Asher Marks, MD, is a Yale Medicine hematologist and oncologist and director of Pediatric Neuro-Oncology. He is also the director of the adolescent and young adult (AYA) cancer program for Yale New Haven Children’s Hospital.

Asher Marks, MD

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In the age of COVID, telehealth and telepsychiatry have gone from alternative solutions to in-person patient care, to necessities that physicians and mental health practitioners have been forced to quickly adopt. 

While relatively sufficient for certain aspects of care delivery, current technologies have the potential to vastly miss the mark when attempting to deliver quality mental health care and support. The effective delivery of psychotherapy, education, and group-based therapies are dependent upon patients and practitioners sharing a therapeutic physical space, being able to communicate via non-verbal cues, and being able to interact without distraction. As current telehealth technologies involve the utilization of telephone and video conferencing, these technologies fall short in achieving the above goals. 

The rapidly evolving landscape of extended reality technologies, however, has presented us with unique tools to enhance our virtual interactions and come closer to the therapeutic experience that is so important to successful delivery of effective and high-quality remote care.

Extended reality is an umbrella term that includes virtual reality (VR), mixed reality (MR), and augmented reality (AR) technologies – all existing on a continuum of immersion. While augmented and mixed reality technologies overlay information on top of real-world elements through the use of a heads-up display (HUD), virtual reality is completely immersive with the incorporation of headphones and body tracking sensors. 

Of the extended reality technologies described above, virtual reality is the most mature, available, and studied, with the earliest literature suggesting its incorporation into medical care and education going back to the very early 90’s (1). Since then, it’s use has been studied in multiple areas, including pain control (2), anxiety (3), education (4), exposure therapy (5) and even fear of death (6). While the exact mechanism of action is unclear beyond its ability to distract and force literal changes of perspective, studies by Hoffman, et. Al. have done some very interesting work looking at the neural correlates of virtual analgesia using fMRI, and showing significantly reduced pain-related brain activity in important regions including the anterior cingulate cortex, primary and secondary somatosensory cortex, insula, and thalamus (7). Similarly, exposure therapy utilizing virtual reality has shown to have direct effects on the prefrontal cortex, as expected during traditional exposure therapy (5).

Although early VR technology required the use of expensive, immobile setups involving powerful computers, wired headsets, and an array of cameras, the past year has seen the availability of consumer ready headsets that can be used without additional cameras or PCs. This has greatly expanded VR’s potential to be incorporated into telehealth and telepsychiatry. To that end, the Adolescent and Young Adult (AYA) Oncology clinic at Yale New Haven Hospital has launched a pilot study looking at the use of VR to engage our AYA patients in support groups led by AYA social worker, Amanda Garbatini. 

The software was designed and subsequently customized by 

 and runs on $400 Oculus Quest headsets. Each support group session is attended by four AYA patients using their headsets from any location with a WiFi or cellular data connection (including their hospital bed). Upon entering the therapeutically curated virtual space, they find themselves sitting in a circle with other participants and a group moderator. Each session runs 45-60 minutes for a total of six sessions. The pilot is nearing its end with a goal of five separate groups participating, for a total of 20 patients. Initial findings are very encouraging.

Important early hurdles to trial and intervention design included ensuring physical and emotional safety (lack of motion sickness and safety plans for any triggering events or suicidal ideation), infection control measures (utilization of sterilization techniques including the use of ultraviolet sanitation between uses), and close collaboration between rapid tech industry timelines and slow academic processes. Metrics have been designed to look at depression, anxiety, and resilience, pre- and post-intervention with encouraging trends towards decreased anxiety and increased resilience already being noted. 

Direct feedback from patients has been most helpful in further development of this intervention, and attendance has been overall without significant issue. Recurring themes include patients noting they are more comfortable meeting virtually when feeling ill, need breaks when headsets get heavy, a desire to have more dynamic and robust avatar selections to better represent themselves, and a desire to meet in person after their six sessions have completed.

Upon completion of this pilot trial and publication of significant findings, our intention is to move forward with a larger, multi-institutional Phase 2 trial assessing risks and benefits of VR based support groups as compared to other viable solutions to the remote care problem.

The AYA population is an ideal starting point due to their technologic savvy and willingness to adopt new technologies, however, another recent pilot has shown VR’s viability in a much older patient population dealing with grief (8). This approach is particularly alluring for patients with rare diseases outside major metropolitan areas, however, access to broadband internet access for geographic and socioeconomic reasons remains a concern. We are hopeful, however, that with the quickly approaching launches of 5G networks and satellite-based internet solutions such as Space X’s upcoming Starlink system these technologies will soon be available to the majority of the population.



1. Krueger M: Virtual reality: a technology in nursing education's future. Nurs Educ Microworld 5:17, 19, 1991

2. Agrawal AK, Robertson S, Litwin L, et al: Virtual reality as complementary pain therapy in hospitalized patients with sickle cell disease. Pediatr Blood Cancer 66:e27525, 2019

3. Gershon J, Zimand E, Pickering M, et al: A pilot and feasibility study of virtual reality as a distraction for children with cancer. J Am Acad Child Adolesc Psychiatry 43:1243-9, 2004

4. Pourmand A, Davis S, Lee D, et al: Emerging Utility of Virtual Reality as a Multidisciplinary Tool in Clinical Medicine. Games Health J 6:263-270, 2017

5. Landowska A, Roberts D, Eachus P, et al: Within- and Between-Session Prefrontal Cortex Response to Virtual Reality Exposure Therapy for Acrophobia. Front Hum Neurosci 12:362, 2018

6. Bourdin P, Barberia I, Oliva R, et al: A Virtual Out-of-Body Experience Reduces Fear of Death. PLoS One 12:e0169343, 2017

7. Hoffman HG, Richards TL, Coda B, et al: Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. Neuroreport 15:1245-8, 2004

8. Knowles LM, Stelzer E-M, Jovel KS, et al: A pilot study of virtual support for grief: Feasibility, acceptability, and preliminary outcomes. Computers in Human Behavior 73:650-658, 2017

Articles

The rapidly evolving landscape of extended reality technologies has presented us with unique tools to enhance our virtual interactions and come closer to the therapeutic experience that is so important to successful delivery of effective and high-quality remote care.

Asher Marks, MD

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