IntroductionBackground

Depression is a debilitating disorder characterized by a persistent low mood and a loss of interest in everyday activities, significantly affecting various dimensions of life []. Globally, approximately 280 million people are afflicted by this condition []. However, only 16.5% of people with depression worldwide receive treatment, indicating a substantial treatment gap []. The scarcity of mental health professionals exacerbates this issue, with figures in low- and middle-income countries being particularly low at 1.4 to 3.8 per 100,000 population []. This shortage of resources highlights the urgent need for innovative solutions in mental health care [].

Digital technologies, now more crucial than ever, have emerged as vital tools in bridging health care gaps []. Among these, immersive technologies (IMTs) such as virtual reality (VR) and augmented reality (AR) stand out for their potential to revolutionize depression care. These technologies offer computer-generated immersive experiences that blend virtual and real environments, with VR providing entirely virtual experiences and AR overlaying virtual objects onto the real world [].

The application of IMTs in mental health leverages their ability to create controlled immersive environments, offering a safe space for individuals to explore coping exercises and techniques [,]. This digital modality encompasses immersive sensory experiences that allow users to interact with a virtual environment [,]. Such interactions have been shown to increase engagement in health care–related tasks [,], which is a crucial challenge in the treatment of anxiety and depression [], providing a novel approach to mental health care. Furthermore, continual improvements in IMT device technology, exemplified by the Meta Quest VR headsets, have further broadened the accessibility of these interventions globally. Moreover, IMTs have proven effective in treating a wide range of mental health conditions, such as anxiety, posttraumatic stress disorder, autism spectrum disorders, and various phobias [-].

Objectives

Although some reviews have examined the use of IMTs in treating depression [-], they have not focused primarily on depression as the assessment goal; nor have they focused on IMT applications specifically aimed at treating depression or on the psychotherapeutic aspects of these interventions. Moreover, the available literature did not address relevant elements, such as the design or implementation of IMT interventions.

Therefore, we aim to map the most rigorous available evidence on IMT interventions targeting depression treatment and identify the gaps related to the design and implementation of these interventions. Given the emerging nature of IMTs in mental health and our specific research focus, a scoping review was deemed the most appropriate methodology. This approach allows for a broad overview of the existing literature, identifying key concepts and highlighting gaps in the research. Furthermore, we decided to focus on randomized clinical trials (RCTs) to ensure a robust and reliable evidence base. RCTs are considered the gold standard in clinical research, providing high-quality data to inform clinical practice and guide future research. By concentrating on RCTs, we aim to capture the most rigorous and scientifically valid studies, thereby enhancing the credibility and applicability of our findings in this emerging area of mental health care.

MethodsOverview

This scoping review adheres to the framework formulated by Arksey and O’Malley [], expanded upon by Levac et al [] and Daudt et al [] and summarized by the JBI Manual for Evidence Synthesis []. Accordingly, we followed five main steps for conducting the scoping review: (1) identifying the research questions; (2) identifying relevant studies; (3) selecting the studies; (4) charting the data; and (5) collating, summarizing, and reporting the results.

Regarding reporting, our study aligns with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) 2020 guidelines [] (). The protocol was preregistered on Open Science Framework [].

Step 1: Identifying the Research Questions

The primary research question guiding this study is What is the available scientific evidence and what are the gaps that exist in this evidence concerning the use of IMTs to address depression among adults?

The study also seeks to address the following secondary questions:

From which regions or countries does the evidence come?Which technical aspects of IMTs have been reported in the evidence?What therapeutic approaches were used?What are the barriers and facilitators to implementing IMT interventions for depression treatment?What outcomes have been evaluated in studies examining the impact of IMT interventions on addressing depression?Step 2: Identifying Relevant Studies

We conducted a systematic search of the following electronic databases: MEDLINE (via PubMed), Scopus, Web of Science, Embase, PsycINFO (via EBSCO), IEEE Xplore, and Cochrane Library. The search strategy incorporated the keywords “virtual reality,” “augmented reality,” “depression,” and “randomized clinical trial.” An example of the search query performed in PubMed is presented in , and the search queries for each database are detailed in . The search was limited to articles published in English and spanned from the inception of each database to October 10, 2023.

Textbox 1. PubMed search query.

Search query

(“Depression”[MeSH] OR “Depressive Disorder”[MeSH] OR depressive*[tiab] OR depression[tiab]) AND “Virtual Reality”[MeSH] OR “virtual reality”[tiab] OR “Augmented Reality”[MeSH] OR “augmented reality”[tiab] OR “VR headset”[tiab] OR “VR glasses”[tiab] OR “virtual environment”[tiab] OR “virtual world”[tiab] OR metaverse[tiab] OR meta-verse[tiab]) AND (“Randomized Controlled Trial”[Publication Type] OR “Randomized Controlled Trials as Topic”[MeSH] OR “randomized clinical trial”[tiab] OR RCT[tiab] OR (randomized[tiab] AND “clinical trial”[tiab]))Step 3: Study Selection

The inclusion and exclusion criteria are detailed in . Secondary studies were excluded, but their references were consulted to identify primary research studies that fulfilled our selection criteria. Similarly, protocols were not included, but registration IDs were consulted in the web to find preliminary or primary results published in articles.

