Archives of Psychiatric Nursing 29 (2015) 613

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Research Paper

Efcacy of the Virtual Reality-Based Stress Management Program

on Stress-Related Variables in People With Mood Disorders: The
Feasibility Study
Lubna Bte Iskhandar Shah a, Samantha Torres b, Premarani Kannusamy c, Cecilia Mui Lee Chng d,
Hong-Gu He e, Piyanee Klainin-Yobas e,
a

Institute of Mental Health, Singapore, Buangkok Green Medical Park, 10 Buangkok View, Singapore
Faculty of Health and Social Care, Dearne Building, University Of Hull, UK
c
Assisi Hospice, Singapore
d
Advanced Practice Nurses, Department of Psychological Medicine, National University Hospital, Singapore
e
Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research Centre Block MD11, Singapore
b

a b s t r a c t
This study aimed to investigate the effect of a VR-based stress management program on people with mood disorders. A quasi-experimental study was conducted in a tertiary hospital in Singapore, and a convenience sample
of 22 was recruited. The program comprised three daily 1-hour sessions incorporating psychoeducation and VRbased relaxation practice. Participants who completed the program had signicantly lowered subjective stress
(t = 6.91, p b 0.001), depression (t = 5.62, p b 0.001), and anxiety (t = 5.54, p b 0.001); and increased skin
temperature (F = 17.71, p b 0.001), perceived relaxation (F = 26.20, p b 0.001) and knowledge (F = 13.77,
p b 0.001). Participants' feedback on the program was positive. Findings from this study contribute to improving
clinical practice and serve as preliminary data to conduct more rigorous research in the future.
2014 Elsevier Inc. All rights reserved.

Across the world, stress has been cited as the second most frequent
health problem aficting individuals' health and well-being (World
Health Organization [WHO], 2005). Stress refers to individuals' physiological responses to any demand perceived to be threatening to the physical, emotional or psychological health (Varvogli & Darviri, 2011). At low
to moderate levels, stress can be benecial to the individuals. However, at
high and persistent levels, stress becomes unhealthy, causing more harm
than benet and can contribute to poor mental health (Wilson, 2009).
Several studies show that stress can trigger mental disorders, especially
mood disorders (Danese & Pariante, 2008). In Singapore, major depressive
disorder (MDD) and bipolar disorder (BD) are commonly found with a lifetime prevalence of 5.8% and 1.2%, respectively (Chong et al., 2012). Individuals with mood disorders often experience illness-related stress, which
further aggravates their mental health problems (Wilson, 2009). As a result,
the persons may encounter relationship breakdowns, occupational disruptions and even premature deaths through suicide (Walsh, 2011).
Stress management interventions, including psychoeducation and relaxation therapy, have been developed for people with mental disorders.
Evidently, psychoeducation was efcacious in mitigating stress-related
Corresponding Author: Piyanee Klainin-Yobas, PhD, RN, Assistant Professor, Alice Lee
Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research
Centre Block MD11, 10 Medical Drive, Singapore 117597.
E-mail addresses: lubna.ishah@gmail.com (L.B.I. Shah),
samanthatorres613@gmail.com (S. Torres), prema_k@assisihospice.org.sg
(P. Kannusamy), cecilia_ml_chng@nuhs.edu.sg (C.M.L. Chng), nurhhg@nus.edu.sg
(H.-G. He), nurpk@nus.edu.sg (P. Klainin-Yobas).
http://dx.doi.org/10.1016/j.apnu.2014.09.003
0883-9417/ 2014 Elsevier Inc. All rights reserved.

outcomes and enhancing patients' knowledge (Bernhard et al., 2006;

