Virtual Reality-Based Interventions for Treating Depression in the Context of COVID-19 Pandemic: Inducing the Proficit in Positive Emotions as a Key Concept of Recovery and a Path Back to Normality.

BACKGROUND: During the COVID-19 pandemic as much as 40% of the global population reported deterioration in depressive mood, whereas 26% experienced increased need for emotional support. At the same time, the availability of on-site psychiatric care declined drastically because of the COVID-19 preventive social restriction measures. To address this shortfall, telepsychiatry assumes a greater role in mental health care services. Among various on-line treatment modalities, immersive virtual reality (VR) environments provide an important resource for adjusting the emotional state in people living with depression. Therefore, we reviewed the literature on VR-based interventions for depression treatment during the COVID-19 pandemic. SUBJECTS AND METHODS: We searched the PubMed and Scopus databases, as well as the Internet, for full-length articles published during the period of 2020-2022 citing a set of following key words: "virtual reality", "depression", "COVID-19", as well as their terminological synonyms and word combinations. The inclusion criteria were: 1) the primary or secondary study objectives included the treatment of depressive states or symptoms; 2) the immersive VR intervention used a head-mounted display (HMD); 3) the article presented clinical study results and/or case reports 4) the study was urged by or took place during the COVID-19-associated lockdown period. RESULTS: Overall, 904 records were retrieved using the search strategy. Remarkably, only three studies and one case report satisfied all the inclusion criteria elaborated for the review. These studies included 155 participants: representatives of healthy population (n=40), a case report of a patient with major depressive disorder (n=1), patients with cognitive impairments (n=25), and COVID-19 patients who had survived from ICU treatment (n=89). The described interventions used immersive VR scenarios, in combination with other treatment techniques, and targeted depression. The most robust effect, which the VR-based approach had demonstrated, was an immediate post-intervention improvement in mood and the reduction of depressive symptoms in healthy population. However, studies showed no significant findings in relation to both short-term effectiveness in treatment of depression and primary prevention of depressive symptoms. Also, safety issues were identified, such as: three participants developed mild adverse events (e.g., headache, "giddiness", and VR misuse behavior), and three cases of discomfort related to wearing a VR device were registered. CONCLUSIONS: There has been a lack of appropriately designed clinical trials of the VR-based interventions for depression since the onset of the COVID-19 pandemic. Moreover, all these studies had substantial limitations due to the imprecise study design, small sample size, and minor safety issues, that did not allow us making meaningful judgments and conclude regarding the efficacy of VR in the treatment of depression, taking into account those investigations we have retrieved upon the inclusion criteria of our particularistic review design. This may call for randomized, prospective studies of the short-term and long-lasting effect of VR modalities in managing negative affectivity (sadness, anxiety, anhedonia, self-guilt, ignorance) and inducing positive affectivity (feeling of happiness, joy, motivation, self-confidence, viability) in patients suffering from clinical depression.

The recording of mental health consultations by patients: clinical, ethical and legal considerations.

The topic of patients recording healthcare consultations has been previously debated in the literature, but little consideration has been given to the risks and benefits of such recordings in the context of mental health assessments and treatment. This issue is of growing importance given the increasing use of technology in healthcare and the recent increase in online healthcare services, largely accelerated by the COVID-19 pandemic. We discuss the clinical, ethical and legal considerations relevant to audio or visual recordings of mental health consultations by patients, with reference to existing UK guidance and the inclusion of a patient's perspective.

Digital psychiatry and COVID-19: the Big Bang effect for the NHS?

The COVID-19 pandemic has brought untold tragedies. However, one outcome has been the dramatically rapid replacement of face-to-face consultations and other meetings, including clinical multidisciplinary team meetings, with telephone calls or videoconferencing. By and large this form of remote consultation has received a warm welcome from both patients and clinicians. To date, human, technological and institutional barriers may have held back the integration of such approaches in routine clinical practice, particularly in the UK. As we move into the post-pandemic phase, it is vital that academic, educational and clinical leadership builds on this positive legacy of the COVID crisis. Telepsychiatry may be but one component of 'digital psychiatry' but its seismic evolution in the pandemic offers a possible opportunity to embrace and develop 'digital psychiatry' as a whole.