Textbox 2. Inclusion and exclusion criteria (we defined immersive technologies as all augmented reality and virtual reality–only applications that belong to the degree of full immersion, according to the definitions provided in the literature [7,10]).

Inclusion criteria

Articles must include randomized clinical trials and be published in peer-reviewed journals.All participants must be aged at least 18 y.Depression must be a primary outcome measured either through clinical assessment or validated screening tests.At least 1 group of participants should have received, or should have been exposed to, immersive technologies using glasses, headsets, or other head-mounted display devices, with or without using other complementary devices.

Exclusion criteria

Secondary studies (systematic, umbrella, narrative, and scoping reviews) and protocols were not considered.Articles in which the immersive technology interventions only focused on exercise as a treatment were not considered.

We searched the various databases of scientific articles and exported all records as RIS format files. These records were imported into EndNote X9 (Clarivate) for automatic and manual duplicate checking. Subsequently, the selection process was carried out on the Rayyan web platform (Rayyan Systems Inc) in 2 phases. First, the records were screened by title and abstract by independent reviewers using the platform. In the second phase, full-text evaluations were conducted to determine compliance with the inclusion criteria. Each document was assessed independently by a pair of reviewers (CMRR and KDC as well as CMRR and PDS) to ensure that they met the eligibility criteria. Review disagreements were solved through consensus, and a third reviewer (DVZ) made a final decision in case disagreements persisted. The reasons for exclusion were documented (). Before the selection process, reviewers undertook a pilot test with 10 articles to standardize the process and gain expertise in using the Rayyan platform.

Step 4: Charting the Data

Two pairs of reviewers (CMRR and KDC as well as CMRR and PDS) independently collected data using a collection form developed for the study protocol and refined at the data collection stage. The reviewers performed a pilot test with 2 documents to standardize information extraction criteria. The collected data included general and study characteristics (country of study, study design, participants’ characteristics, the type of depression outcome, and intervention and control descriptions), IMT intervention technical aspects (devices, the amount of time used and frequency of use, the setting of use, duration, IMT design framework consulted, and the degree of guidance), therapeutic approach used, and implementation characteristics (implementation framework used, implementation stage, and barriers and enablers). Study designs were categorized following the clinical trial classification formulated by Hopewell et al []. The implementation stages were defined as follows: (1) preliminary, if it was a pilot or feasibility study; (2) implementation, if it was mentioned that the RCT had been developed after a pilot or feasibility study; and (3) unclear, if there was no mention of it being a pilot or feasibility study, and there was no reference either to the results from these studies.

Step 5: Collating, Summarizing, and Reporting the Results

We used a narrative approach to synthesize data []. We describe the information in the Results section using frequencies and percentages. Detailed information for each included article is presented in cross-tables. In addition, the geographic location of the studies is visualized as a bubble plot, categorized by year.

ResultsOverview

Our search strategy identified 1052 records; after removing 477 (45.34%) duplicates, the remaining 575 (54.66%) records were screened by title and abstract. Of these 575 records, 52 (9%) underwent full-text review. Of these 52 records, 36 (69%) were excluded, mainly on account of being the wrong type of publication (n=15, 42%); thus, 16 (31%) reports [-] from 15 studies were included in the review ().

‎Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flowchart outlining the search and selection process.

illustrates an uneven distribution of research evidence on IMT interventions for depression management across different regions and income levels. European countries dominate the research landscape (10/16, 63%) [,,-,-], with Poland alone contributing more than half of the reports (9/16, 56%) [,,-,-] between 2021 and 2023. However, Poland showed a decreasing trend; of the 9 reports in this review, 5 (56%) were published in 2021, while only 1 (11%) was published in 2023. China maintains a steady presence in Asia with a study each in 2022 [] and 2023 [], amounting to 13% (2/16) of the total. By contrast, the United States [], Australia [], Brazil [], and Iran (the only lower–middle-income country contributing to this research field) [] contributed only 1 (6%) study each to the total of 16 studies. The trend analysis indicates a fluctuating global interest in the field, with a concentration of research in Europe (10/16, 63%) [,,-,-], intermittent contributions from other regions, and a spike in publications during 2022 (7/16, 44%) [,,,,,,].

‎Figure 2. Trends of publication by geographic location of the reports.

illustrates the general characteristics of the selected reports. The majority (15/16, 94%) [-,-] adopted a parallel group design, while a single study (1/16, 6%) used a crossover trial design []. Among the 16 reports, only 1 (6%) featured 3 arms (2 control groups alongside 1 VR intervention group) []. Regarding the research timeline, most of the studies (9/16, 56%) were conducted between 2020 and 2021 [,,,-,,]. However, for 3 (19%) of the 16 studies, the specific study period was not reported [,,].