Colom et al., 2003; Gamito et al., 2010; Oaz, Hatipoglu, & Aydin,
2008; Pratt et al., 2005), and relaxation therapy helped reduce depression among participants (Chen et al., 2009; Jorm, Morgan, & Hetrick,
2009; Knubben et al., 2007; Watkins & Moberly, 2008). Furthermore,
the combination of psychoeducation and relaxation therapy appears
to reduce depression among people with dysthymic disorder (Little,
Kligler, Homel, Belisle, & Merrel, 2009). Additionally, virtual reality
(VR) technology has been increasingly used in the mental health domain in the past 10 years.
The VR is a set of technology (such as graphical displays with sound)
that contains a convincing interface to stimulate the immersion and/or
interaction between users and created environments (Brooks, 1999,
November/December). The users may feel like being there in the VR
environment after experiencing vivid visual images and accompanying
audio materials. For people with mood disorders, the VR device could be
used as an innovative tool to deliver psychoeducation. It may also serve
as a powerful visual imagery tool to induce relaxation and enhance positive emotions (Ku et al., 2007). However, there is limited empirical evidence to support the effects of VR on people with mood disorders,
suggesting enormous knowledge gaps in the literature.
The utilization of VR in stress management interventions is an
emerging science with promising benets. A randomized controlled
trial tested the effectiveness of the interreality (VR-based stress management program) on teachers and nursing professionals (Pallavicini
et al., 2013). In this study, participants showed signicantly lower

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

perceived stress in comparison to controls (Pallavicini et al., 2013). Another study tested the ESCAPE (VR stress management program) on
university students and public ofcers (Villani & Riva, 2012). Participants had signicantly lower heart rate than those in the control
group (Villani & Riva, 2012). Little is known about the effects of VR
stress management interventions on people with mental disorders.
The VR has been used as a tool to deliver exposure therapy,
psychoeducation, and relaxation therapy in people with anxiety
disorders. A quasi-experimental study tested the virtual realityincorporated psychoeducation intervention on ten participants with
posttraumatic stress disorder (PTSD) and found that the participants
in the experimental group had signicantly lower depression (Gamito
et al., 2010). Similarly, another quasi-experimental research reported
that the virtual-reality based psychoeducation helped reduce anxiety
and depression among 14 individuals with social anxiety disorder
(Yuen et al., 2013). Furthermore, a randomized controlled trial (RCT)
was conducted to compare the VR-guided combined psychoeducation
and relaxation therapy with cognitivebehavioral therapy (CBT) in 39
patients with anxiety disorders (Banos et al., 2011). Findings showed
that participants in the VR group had signicantly lowered depression
and greater relaxation intensity than controls. However, there were
no signicant differences in anxiety between these two groups.
THE CURRENT STUDY
Despite the encouraging ndings, it is not known if the VR technology is benecial for individuals with mood disorders. Furthermore,
there is a dearth of studies exploring the effects of stress management
interventions on stress-related variables in individuals with mood disorders, especially in Asian populations, reecting gaps in the literature.
Guided by existing empirical evidence, we developed the three-session
VR-based stress management (VR DE-STRESS) program for people with
mood disorders. This study then aimed to test the feasibility and initial

Environment
Internal
External
Created

Person
Physiological
Psychological
Sociocultural
Developmental
Spiritual

effects of the program in a hospital setting. Research questions were:

a) would the VR DE-STRESS Program mitigate objective stress, subjective stress, depression, and anxiety among people with mood disorder?
and b) would the program enhance participants' relaxation levels and
patient knowledge?
THEORETICAL FRAMEWORK
The Neuman System Model (Neuman & Fawcett, 2002) provided a
theoretical framework to guide this study. The model focuses on
stressors; and the interaction between people and their environment,
which is an integral aspect of mental wellbeing. The Neuman System
Model comprises four major domains; person, environment, health
and nursing (Fig. 1). In this study, person refers to individuals with
mood disorders, who constantly interact with environments to achieve
a state of health and wellbeing. Environment could be the source of
stressors for the person. In this study, stressors refer to undesirable
stimuli encountered by people with mood disorders (such as hospitalization and relationship breakdowns). Without proper management,
stressors may disrupt the person's equilibrium, contributing to poor
health or delayed recovery. Health in this study was represented by
levels of subjective and objective stress, depression, anxiety, perceived
relaxation and knowledge. Stress refers to the person's biophysiological and psychological changes in response to stressors from
the environments. Within the Neuman System model (Neuman &
Fawcett, 2002), nursing is a profession that assists persons to achieve
and/or resume their state of equilibrium. In this study, the VR DESTRESS Program represented a nursing tertiary prevention intervention,
which aimed to maintain optimal wellness by restoring balance to the
client through reconstitution. Reconstitution is the process whereby
the client utilizes resources to prevent further stress. Through the VR
DE-STRESS Program, people with mood disorder learned skills to manage with their stress.

