Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): a meta-analysis

Figures & data

Figure 1. PRISMA flowchart of screening, exclusion, and inclusion criteria.

Table 1. Characteristics of the nine studies included in the meta-analysis.

				VR treatment			Control group
Study	Country	Sample	Psychiatric history/Medication (N)	n	Age M (SD)	% male	n	Age M (SD)	% male	VR environment	Sessions	Control condition
Difede et al. (2007)	US	Firefighters, disaster relief workers, civilians with trauma related to September 11 attacks with PTSD according to DSM-IV-TR	5 (4 prolonged exposure without meaningful improvement; 1 “treated elsewhere”/2 (stable mediation)	10	40.92 (9.90)	92	8	45.13 (7.14)	88	Simulation of September 11 attacks	Max. 14 (M = 7.5. SD = 3.6)	Waitlist
Gamito et al. (2010)	Portugal	Portuguese colonial war veterans with PTSD according to DSM-IV	n. r./stable medication	4	whole sample: age (M = 63.5, SD = 4.43)	100	3	n. r.	100	Simulation of unspecified wartime environments (dense vegetation)	12	Waitlist
Ready et al. (2010)	US	Vietnam war veterans with CAPS > 60	all were in Veterans Affairs treatment > 3 months/stable medication	5	57 (3.02)	100	4	58 (3.05)	100	Simulation of Vietnam wartime environments	10	Present-centred therapy
McLay et al. (2011)	US	Active duty military personnel with past Iraq or Afghanistan deployment with PTSD (according to Mini-International Neuropsychiatric Interview and CAPS > 40)	n. r./n. r.	10	28 (Range: 22–43)	90	10	28.8 (Range: 21–45)	100	Simulation of Iraq and Afghanistan wartime environments	M = 8.8	Treatment as usual in Veterans Affairs Facilities
Miyahira et al. (2012)	US	Active duty military personnel with past Iraq or Afghanistan deployment with PTSD symptoms	n. r./n. r.	10	n. r.	95 (before dropouts)	10	n. r.	95 (before dropouts)	Simulation of unspecified wartime environments	10	Minimal attention (only telephone contacts every 2 weeks)*
Roy et al. (2014)	US	Active duty military personnel/veterans with Iraq or Afghanistan deployment with CAPS > 40	n. r./n. r.	9	34.5 (n. r.)	88	10	34.1 (n. r.)	100	Simulation of Iraq and Afghanistan wartime environments	12	Imaginal exposure
Cárdenas-López et al. (2015)	Mexico	Civilians with crime-related trauma experience with CAPS > 40	n. r./none	10	28.1 (14.9)	50	10	39.8 (15.96)	30	Simulation of unsafe locations in Ciudad Juarez (Mexico)	10	Imaginal exposure
Reger et al. (2016)^†	US	Active duty military personnel with past Iraq or Afghanistan deployment with PTSD according to DSM-IV-TR	53/stable medication	30	29.52 (6.47)	96	32	30.89 (7.90)	94	Simulation of Iraq and Afghanistan wartime environments	10	Imaginal exposure
							47	30.39 (7.09)	98			Waitlist
McLay et al. (2017)	US	Active duty military personnel with past Iraq or Afghanistan deployment with PTSD according to DSM-IV and CAPS > 40	n. r./n. r.	36	33 (8.33)	93	38	32 (7.71)	100	Simulation of Iraq and Afghanistan wartime environments	M = 10.28	Control exposure, with stimuli being presented as computer images

Reported sample sizes are completer samples. n. r. = not reported. CAPS = Clinician-Administered PTSD Scale. *treated as waitlist control condition in our analysis ^†participants were allocated to two control groups (imaginal exposure or waitlist).

Figure 2. Forest plot of the standardized mean difference (Hedges’ g) in post-treatment CAPS scores of VR treatments compared to control conditions (waitlist and active control). A positive effect size indicates that the outcome was in favour of VR treatment. Average effect was calculated using a random-effects model.

Figure 3. Forest plot of the standardized mean difference (Hedges’ g) in post-treatment depression scores of VR treatments compared to control conditions (waitlist and active control). A positive effect size indicates that the outcome was in favour of VR treatment. Average effect was calculated using a random-effects model.

*Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., … Hoffman, H. G. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 68(11), 1639–1647.

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*Gamito, P., Oliveira, J., Rosa, P., Morais, D., Duarte, N., Oliveira, S., & Saraiva, T. (2010). PTSD elderly war veterans: A clinical controlled pilot study. Cyberpsychology, Behavior, and Social Networking, 13(1), 43–48.

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*Ready, D. J., Gerardi, R. J., Backscheider, A. G., Mascaro, N., & Rothbaum, B. O. (2010). Comparing virtual reality exposure therapy to present-centered therapy with 11 U.S. Vietnam Veterans with PTSD. Cyberpsychology, Behavior, and Social Networking, 13, 49–54.

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*McLay, R. N., Wood, D. P., Webb-Murphy, J. A., Spira, J. L., Wiederhold, M. D., Pyne, J. M., & Wiederhold, B. K. (2011). A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder. Cyberpsychology, Behavior, and Social Networking, 14, 223–229.

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*Miyahira, S. D., Folen, R. A., Hoffman, H. G., Garcia-Palacios, A., Spira, J. L., & Kawasaki, M. (2012). The effectiveness of VR exposure therapy for PTSD in returning warfighters. Studies in Health Technology and Informatics, 181, 128–132.

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*Roy, M. J., Costanzo, M. E., Blair, J. R., & Rizzo, A. A. (2014). Compelling evidence that exposure therapy for PTSD normalizes brain function. Studies in Health Technology and Informatics, 199, 61–65.

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*Cárdenas-López, G., de la Rosa-Gómez, A., Durán-Baca, X., & Bouchard, S. (2015). Virtual reality PTSD treatment program for civil victims of criminal violence. In P. Cipresso & S. Seriono (Eds.), Virtual reality: Technologies, medical applications and challenges (pp. 269–289). New York, NY: Nova Science.

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*Reger, G. M., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K. M., Kevin, M., … Gahm, G. A. (2016). Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deployment-related posttraumatic stress disorder (PTSD). Journal of Consulting and Clinical Psychology, 84, 946–959.

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*McLay, R. N., Baird, A., Webb-Murphy, J., Deal, W., Tran, L., Anson, H., … Johnston, S. (2017). A randomized, head-to-head study of virtual reality exposure therapy for posttraumatic stress disorder. Cyberpsychology, Behavior, and Social Networking, 20, 218–224.

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