Table 1. Characteristics of included studies.ReportsYear of study developmentCountry of study developmentStudy designParticipant characteristicsSpecific depressive conditions studied and the measurement scale usedSample sizeVRa group intervention descriptionNon-VR group intervention descriptionEffectCieślik et al [], 20232022PolandParallel group 2-arm randomized controlled trial+masked outcome assessor+2 time point measures (before and after the intervention)Sex: female (60/60, 100%); age (y): mean 68.2 (SD 5.5)Depression among older adults measured using the GDS-30b60 (randomized; intervention: 30; control: 30)General fitness training (40 min of low-intensity general fitness exercises)+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)General fitness training (20 min)+relaxation session (10 min) and psychoeducation (10 min)Intervention: baseline=mean 13.10 (SD 4.26); after treatment=mean 7.33 (SD 3.88); Cohen d=1.86, 95% CI 1.26 to 2.45; control: baseline=mean 13.27 (SD 3.80); after treatment=mean 11.57 (SD 5.49); Cohen d=0.42, 95% CI 0.04 to 0.79; test used: ANCOVAc (between groups); P<.001Czech et al [], 2022UnclearPolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: female (16/16, 100%); age (y): intervention=mean 50.6 (SD 12.6); control=mean 59.6 (SD 7.9); other: participants with breast cancerDepressive symptoms measured by Beck Depression Inventory16 (randomized; intervention: 9; control: 7)Virtual Therapeutic Garden: intense visual, auditory, and kinesthetic stimuli through garden immersion with the therapist’s voice guiding the patientStandard of care (not specified)Intervention: baseline=mean 13.33 (SD 5.57); after treatment=mean 8.11 (SD 6.17); control: baseline=mean 9.00 (SD 7.07); after treatment=mean 7.00 (SD 5.51); test used: 1-way repeated measures ANOVA (for time and groups); P=.04Farahimanesh et al [], 20232021IranParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 18/30 (60%); control=female 15/30 (50%); age (y): intervention=mean 49.1 (SD 10.9); control=mean 49.7 (SD 10.4); other: at least 2 months of social distancing measures related to the COVID-19 pandemicDepressive symptoms measured by the Depression Anxiety Stress Scale-2160 (randomized; intervention: 30; control: 30)COVID Feel Good: a daily intervention with 7 thematic modules, each with two integrated parts: (1) watching a 10-min 360-degree VR video titled Secret Garden+listening to a relaxation induction narrative and (2) social tasks with a different purpose for each day of the wkNo treatmentIntervention: baseline=mean 6.6 (SD 3.1); group 1 after intervention=mean 6 (SD 2.86); group 2 after intervention=mean 5.63 (SD 2.95); control: baseline=mean 6.93 (SD 2.78); group 1 after treatment=mean 6.93 (SD 2.38); group 2 after treatment=mean 6.90 (SD 2.34); test used: ANOVA (for time and groups); P=.002Jóźwik et al [], 2021UnclearPolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: female (26/26, 100%); age (y): mean 65.4 (SD 8.0); intervention=mean 65.6 (SD 10.1); control=mean 65.2 (SD 6.5); other: participants with ischemic heart diseaseDepressive symptoms measured by the HADSd52 (randomized; intervention: initial=26, at conclusion=17; control: 26)Interval training on a cycle ergometer (40 min)+general fitness exercises (40 min)+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Interval training on a cycle ergometer (40 min)+general fitness exercises (40 min)+Schultz autogenic training guided by therapist and CD recordingIntervention: baseline=mean 6.14 (SD 3.77); after treatment=mean 4.86 (SD 3.48); mean difference=−1.29 (95% CI −2.12 to −0.46); control: baseline=mean 6.35 (SD 3.91); after treatment=mean 6.53 (SD 3.86); change=0.18 (95% CI −0.16 to 0.52); test used: 2-way repeated measures ANOVA (for time and groups); P=.01Jóźwik et al [], 20212020PolandParallel group 2-arm randomized controlled trial+masked outcome assessor+2time point measures (before and after the intervention)Sex: intervention=female 17/28 (61%); control=female 25/49 (51%); age (y): intervention=mean 66 (SD 9.7); control=mean 63.9 (SD 6.9); other: participants with coronary artery disease+cardiac rehabilitation phase IIDepressive symptoms measured by the HADS100 (randomized; intervention: initial=50, at conclusion=28; control: initial=50; at conclusion=49)Interval training on a cycle ergometer (40 min)+general fitness exercises (40 min)+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Interval training on a cycle ergometer (40 min)+general fitness exercises (40 min)+Schultz autogenic training via CD recording (20 min)Intervention: baseline=mean 6.41 (SD 4.21); after treatment=mean 