Does early intervention for psychosis work? An analysis of outcomes of early intervention in psychosis based on the critical period hypothesis, measured by number of admissions and bed days used over a period of six years, the first three in an early intervention service, the second three in a community mental health team.

BACKGROUND: early Intervention in Psychosis (EI) was introduced into the British NHS as a result of the NHS Plan, about eleven years ago. The intention was to provide thebest possible care or patients with a first episode of psychosis. Recently however, long term studies over five years have suggested that early gains may be lost. METHODS AND AIMS: we wished to establish whether our own group of patients who had received Early Intervention continued over six years to have better outcomes than patients treated in Community Mental Health Teams. To do this we analysed statistically the data on the readmissions and bed days used by our patients over the first six years of illness. RESULTS: We found that patients, both in the whole two groups and in different sub-groups appeared to demonstrate a number of advantages, not always statistically significant, in favour of the EI treated team. DISCUSSION: in many cases, the small size of the samples may have impeded us observing statistically significant differences, however, in general, it appeared that there were a number of advantages in favour of the EI treated team. CONCLUSION: our study, though small, does appear to support the view that Early Intervention Services do improve outcomes and that some of the improvement may endure after the patient leaves EI services. Much larger studies ae however required.

Developing outcome measures for serious mental illness; using early intervention as an example.

Developing useful outcome measures for the treatment of serious mental illness remains an important challenge for the newly re-configured Mental Health Services in the United Kingdom, towards the latter part of the ten year period covered by the National Service Framework. The present authors have taken the opportunity to develop a method for measuring outcomes in psychotic illness while developing a service for Early Intervention in Psychosis. The results are mentioned shown, but will be discussed in detail elsewhere. This article will focus on the development of the method for measurements which demonstrate functional improvement and improvement in quality of life. We shall show that, in order to measure outcomes, it is necessary to systematically record information from the first presentation of the case, so as later to be able to demonstrate what change has been accomplished. We shall also demonstrate that this activity is part of a necessary ongoing audit activity for services, but that, since there is no certain knowledge of what outcomes could have been expected prior to the implementation of new service developments, it is necessary to include a control group recruited from previous services, in order to establish meaningful benchmarks or norms to which the outcomes of a new service such a control group constitutes audit rather than research, but should be still amenable to statistical analysis. In order to be meaningful, and since serious mental illness may well be chronic, it is necessary that outcome measures should be carried out regularly, after specified periods of time. We also argue for the use of appropriate rating scales, which measure both the number and the intensity of symptoms and for computer base notes in order to facilitate regular audit.

The clinical dilemma--prescribing in pregnancy.

Antipsychotic prescription in pregnancy is a complex topic and raises a great deal of anxiety in professionals. There is limited data about atypical antipsychotic prescription in pregnancy and its possible teratogenicity. There are no randomised controlled studies of atypical antipsychotic use in pregnancy due to obvious reasons of ethical issues. We present two cases where a choice had to be made as to whether to prescribe Olanzapine during pregnancy, with different results.

Three year outcomes in an early intervention service for psychosis in a multicultural and multiethnic population.

BACKGROUND: Concern has been expressed that it may be difficult to provide certain interventions to some ethnic groups in an Early Intervention Service for Psychosis, and that as a consequence, three-year outcomes for the different Ethnic Groups may be different in different groups. To test whether there are differences between the three year outcomes of different ethnic groups represented in the patient population of an Early Intervention service for Psychosis. SUBJECTS AND METHODS: The three-year outcomes for the first group of 62 Patients to receive three years treatment in the Early Intervention Service in Luton, Bedfordshire were examined. This group well represented the ethnic mix of the population of Luton. RESULTS: It does not appear that there are major differences between the three-year outcomes of any one of the three groups studied. However the South Asian Patients appear to present earlier, with shorter DUPs, seemed more likely to marry, live with their families, and seem more likely to return to higher education after a first psychotic episode of psychosis compared to the Caucasians. Afro-Carribeans and South Asians were more likely to be unemployed, but many South Asians were employed, as were Caucasians. The fewest persons employed were in the Afro-Caribbean group. While slightly more South Asians and Afro-Carribeans were admitted compulsorily under the mental health act over the three years, 60% of each of the two non-white groups were never admitted compulsorily. This is different from the reported national trends of the Mental Health act being used excessively with the Afro-Caribbean population. DISCUSSION: No previous study has looked at the outcomes of Early Intervention Services for First Psychotic Episodes according to the Ethnic Origin of the Clients. The better outcomes seen with South Asians are probably due to cultural factors among the South Asians born in this country, rather than to issues related to the Psychotic Illness itself. CONCLUSION: These findings are important in planning services in areas where there is much ethnic diversity. The above conclusions must be understood as relating to patients who are well engaged with services. It would be unwise to extrapolate these outcomes to patients in the general population who have not engaged with services.

