Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent in-vivo exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants (n = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of in-vivo exposures since last assessment. Number of in-vivo exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent in-vivo exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit in-virtuo to in-vivotransitioning components.

Background: The life transition between late adolescence and emerg- ing adulthood is often troubled, with one in three university students showing symptoms of depression and anxiety. Help-seeking behavior is low due to emotional and practical barriers, generating a treatment gap. The purpose of this project is to map Swedish university stu- dents’ mental health problems and deliver e-health interventions to those at risk, thus reducing the treatment gap. The project is the first in a Swedish partnership with the WHO WMH-ICS 20-country international consortium.

Methods: The project is organized in four work packages (WPs) over four years, beginning in 2020. An annual epidemiological survey targeting first-year students will map mental health problems and disor- ders, including suicidal thoughts and behaviors (WP1), and annual follow-up surveys will track participants’ developmental trajectories in terms of persisting problems and help-seeking behavior (WP2). Students identified as at-risk will be offered participation in a three-arm random- ized controlled trial (RCT), delivering guided or unguided transdiagnostic e-treatment, or treatment as usual in a control group (WP3). At 5-week follow-up, participants at higher risk of failing treatment according to a precision treatment algorithm will be randomized to personally adapted e- treatment or continued WP3 treatment in a secondary trial-within-trial (WP4). WP1 will begin in the spring of 2020 with a pilot survey at selected Swedish universities

Results: We anticipate being able to present preliminary pilot survey results.Conclusions and implications: We envisage high potential for reducing mental health problems among Swedish university students, improving academic performance and reducing dropout.

Introduction: Online gambling, popular among both problem and recreational gamblers, simultaneously entails both heightened addiction risks as well as unique opportunities for prevention and intervention. There is a need to bridge the growing literature on learning and extinction mechanisms of gambling behavior, with account tracking studies using real-life gambling data. In this study, we describe the development and validation of the Frescati Online Research Casino (FORC): a simulated online casino where games, visual themes, outcome sizes, probabilities, and other variables of interest can be experimentally manipulated to conduct behavioral analytic studies and evaluate the efficacy of responsible gambling tools.

Methods: FORC features an initial survey for self-reporting of gambling and gambling problems, along with several games resembling regular real-life casino games, designed to allow Pavlovian and instrumental learning. FORC was developed with maximum flexibility in mind, allowing detailed experiment specification by setting parameters using an online interface, including the display of messages. To allow convenient and rapid data collection from diverse samples, FORC is independently hosted yet integrated with the popular crowdsourcing platform Amazon Mechanical Turk through a reimbursement key mechanism. To validate the survey data quality and game mechanics of FORC, n = 101 participants were recruited, who answered an questionnaire on gambling habits and problems, then played both slot machine and card-draw type games. Questionnaire and trial-by-trial behavioral data were analyzed using standard psychometric tests, and outcome distribution modeling.

Results: The expected associations among variables in the introductory questionnaire were found along with good psychometric properties, suggestive of good quality data. Only 6% of participants provided seemingly poor behavioral data. Game mechanics worked as intended: gambling outcomes showed the expected pattern of random sampling with replacement and were normally distributed around the set percentages, while balances developed according to the set return to player rate.

Conclusions: FORC appears to be a valid paradigm for simulating online gambling and for collecting survey and behavioral data, offering a valuable compromise between stringent experimental paradigms with lower external validity, and real-world gambling account tracking data with lower internal validity.

Virtual Reality (VR) can be used as a therapeutic tool to conduct efficacious in-session exposure therapy by presenting virtual equivalents of phobic stimuli, yet past hardware restrictions hindered implementation in routine care and effectiveness studies. The current study examines the effectiveness of a VR-assisted treatment protocol for public speaking anxiety with demonstrated efficacy, this time in routine care, using affordable VR hardware. Participants (n = 23) were recruited via a private clinic and treated by one of four psychologists with only minimal VR-training. Using a single-subject design and dual-slope modeling (adjusting the treatment-onset slope for treatment effects), we found a significant, large decrease in self-rated public speaking anxiety following the primary three-hour session, similar in magnitude to the previous efficacy trial. Multilevel modeling of in-session process measures suggests that the protocol works as intended, by decreasing catastrophic belief expectancy and distress, and increasing perceived performance quality. Adherence to the online transition program that followed-encouraging in-vivo exposure-was relatively poor, yet symptoms decrease continued. No change was observed over the three-month follow-up period. We conclude that VR exposure therapy can be effective under routine care conditions and is an attractive approach for future, large-scale implementation and effectiveness trials.

Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention.

Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods.

Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis.

Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal.

Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences.

Background: Virtual Reality exposure therapy (VRET) is an evidence-based treatment of phobias and recent research suggests that this applies also to self-contained, automated interventions requiring no therapist guidance. With the advent and growing adoption of consumer VR technology, automated VR intervention have the potential to close the considerable treatment gap for specific phobias through dissemination as consumer applications, self-help at clinics, or as blended treatment. There is however a lack of translational effectiveness studies on VRET treatment effects under real-world conditions.