5.06 (SD 3.88); control: baseline=mean 7.35 (SD 3.80); after treatment=mean 7.27 (SD 4.00); test used: t test for independent trials; P=.07 for posttreatment measurementsKiper et al [], 20222020PolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 17/30 (57%); control=female 13/30 (43%); age (y): intervention=mean 65.5 (SD 6.7); control=mean 65.6 (SD 4.9); other: participants with a history of ischemic stroke and older adult depression diagnosed using the GDS-30 (>10)Older adult depression measured using the GDS-30; depressive symptoms measured using the HADS (depression subscale)60 (randomized; intervention: initial=30, at conclusion=22; control: initial=30, at conclusion=17)First 3 wks: functional rehabilitation (60 min)+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient); next 3 weeks: functional rehabilitation (60 min)First 3 wks: functional rehabilitation (60 min)+Schultz autogenic training via CD recording (20 min); next 3 wks: functional rehabilitation (60 min)GDS-30—intervention: baseline vs group 1 after treatment=mean difference −6.33 (95% CI −4.42 to −8.24); baseline vs group 2 after treatment=mean difference −6.60 (95% CI −4.69 to −8.51); control: baseline vs group 1 after treatment=mean difference −3.40 (95% CI −1.49 to −5.31); baseline vs group 2 after treatment=mean difference −3.17 (95% CI −1.26 to −5.08); test used: 2-way repeated measures ANOVA (for time and groups); P<.01; HADS (depression scale)—intervention: baseline vs group 1 after treatment=mean difference –1.50 (95% CI –0.32 to –3.32); baseline vs group 2 after treatment=mean difference –2.05 (95% CI –0.23 to –3.87); control: baseline vs group 1 after treatment=mean difference 0.79 (95% CI –1.08 to –2.66); baseline vs group 2 after treatment=mean difference 0.73 (95% CI –1.13 to –2.61); test used: 2-way repeated measures ANOVA (for time and groups); P<.31Lakhani et al [], 20202019AustraliaCrossover group 2-arm randomized controlled trial+3 time point measures (1 before and 2 after the intervention)Sex: group 1=female 0/10 (0%); group 2=female 8/14 (57%); age (y): group 1=mean 56.2 (SD 20.7); group 2=mean 48.0 (SD 16.2); other: participants with spinal cord injuryDepressive symptoms measured using the Patient Health Questionnaire-824 (randomized; group 1: initial=10, at conclusion=6; group 2: initial=14, at conclusion=10)Standard of care (tailored regular rehabilitation involving occupational therapy and physiotherapy)+VR session of environment exposure using the National Geographic app and the YouTube VR appStandard of care (tailored regular rehabilitation involving occupational therapy and physiotherapy)Group 1: baseline=mean 5.83 (SD 4.71); group after intervention treatment=mean 3.33 (SD 3.44); control group after treatment=mean 4.17 (SD 5.04); group 2: baseline=mean 5.50 (SD 2.99); control group after treatment=mean 6.30 (SD 1.95); intervention group after treatment=mean 5.90 (SD 3.28); test used: paired t test (between groups); P=.04 (between baseline and after the control treatment) and P=.47 (between after the control treatment and after the intervention treatment); test used: 1-way ANOVA (within groups); P=.09 (group 1) and P=.83 (group 2)Paul et al [], 20222020-2021United StatesParallel group 3-arm randomized controlled trial+4 time point measures (1 before and 3 after the intervention)Sex: initial=female 7/13 (54%); complete study=female 4/10 (10%); age (y): initial=mean 35.4 (SD 12.3); complete study=mean 34.6 (SD 11.50); other: participants with major depressive disorder diagnosed using the Patient Health Questionnaire-8 (score>10)Depressive symptoms measured using the Patient Health Questionnaire-913 (randomized; intervention: initial=5, at conclusion=3; control 1: 4 and control 2: 4)Behavioral activation therapy via teleconference platform+VR activities (360-degree YouTube VR videos) after teleconference session (during the wk)Control 1: verbally asked questions for depression screening using the Patient Health Questionnaire-9 via telephone call; control 2: behavioral activation therapy via teleconference platform+in-person activities after teleconference session (during the wk)Intervention: baseline vs posttreatment 3=mean difference −5.67; control 1: baseline vs posttreatment 3=mean difference −3.00; control 2: baseline vs posttreatment 3=mean difference −0.25 (no statistical test was used)Rodrigues et al [], 20222020-2021BrazilParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 11/22 (50%); control=female 11/22 (50%); age (y): intervention=mean 48.9 (SD 13.9); control=mean 48.5 (SD 16.9); other: participants with COVID-19 infectionDepressive symptoms measured by the HADS44 (randomized; intervention: 22; control: 22)Usual therapy (activities to guide the hospitalization process, coping with the hospitalization process, energy conservation, daily living activity training, cognitive rehabilitation, internet-based call or visit, positioning, mobility joint, functional mobility, kinesiotherapy, assistive technology, sensory stimulation tailored to patient needs)+VR therapy (360-degree videos with images of landscapes and mindfulness techniques)Usual therapy (activities to guide the hospitalization process, coping with the hospitalization process, energy conservation, daily living activity training, cognitive rehabilitation, internet-based call or visit, positioning, mobility joint, functional mobility, kinesiotherapy, assistive technology, sensory stimulation tailored to patient needs)+VR control (videos with advertisements not related to relaxation and well-being content)Intervention: baseline=mean 9.83 (SD 4.31); after treatment=mean 7.17 (2.79); Cohen d=0.73; control: baseline=mean 15.00 (SD 10.31); after treatment=mean 13.00 (SD 9.49); Cohen d=0.20; test used: Wilcoxon test (within groups); P=.04 (intervention) and P=.08 (control); test used: Mann-Whitney U test (between groups); P>.05Rutkowski et al [], 20212020PolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 21/25 (84%); control=female 20/25 (80%); age (y): intervention=mean 64.4 (SD 5.7); control=mean 67.6 (SD 9.4); other: participants with chronic obstructive pulmonary disease and depression or anxiety diagnosed using the Hamilton Anxiety and Depression Scale (score>8)Depressive symptoms measured using the HADS50 (randomized; intervention: 25; control: 25)Traditional pulmonary rehabilitation program (15-30 min)+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Traditional pulmonary rehabilitation program (15-30 min)+Schultz autogenic training session (20 min)Intervention: baseline=mean 7.96 (SD 2.76); after treatment=mean 6.04 (SD 3.21); control: baseline=mean 6.64 (SD 2.80); after treatment=mean 7.08 (SD 3.56); test used: repeated measures ANOVA (within groups); P=.001 (intervention) and P=.45 (control)Rutkowski et al [], 20222021PolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: female 20/32 (69%); age (y): mean 57.8 (SD 4.9); other: participants with COVID-19 infectionDepressive symptoms measured using the HADS32 (randomized; intervention: 16; control: 16)Pulmonary rehabilitation program+VR-based exercise capacity training: bicycle ergometer+Virtual Park VR experience (bicycle trip in an island simulation synced with ergometer)+VR-based relaxation (Virtual Therapeutic Garden: intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Pulmonary rehabilitation program+traditional exercise capacity training: bicycle ergometer exercise+Schultz autogenic trainingIntervention: baseline=mean 6.9 (SD 3.9); after treatment=mean 4.7 (SD 3.5); control: baseline=7.64 (4.5); after treatment=6.6 (4.8); test used: paired t test (within groups); P=.008 (intervention) and P=.02 (control)Szczepańska-Gieracha et al [], 2021UnclearPolandParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: female 20/32 (63%); intervention=female 9/15 (60%); control=female 11/17 (65%); age (y): mean 68.9 (SD 6.3); intervention=mean 69.5 (SD 7.5); control=mean 68.4 (SD 5.0); other: participants with coronary artery diseaseDepressive symptoms measured using the HADS34 (randomized; intervention: initial=17, at conclusion=15; control: 17)Cardiac rehabilitation (1.5 h): cardiological training individually prescribed based on an exertion test and heart rate reserve+Virtual Therapeutic Garden (20 min of intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Cardiac rehabilitation (1.5 h): cardiological training individually prescribed based on an exertion test and heart rate reserve+Schultz autogenic training (20 min) delivered by a therapist and CD recordingIntervention: baseline=mean 9.00 (SD 2.39); after treatment=mean 6.93 (SD 3.01); Cohen d=0.89; P=.003; control: baseline=mean 9.24 (SD 2.41); after treatment=mean 9.35 (SD 2.50); Cohen d=−0.15; test used: paired t test (within groups); P=.003 (intervention) and P=.54 (control)Szczepańska-Gieracha et al [], 20212019PolandParallel group 2-arm randomized controlled trial+masked outcome assessor+3time point measures (1 before and 2 after the intervention)Sex: female 23/23 (100%); age (y): mean 70.7 (SD 13.7); intervention=mean 70.2 (SD 4.9); control=mean 71.2 (SD 4.4); other: female older adult with severe depression (GDS-30 score>10) and nonrespondent to treatment programOlder adult depression