Psychiatry · Medical Literature
Assessing the effects of virtual reality-based positive psychotherapy on emotion, life satisfaction, and suicidal ideation in major depression: A mixed-methods randomized controlled trial.
Abstract
Positive psychotherapy (PPT) targets the enhancement of well‑being in individuals with major depressive disorder (MDD), and virtual reality (VR) offers an immersive medium for delivering such experiential interventions. However, most VR-based approaches for depression are grounded in cognitive‑behavioral frameworks, leaving the application of PPT within VR environments largely unexplored. This study examined the effects of VR-based PPT on emotional experiences, life satisfaction, and suicidal ideation in individuals with MDD. In this sequential explanatory mixed‑methods study, 78 patients were randomly assigned to VR-based positive psychotherapy (intervention; n = 39) or an equivalent face-to-face format (control; n = 39). Both groups received three sessions of positive psychotherapy, differing only in delivery mode. The quantitative phase assessed changes in affect, life satisfaction, and suicidal cognitions before and after each session using the PANAS, SWLS, and B-SCS. A subsequent qualitative analysis of the intervention group was conducted to contextualize and further interpret the quantitative findings. The results demonstrated a significant multivariate effect over time (Wilks' Lambda = 0.316, F(20,57) = 6.176, ɳ² = 0.684, P < 0.001), indicating significant improvements in the outcome measures across sessions. Within‑group effect sizes ranged from small to moderate (d = 0.02-0.53), with comparable improvements observed in both the VR-supported and face-to-face formats. Qualitative findings further enriched the interpretation of these patterns, yielding two overarching themes: "user-friendly program" and "efficient psychotherapy program." Both VR-based and face-to-face positive psychotherapy were associated with improvements in emotional experiences, life satisfaction, and suicidal ideation in individuals with major depressive disorder. VR-based delivery appeared feasible and acceptable, with outcomes comparable to the traditional face-to-face format in this preliminary trial. Further studies with larger samples and longer follow-up are needed to confirm these findings and clarify their clinical implications. Trial registration: This trial was prospectively registered in the Iranian Registry of Clinical Trials (IRCT20201001048893N7, registration date: 16 November 2022, URL: https://irct.behdasht.gov.ir/trial/66424) prior to the enrollment of the first participant.
Clinical relevance
Major depressive disorder (MDD) remains a leading cause of global disability, and positive psychotherapy (PPT) — which targets well-being enhancement rather than symptom reduction alone — represents an underutilized therapeutic framework. This trial addresses a critical evidence gap by examining whether immersive virtual reality (VR) can serve as a viable delivery platform for PPT, potentially expanding access and engagement for patients with MDD. Given the growing interest in digital and remote mental health interventions, clinicians need preliminary efficacy and feasibility data to inform adoption decisions.
Key findings
1. A significant multivariate effect over time was demonstrated across all outcome measures (Wilks' Lambda = 0.316, F(20,57) = 6.176, partial η² = 0.684, P < 0.001), indicating that both delivery formats were associated with meaningful improvements across sessions. 2. Within-group effect sizes ranged from small to moderate (Cohen's d = 0.02–0.53) across measures of affect (PANAS), life satisfaction (SWLS), and suicidal cognitions (B-SCS), with no statistically significant between-group differences reported, suggesting outcome equivalence between VR-based and face-to-face PPT. 3. Both the intervention (VR-based PPT; n = 39) and control (face-to-face PPT; n = 39) groups received an identical three-session PPT protocol, differing exclusively in delivery modality, providing a well-controlled comparison of format rather than content. 4. Suicidal ideation, as measured by the Beck Suicidal Cognition Scale (B-SCS), showed improvement in both groups, representing a clinically significant finding in a population at elevated suicide risk. 5. Qualitative analysis of the VR intervention group yielded two overarching themes — 'user-friendly program' and 'efficient psychotherapy program' — supporting the feasibility and acceptability of VR as a therapeutic medium for MDD. 6. The study employed a sequential explanatory mixed-methods design, with the qualitative phase contextualizing quantitative results; however, the sample size (N = 78) and absence of long-term follow-up data limit generalizability and durability conclusions.
Practice implications
Clinicians treating adults with MDD may consider VR-based positive psychotherapy as a feasible and acceptable alternative to traditional face-to-face delivery, particularly for patients with barriers to in-person care such as mobility limitations, stigma, or geographic constraints, given comparable short-term outcomes in affect, life satisfaction, and suicidal cognitions. The three-session PPT protocol — focused on well-being enhancement rather than deficit correction — may serve as a useful adjunct to standard pharmacological and cognitive-behavioral treatments, especially in patients with residual anhedonia or low life satisfaction. However, given the preliminary nature of this trial (small sample, no long-term follow-up, single-center design, and registration in the Iranian Clinical Trials Registry), adoption should be cautious and ideally situated within larger confirmatory trials before routine clinical implementation.