Methods: We conducted a single-arm (n = 25), single-subject study of automated, gamified VRET for fear of spiders, under simulated real-world conditions. After setup and reading instructions, participants completed the automated, single-session treatment by themselves. Self-rated fear of spiders and quality of life served as outcome measures, measured twice before, and one and two weeks after treatment, and at a six-month follow-up. Session characteristics and user experience measures were collected at the end of the session.

Results: Mixed-effects modeling revealed a significant and large (d = 1.26) effect of treatment-onset on phobia symptoms (p < .001), and a small (d = 0.49) effect on quality of life (p = .025). Results were maintained at a six-month follow-up (p > .053). The intervention was tolerable and practical. There were no significant correlations between any user experience measure and decrease in phobia symptoms (p > .209).

Conclusions: An automated VRET intervention for fear of spiders showed equivalent effects on phobia symptoms under effectiveness conditions as previously reported under efficacy conditions. These results suggest that automated VRET applications are promising self-help treatments also when provided under real-world conditions.

Instruments that investigate different aspects of gambling activities are needed to distinguish negative consequences. Because gambling is a complex activity that occurs both offline and online, different questionnaires are necessary for screening and risk classification. GamTest, an instrument used by several gambling companies, was designed to cover different aspects of gambling: money and time spent, as well as social, financial, and emotional consequences. This study explores GamTest’s psychometric properties in a general population. A total of 2,234 Swedish respondents completed an online survey containing demographic questions, the questionnaire (GamTest), and the Problem Gambling Severity Index (PGSI). A confirmatory factor analysis was performed and GamTest’s reliability and validity tested. The confirmatory factor analysis yielded an inclusive fit. The internal consistency (omega) for the five factors was high (.79–.91), indicating good reliability, and a high positive correlation with the PGSI supported the validity of the GamTest. The inclusive fit of the confirmatory factor analysis can be explained by the low endorsement of negative consequences of gambling in the sample. However, GamTest seems to have good reliability and validity. The utility of GamTest is discussed in relation to its psychometric properties and its use in the responsible gambling tool Playscan.

Pour être en mesure d’évaluer les conséquences négatives du jeu, il nous faut des instruments qui étudient différents aspects de ces activités. Comme le jeu est une activité complexe qui se déroule à la fois hors ligne et en ligne, différents questionnaires sont nécessaires à des fins de dépistage et de classification des risques. Le GamTest est un instrument utilisé par plusieurs entreprises de jeux d’argent. Il a été concu pour couvrir différents aspects du jeu: l’argent dépensé et le temps passé, ainsi que les conséquences sociales, financières et émotionnelles. Cette étude explore les propriétés psychométriques du GamTest dans une population en général. Au total, 2234 Suédois ont répondu à un sondage en ligne contenant des questions démographiques, le questionnaire (GamTest) et l’indice de gravité du jeu problématique. Une analyse factorielle de confirmation a été effectuée. La fiabilité et la validité du GamTest ont également été testées. L’analyse factorielle de confirmation a donné un ajustement inclusif. La cohérence interne (Omega) pour les cinq facteurs était élevée (0,79 à 0,91) indiquant une bonne fiabilité. Une corrélation positive élevée avec l’IGPJ a confirmé la validité du GamTest. L’ajustement inclusif de l’analyse factorielle peut s’expliquer par le faible endossement des conséquences négatives du jeu dans l’échantillon. Cependant, le GamTest semble être fiable et valide. L’utilité du Gamtest est abordée sous l’angle de ses propriétés psychométriques et de son utilisation dans l’outil de jeu responsable Plyscan.

Background: The aim of this study was to investigate the effects of a web-based treatment program with therapist guidance for adults and adolescents with regular cannabis use from the general population.

Methods: A double blinded randomized controlled trial with a parallel group design was conducted (intervention group n = 151, wait-list control group n = 152). Follow-up 12 weeks from treatment commencement of a 13-module intervention. The primary outcome was frequency of cannabis use. Time by group interaction effects were modeled using generalized estimated equations and the instrumental variable approach was used to estimate the effect of intervention adherence.

Results: At follow-up, the intention to treat (ITT) analyses did not show any significant time by group effects. A significant association between intervention adherence and scores on the cannabis abuse screening test (CAST) was found. Secondary analysis excluding participants who had received other professional help revealed time by group effects for secondary outcomes gram cannabis consumed past week, number of dependency criteria and CAST score. Due to methodological limitations, these latter results should be interpreted with caution.

Conclusions: In this study we did not find a web-based treatment program with therapist guidance to be more effective than a waiting-list in reducing frequency of cannabis use.

Trial registration: The trial was pre-registered at ClinicalTrials.gov (NCT02408640) April 3, 2015

Background: Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost.

Method: We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being.

Discussion: This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care.

Trial registration: Clinical trials.gov, NCT ID: NCT03946098. Registered 10 May 2019

Background: Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome.

Objective: In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format—the Virtual Therapist Alliance Scale (VTAS)—by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome.

Methods: A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures.

Results: The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up.

Conclusions: These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment.