Virtual Humans in Augmented Reality: A First Step towards Real-World Embedded Virtual Roleplayers

Virtual Humans: Putting Realistic People in Realistic... (Michael Black)

Part 4: How Psychiatric Formulation can be combined with AI

Lifestory Perspective

The Body Keeps The Score

Mother meets her deceased daughter through VR

Dimensional Perspective

Research Related to Big Five Personality (Neuroticism) and Therapy

Behavioral Perspective

What is… Cue-Exposure Therapy?

Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review

Help Club: VR Peer Support Group Platform

Disease Perspective

[Review of] Virtual Reality Therapy in Mental Health

Use of VR to reduce the severity of auditory hallucinations 

Part 5: Limitations

Conclusion

This episode covers the non-drug related treatments of chronic pain as well as my work over the last 3 years studying psychological informed virtual reality programs that can be self-administered by the patient in their home. It's a long episode because I cover not only chronic pain, but also remote clinical trials. Given my interest in psychiatry and my previous work, this episode does not focus as much on physical therapy as it does psychology-related treatments. However, several of the resources below pertain to physical therapy for chronic pain. In the discussion on remote trials I provide a few key takeaways for startups and researchers. 



Challenges facing chronic pain treatment

Workforce projections 2010–2020: annual supply and demand forecasting models for physical therapists across the United States

Pain psychology: A global needs assessment and national call to action

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

Nondrug based treatments

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

Psychological therapies for the management of chronic pain (excluding headache) in adults

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

My work in Chronic Pain

An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19

Other VR papers

Virtual reality for acute and chronic pain management in adult patients: a narrative review

Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study

Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial

Embodiment in Virtual Reality for the Treatment of Chronic Low Back Pain: A Case Series

Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis

Hypnosis Associated with 3D Immersive Virtual Reality Technology in the Management of Pain: A Review of the Literature

Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study

A Virtual Reality Game for Chronic Pain Management: A Randomized, Controlled Clinical Study

Can hypnosis and virtual reality reduce anxiety, pain and fatigue among patients who undergo cardiac surgery: a randomised controlled trial Protocol

Virtual reality distraction induces hypoalgesia in patients with chronic low back pain: a randomized controlled trial

The first medical publication on PubMed that used virtual reality was for phobias and this is the episode on that topic. I had a great conversation with a VR expert that has been treating patients with phobias using virtual reality for 20 years, Les Posen. I then talk about the current evidence for this type of VR therapy and some of the different ways it can be delivered. 

Outline 

Define a phobia

Categories of phobic disorders: Agoraphobia, Specific Phobias, Social Anxiety Disorder

1st line treatment: Exposure therapy via patient's imagination, real exposure (in vivo), virtual reality 

Other diseases that are treated with exposure therapy

Conversation with Les Posen

Past: Why Phobias were one of the first uses of the technology? 

Present: How does virtual reality stack up against in vivo exposure? 

Future: How can therapists do virtual reality therapy remotely and how can patients self administer therapy when needed? 



Links (use google podcast or anchor to click through these links)

Presence as the Defining Factor in a VR Application

Virtual reality graded exposure in the treatment of acrophobia: A case report

Review papers (the last one of the 4 was the one I talked about in the episode)

Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review

Using Virtual Technology for Fear of Medical Procedures: A Systematic Review of the Effectiveness of Virtual Reality-Based Interventions

Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review

Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?—A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia

Here are the automated studies I talked about (plus I found a third one after I made the episode) ->

Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial

Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial

This last that I didnt talk about in the podcast episode is awesome! They actually tested the participants with a real tower for their fear of heights. 

Effectiveness of a stand-alone, smartphone-based virtual reality exposure app to reduce fear of heights in real-life: a randomized trial

In this episode, we will talk about procedures that cause anxiety or pain that have been paired with immersive technology (most often with virtual reality). We will start with a use case that is specific to psychiatry with the combination of virtual reality with ketamine infusions for chronic pain. Then we will go back to when I started exploring the uses of VR with my work using it during dental procedures. In the second half of the episode, we will talk about hospital-based procedural pain and anxiety along with the research for those areas. 

By the end of the episode, you will know about the kinds of software programs used for procedural pain and anxiety


Floating 2-D TV screens (aka a void theater, check out Netflix VR if you have a headset)
Immersive VR games for pain reduction 
Relaxing 360-degree videos
Relaxing Immersive VR environments 
VR programs with psychological content - Biofeedback with breath or heart rate and guided relaxation. 

Links to resources

Ketamine (disclaimer there are no published papers on what Dr. Omer Liran has done with VR, but this is the closest thing) 

Combining Ketamine and Virtual Reality Pain Control During Severe Burn Wound Care: One Military and One Civilian Patient

Dentistry

The Impact of Virtual Reality Distraction on Pain and Anxiety during Dental Treatment in 4-6 Year-Old Children: a Randomized Controlled Clinical Trial

Virtual Reality Distraction for Pain Control During Periodontal Scaling and Root Planing Procedures

Virtual Reality Relaxation to Decrease Dental Anxiety: Immediate Effect Randomized Clinical Trial

Pediatrics

Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety

Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomized, controlled trial (FOREVR Peds trial)

Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients

Virtual reality during pediatric vascular access: A pragmatic, prospective randomized, controlled trial


The above study is a negative study that was well designed which is important for the field. VR does not always do better than the standard of care. 

Adult medicine use cases

Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults.

Modulation of thermal pain-related brain activity with virtual reality: evidence from fMR

Pain Distraction During Ambulatory Surgery: Virtual Reality and Mobile Devices

Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A systematic review and meta-analysis of randomized controlled trials

In this episode, we will begin the discussion on the different uses of immersive technology for patient education with those that help familiarize patients with procedures. I start the episode on electroconvulsive therapy (ECT) and why it's a good candidate for immersive patient education within psychiatry. 

Outline

Indications for ECT

History of ECT and stigma in Media

Concern about ECT from patients

Immersive patient education categories: Familiarize with procedures vs Education as part of treatment

Factors that drive the need for patient education related to procedures

Kinds of immersive content in procedure-related patient education


Image-based VR
360-degree videos
Computer Generated VR simulations

My experience with immersive patient education

Links

ECT citations

The Origins of Electroconvulsive Therapy (ECT)

Knowledge and attitudes regarding electroconvulsive therapy among medical students and the general public

Patients' perspectives on electroconvulsive therapy: systematic review

Efficacy of ECT in depression: a meta-analytic review

Image-based VR patient education

Impact of Neurosurgical Consultation With 360-Degree Virtual Reality Technology on Patient Engagement and Satisfaction

Novel application of virtual reality in patient engagement for deep brain stimulation: A pilot study

360-degree video patient education research 

Virtual Reality to Reduce Pre-procedure Anxiety Prior ECT (PERFECT-VR)

Effect of an Immersive Preoperative Virtual Reality Experience on Patient Reported Outcomes: A Randomized Controlled Trial

Computer Generated VR simulations

The Stanford Virtual Heart

My experience with patient education

Video of a patient education program I designed back when I was in radiation oncology

In this episode, I provide an intro to the podcast series. Several of the episodes will be framed around a current treatment in psychiatry or an important concept within the field. As I say in the episode I will only cover psychiatric concepts as they related to immersive technology. However, if you are curious about how far virtual reality and augmented reality might be incorporated into mental health then this is the podcast for you.