measured using the GDS-3025 (randomized; intervention: initial=13, at conclusion=11; control: 12)Support group meetings: general fitness training (40 min) and relaxation exercises, as well as health-promoting education and psychoeducation (20 min)+Virtual Therapeutic Garden (intense visual, auditory, and kinesthetic stimuli through immersion in a garden with the therapist’s voice guiding the patient)Support group meetings: general fitness training (40 min) and relaxation exercises, as well as health-promoting education and psychoeducation (20 min)Intervention: baseline=mean 12.27 (SD 4.45); group 1 after treatment=mean 8.27 (SD 3.60); group 2 after treatment=mean 7.27 (SD 2.57); control: baseline=mean 12.25 (4.53); group 1 after treatment=mean 12.75 (4.82); group 2 after treatment=mean 11.83 (2.62); test used: repeated measures ANOVA (within groups); P<.001 (intervention) and P=.61 (control); test used: repeated measures ANOVA (for time and groups); P<.001Vlake et al [], 20222020-2021NetherlandsParallel group 2-arm randomized controlled trial, open label+3 time point measures (1 before and 2 after the intervention)Sex: intervention=female 10/45 (22%); control=female 16/44 (64%); age (y): intervention=median 61 (IQR 54-65); control=median 59 (IQR 51-65); other: participants included survivors of COVID-19 infection who had been discharged from the ICUeDepressive symptoms measured using the HADS89 (randomized; intervention: initial=45; 1-month assessment=45 and 3-month assessment=39; control: initial=44; 1-month assessment=44 and 3-month assessment=38)Intensivist consultation (60 min): revision of treatment, screening for postintensive care syndrome–related impairment, and referral to appropriate health provider+intensive care unit VR (14 min of an informational VR video aimed to immerse patients in the ICU environment and provide voice-over explanations regarding different facets of the ICU and ICU treatment, which consisted of 6 scenes covering topics such as ICU equipment, procedures, and COVID-19)Intensivist consultation (60 min): treatment revision, postintensive care syndrome–related impairment screening, and referral to the appropriate health providerIntervention: baseline=18%; 1 month after treatment=24%; 3 months after treatment=23%; control: baseline=33%; 1 month after treatment=41%; 3 months after treatment=29%; test used=logistic regression (for time points); P=.57 (baseline vs first time point 1 month after the treatment) and P=.51 (baseline vs second time point 3 months after the treatment)Zhang et al [], 20222021ChinaParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 38/38 (100%); control=female 39/39 (100%); age (y): intervention=mean 52.3 (SD 7.7); control=mean 51.0 (SD 7.9); other: participants with a history of breast cancer and 2 courses of chemotherapy completedDepressive symptoms measured using the Self-Rating Depression Scale90 (randomized; intervention: initial=45, at conclusion=38; control: initial=45, at conclusion=39)Care as usual+VR-CALMf intervention (30 min): immersion in calming and beautiful virtual environments (such as the seaside or Butterfly Valley) while receiving CALM therapy delivered by a trained therapistCare as usualIntervention: baseline=mean 51.320 (SD 11.552); after treatment=mean 46.630 (SD 9.824); control: baseline=mean 48.640 (SD 4.934); after treatment=mean 50.210 (SD 3.806); test used: paired t test (within groups); P≤.001 (intervention) and P=.14 (control)Zhang et al [], 20232021-2022ChinaParallel group 2-arm randomized controlled trial+2 time point measures (before and after the intervention)Sex: intervention=female 17/30 (57%); control=female 16/30 (53%); age (y): intervention: mean 33.5 (SD 11.1); control: mean 35.3 (SD 10.6); other: participants with leukemia undergoing chemotherapyDepressive symptoms measured using the Center for Epidemiological Studies Depression Scale63 (randomized; intervention: initial=32, at conclusion=30; control: initial=31, at conclusion=30)Usual care: addressing patients’ physiological needs and routine psychological care+VR meditation (20 min of 360-degree videos composed of images of landscapes [beach or forest], background music, and meditation guidance)Usual care: addressing patients’ physiological needs and routine psychological careIntervention: baseline=mean 14.23 (SD 8.11); after treatment=mean 11.13 (SD 6.01); control: baseline=mean 14.03 (SD 7.68); after treatment=mean 14.10 (SD 7.18); test used: paired t test (within groups); P<.001 (intervention) and P=.93 (control); test used: independent 2-tailed t test (between groups); P=.19 (after treatment)

aVR: virtual reality.

bGDS-30: Geriatric Depression Scale-30.

cANCOVA: analysis of covariance.

dHADS: Hospital Anxiety and Depression Scale.

eICU: intensive care unit.

fVR-CALM: Managing Cancer and Living Meaningfully based on VR.

Participant demographics showed that, of the 16 reports, 5 (31%) exclusively involved female participants [,,,,]; furthermore, 7 (44%) included participants whose mean or median age was >60 years [,-,,,], while only 2 (13%) included participants whose mean age was <45 years [,]. Comorbid conditions were noted as inclusion criteria in 15 (94%) of the 16 studies. Among these 15 studies, cancer [,,], heart disease [,,], and COVID-19 infection [,,] were reported in 3 (20%) studies each. Other conditions such as chronic obstructive pulmonary disease [], social isolation [], stroke [], and spinal cord injury [] were also mentioned.

Of the 16 reviewed reports, 14 (88%) assessed depressive symptoms [-,-,-]. The most widely used instrument was the Hospital Anxiety and Depression Scale (8/16, 50%) [-,-,]. Other questionnaires used to measure depressive conditions included the Beck Depression Inventory [], the Patient Health Questionnaire-8 [], the Patient Health Questionnaire-9 [], the Center for Epidemiological Studies Depression Scale [], the Depression Anxiety Stress Scale-21 [], and the Self-Rating Depression Scale []. In addition to depressive symptoms, older adult depression was explicitly evaluated in 3 (19%) of the studies [,,], using the Geriatric Depression Scale-30.

Regarding the effects of IMTs on depression, only 1 (6%) of the 16 studies reported no improvement in depression scales []. Among the 15 studies that demonstrated a positive effect, 11 (73%) reported statistically significant results [-,,-,,]; 1 (7%) reported nonsignificant results []; 2 (13%) reported mixed results [,], indicating variability in statistical significance across different measures or outcomes; and 1 (7%) did not perform any statistical analysis [].

Technical Aspects of IMT Interventions

The reports included in this review all feature VR interventions, showcasing a broad spectrum of technical characteristics (). The VR interventions varied, with a majority of the studies (9/16, 56%) implementing the Virtual Therapeutic Garden intervention [,,-,-] and 13% (2/16) conducting VR exposure sessions using content from the National Geographic app and the YouTube VR app [,]. Unique interventions included COVID Feel Good [], ICU-VR [], VR-CALM [], general VR therapy [], and individually tailored VR meditation programs.

Table 2. Technical characteristics of the immersive technology interventions.ReportsVRa interventionDevice characteristicsAmount of time used and frequency of useIntervention durationSetting of useUsability assessmentVR design framework usedDegree of guidanceCieślik et al [], 2023Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device (VR HTC Vive goggles+HTC Vive controllers)20 min/session, twice a wk4 wkUnclearNot mentionedNot mentionedSelf-administered therapyCzech et al [], 2022Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device15 min/session, daily2 wk (8 sessions)Hospital (it is not clear whether participants were ambulatory or inpatients)Not mentionedNot mentionedUnclearFarahimanesh et al [], 2023COVID Feel GoodType: unclear; the study mentions that a head-mounted display or cardboard headset could be used, but there is no information about the VR device type used; specific type: unclear20 min/session, daily7 daysUnclearNot mentionedNot mentionedUnclearJóźwik et al [], 2021Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne deviceUnclear time per session and frequencyUnclearHospital (it is not clear whether participants were ambulatory or inpatients)Not mentionedNot mentionedUnclearJóźwik et al [], 2021Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device (HTC Vive PRO VR goggles+unspecified controllers)20 min/session, 3 times a wk3 wk (8 sessions)Hospital (ambulatory)Not mentionedNot mentionedUnclearKiper et al [], 2022Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device (HTC Vive PRO VR goggles+unspecified controllers)20 min/session; frequency unclear3 wk (10 sessions)Hospital (inpatient)Not mentionedMethodology of VR clinical trials in health care by an international working groupUnclearLakhani et al [], 2020VR session of environment exposure using the National Geographic App and the YouTube VR appType: headset; specific type: Oculus Go20 min/session, daily1 wk (3 sessions)Hospital (ambulatory)Not mentionedNot mentionedUnclearPaul et al [], 2022VR session of environment exposure using YouTube VR videosType: headset; specific type: LimbixTime per session and frequency unclear3 wkHome basedNot mentionedNot mentionedSelf-administered therapyRodrigues et al [], 2022VR therapy (360-degree videos with images of landscapes and mindfulness techniques)Type: smartphone VR headset; specific type: Oculos Realidade Virtual 3D Gamer Warrior JS080 (adaptable with smartphone)10 min/session, once1 sessionHospital (inpatient)Not mentionedNot mentionedPredominantly self-helpRutkowski et al [], 2021Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device20 min/session, 5 times a wk2 wkHospital (it is not clear whether participants were ambulatory or inpatients)Not mentionedNot mentionedUnclearRutkowski et al [], 2022Virtual Therapeutic GardenType: headset; specific type: VR TierOne device (VR goggles+controllers)Unclear time per session, 5 times a wk3 wkHospital (inpatient)Not mentionedNot mentionedUnclearSzczepańska-Gieracha et al [], 2021Virtual Therapeutic GardenType: headset; specific type: VR TierOne device (HTC Vive PRO VR goggles+unspecified controllers)20 min/session, twice a wk4 wk (8 sessions)Hospital (inpatient)Not mentionedMethodology of VR clinical trials in health care by an international working groupPredominantly self-helpSzczepańska-Gieracha et al [], 2021Virtual Therapeutic GardenType: headset+controllers; specific type: VR TierOne device20 min/session, twice a wk4 wkUnclearNot mentionedMethodology of VR clinical trials in health care by an international working groupUnclearVlake et al [], 2022ICU-VRType: headset+headphones; specific type: Oculus Go+unspecified headphones14 min/session, once1 sessionHospital (ambulatory)Not mentionedNot mentionedPredominantly self-helpZhang et al [], 2022VR-CALMType: headset+controllers; specific type: unclear30 min/session; frequency unclear3 mo (6 sessions)Hospital (inpatient)Not mentionedNot mentionedMinimal-contact therapyZhang et al [], 2023Tailored VR meditationType: headset; specific type: PRO 6 DOF (Beijing Iqiyi Intelligent Technology)20 min/session, daily14 dHospital (inpatient)Not mentionedNot mentionedPredominantly self-help

aVR: virtual reality.