Three year outcomes of an early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team. Preliminary results.

Forty patients who had been treated for three years in an ad-hoc, assertive treatment team for patients who had suffered a first psychotic episode were compared to forty patients who had been followed up after a first psychotic episode in a community mental health team. All patients had suffered a first or early psychotic episode. The main differences between the two teams was that the ad-hoc team was assertive in its approach, offered more structured psycho-education, relapse prevention and psycho-social interventions, and had a policy of using atypical anti-psychotics at the lowest effective dose. There were many differences in outcome measures at the end of three years between the two groups. The EI patients are more likely to be taking medication at the end of three years. They are more compliant with medication. They are more likely to be prescribed atypical medication. The EI patients are more likely to have returned to work or education. The EI patients are more likely to remain living with their families. They are less likely to suffer depression to the extent of requiring anti-depressants. They appear to commit less suicide attempts. The patients in the EI service also appear to be less likely to suffer relapse and re-hospitalisation, and are less likely to have involuntary admission to hospital. They have systematic relapse prevention plans based on early warning signs. They and their families receive more psycho-education. These indications suggest that the EI patients are at the end of three years better able to manage their illness/vulnerability on their own than the CMHT patients. More patients in the EI group stopped using illicit drugs than in the CMHT group. All the above changes were statistically significant except for the number of patients who stopped using illicit drugs. In this case it is believed that the sample size was too small to demonstrate significance. These results suggest that an ad-hoc early intervention team is more effective than standard community mental health team in treating psychotic illness.

An early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team. Basic concepts and the service.

Early intervention in psychotic illness is a key area of development in community mental health. In this first of a series of articles the basic concepts of early intervention in psychosis are described, as is the present policy of the UK government for developing early intervention services throughout England. The development of an early intervention service in Luton, Bedfordshire is then described. Subsequent articles will describe the three year outcomes of this service, compared with treatment as usual in a community mental health team.

Three year outcomes of an early intervention for psychosis service as compared with treatment as usual for first psychotic episodes in a standard community mental health team - final results.

Sixty-two patients who had been treated for three years in an ad-hoc, assertive treatment team for patients who had suffered a first psychotic episode were compared to sixty-two patients who had been followed up after a first psychotic episode in a community mental health team. All patients had suffered a first or early psychotic episode. The main differences between the two teams was that the ad-hoc team was assertive in its approach, offered more structured psycho-education, relapse prevention and psycho-social interventions, and had a policy of using atypical anti-psychotics at the lowest effective dose. There were many differences in outcome measures at the end of three years between the two groups. The EI patients are more likely to be taking medication at the end of three years. They are more compliant with medication. They are more likely to be prescribed Atypical Medication. The EI patients are more likely to have returned to Work or Education. The EI patients are more likely to remain living with their families. They are less likely to suffer depression to the extent of requiring anti-depressants. They appear to commit less suicide attempts. The patients in the EI service also appear to be less likely to suffer relapse and re-hospitalisation, and are less likely to have involuntary admission to hospital. They have systematic relapse prevention plans based on Early Warning Signs. They and their families receive more psycho-education. These indications suggest that the EI patients are at the end of three years better able to manage their illness/vulnerability on their own than the CMHT patients. More patients in the EI group stopped using illicit drugs than in the CMHT group. All the above changes were statistically significant except for the total improvement in employment status and education status, which however approached significance. These results suggest that an ad-hoc Early Intervention Team is more effective than standard Community Mental Health Team in treating psychotic illness.