The immersion devices predominantly used were stand-alone VR headsets (14/16, 88%) [,,-,-]. Of the remaining 2 studies, 1 (50%) used VR headset adapters for smartphones [], whereas 1 (50%) did not specify the type of device used []. The types of specific VR devices varied, with the VR TierOne device (9/16, 56%) [,,-,-] and Oculus Go (2/16, 13%) being the most commonly reported [,].

The duration of VR interventions ranged from a single session to daily sessions over up to 8 weeks. However, most of the interventions (10/16, 63%) were administered over a period of 1 day [,] to 3 months [], with 3 weeks (4/16, 25%) being the most common intervention period [,,,]. The frequency of sessions varied, with daily sessions reported in 4 (25%) of the 16 reports [,,,] and less frequent sessions noted in the others (12/16, 75%). The majority of the interventions (9/16, 56%) were to be used for 20 minutes per session [,,-,,,,]; 3 (19%) of the 16 reports did not specify the session length [,,].

The settings for the interventions were predominantly hospital based (11/16, 69%), with a mix of inpatient, ambulatory, or unclear settings. Only 2 (13%) of the 16 reports specified the intervention as self-administered therapy, with the remaining studies (14/16, 88%) not clearly reporting the degree of guidance provided. None of the reports mentioned usability evaluation as part of their methods or results.

Regarding the VR design framework, only 2 (13%) of the 16 reports mentioned using the methodology of VR clinical trials in health care by an international working group. The rest of the reports (14/16, 88%) did not mention any design framework used.

Therapeutic Approaches

The analysis of therapeutic approaches used in the IMT interventions reveals a varied landscape of techniques (). Ericksonian psychotherapy was used in 9 (56%) of the 16 reports, indicating its recognized role in VR-based interventions. Mindfulness-based cognitive therapy was the second leading therapeutic approach featured, used in 13% (2/16) of the reports, while cognitive behavioral therapy and behavioral activation were mentioned in only 6% (1/16) of the reports each. Other therapeutic methods included personal psychotherapy based on Managing Cancer and Living Meaningfully (1/16, 6%) [] and the Roy Adaptation Model (1/16, 6%) [].

Table 3. Therapeutic approaches used in the immersive technology interventions.ReportsEricksonian psychotherapyMindfulness-based cognitive therapyCognitive behavioral therapyBehavioral activationOthersCieślik et al [], 2023✓    Czech et al [], 2022✓    Farahimanesh et al [], 2023  ✓  Jóźwik et al [], 2021✓    Jóźwik et al [], 2021✓    Kiper et al [], 2022✓    Lakhani et al [], 2020     Paul et al [], 2022   ✓ Rodrigues et al [], 2022 ✓a   Rutkowski et al [], 2021✓    Rutkowski et al [], 2022✓    Szczepańska-Gieracha et al [], 2021✓    Szczepańska-Gieracha et al [], 2021✓✓   Vlake et al [], 2022     Zhang et al [], 2022    ✓Zhang et al [], 2023    ✓

aIt is unclear whether all patients in the virtual reality group received a mindfulness-based intervention or just 360-degree videos.

Implementation Characteristics

Regarding the stages of implementation, 2 (13%) of the 16 articles were at a preliminary stage (pilot or feasibility study). By contrast, 6 (38%) of the 16 studies had progressed to the implementation stage (referring to prior feasibility results); the remaining articles (8/16, 50%) did not clearly delineate their implementation phase. No article reported an implementation framework used, nor were barriers or enablers of implementation identified.

Most of the reports (15/16, 94%) declared no conflicts of interest; an exception was found in 1 (6%) of the 16 articles, where a potential conflict was disclosed due to an author’s corporate affiliation, emphasizing the importance of transparency in research affiliations and possible biases. Funding sources varied, with half of the studies (8/16, 50%) reporting no external funding, suggesting that a significant portion of research in this area is conducted independently of external financial support. Notably, individual studies were supported by grants from prominent institutions such as the National Science Foundation of China as well as national research grants, demonstrating the global investment in health VR intervention research. All included reports reported ethical oversight, ranging from institutional review boards to national ethics committees.

DiscussionPrincipal Findings

Our scoping review, conducted in accordance with the framework formulated by Arksey and O’Malley [], identified a total of 16 peer-reviewed articles focusing on the use of IMTs in treating depression. In comparison, other reviews using similar methodologies and research questions have reported varying numbers of studies; for instance, Fodor et al [] found 24 studies examining the effects of VR interventions on depressive outcomes, whereas Zeng et