Nursing
Tertiary prevention
intervention

Health
Health-related
variables

Subjective
Stress

Objective
Stress

Stressors

Persons with
Mood
Disorders

The VR DESTRESS
PROGRAM

Depression

Education
Relaxation
Anxiety

Perceived
Relaxation

Knowledge

Fig. 1. Research framework guided by the Neuman System Model (Neuman & Fawcett, 2002).

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

METHOD
Research Design and Sample
A single-group, pretestposttest, quasi-experimental research design and convenience sampling were used. This study was undertaken
at a mental health ward of a tertiary hospital in Singapore. Our target
population included inpatients diagnosed with MDD and BD (with depressive episode). Patients were invited to the study if they: a) aged between 21 to 65 years, b) were procient at understanding and
communicating in English, and c) were diagnosed with MDD or BD by
their attending psychiatrist. Patients were excluded if they: a) had
acute psychiatric symptoms (such as suicidal ideations, an episode of
psychosis, intellectual disability or cognitive impairment) diagnosed
by their psychiatrist, b) were pregnant, and c) had uncontrolled medical
conditions requiring hospitalization. These conditions were excluded
because they might confound research ndings.
Participant recruitment commenced following an approval from
hospital ethics committee and hospital administrators. One of the researchers (LS) liaised with clinical staff (such as advanced practice
nurses, registered nurses, and psychiatrist) to identify potential participants based on the inclusion/exclusion criteria. Then, the researcher
approached eligible patients, explained the purpose of the study, distributed the participation information sheet, and invited them to
partake in the study. Patients who agreed to participate were asked to
sign a consent form in the presence of clinical staff. Subsequently, the researcher scheduled the VR DE-STRESS Program at patients' convenience.
The VR DE-STRESS Program
The individual-based VR DE-STRESS Program was developed for individuals with mood disorders. The program had three daily 1-hour
sessions comprising two major components: psychoeducation and relaxation practice (via VR-based relaxation videos). The psychoeducation
covered information about stress, stress management, mood disorders,
positive thinking and relaxation techniques. Furthermore, participants
practiced three relaxation techniques: abdominal breathing, muscle relaxation and guided imagery using a beach scenario (Table 1). Content
of the psychoeducation as well as a step-by-step guide to the relaxation
exercises were consolidated in a participant education manual (PEM)
provided to the participant in the study. At the end of the program,
participants also received a relaxation audio CD for their optional
home practice.
At the beginning of each session, the researcher brought each participant to a private room within the ward. The psychoeducation component was delivered via face-to-face discussion. Then, the researcher
demonstrated how to carry out the relaxation exercise based on the instructions in the PEM. The participants practiced the technique with
guidance from the researcher. Subsequently, they practice relaxation
techniques while wearing the VR device and viewing instructional relaxation videos. When the relaxation component was completed, the
VR device was removed. Finally, the researcher provided a session summary of learned knowledge and skills. Time was allowed for discussion
and questions before the end of each session.
The intervention procedure was repeated for the following two sessions. The delivery of the VR DE-STRESS Program was standardized for

all participants to ensure the control of confounding variables such as

the environment, mode of measurements, facilitator style and treatment adherence. All participants were brought to the same room and
were requested to sit on the same cushioned chair provided. The
room was air-conditioned with room temperature maintained at 23
degree Celsius across all sessions. Standardized instruments and devices
were used to obtain measurements for all outcome variables across
participants.
The same facilitator (LS) carried out the intervention for all participants. The Intervention Checklist was used to ensure that the facilitator
strictly adhered to the intervention protocol. Additionally, the facilitator
received three training sessions by performing the intervention sessions
on three simulated patients (healthy volunteers) on 3 different days.
Two investigators specialized in mental health nursing (PKY and CC)
observed the simulated sessions and provided comments for improvement. After the three training sessions, the two observers agreed that
the facilitator was able to perform according to the treatment protocol.
The VR Equipment and Relaxation Videos
The VR device is a lightweight, head-mounted display (model ITGPCX3), suitable for one viewer (Fig. 1). The device was used to guide
the relaxation practice in the VR DE-STRESS Program. Using this device,
the participant viewed relaxation videos showcasing three relaxation
techniques; abdominal breathing, muscle relaxation and guided imagery. The relaxation videos contained visual presentations, soothing auditory instructions (with female voice in English) and relaxing music.
A cyber-sickness is noted as a potential side-effect of interventions
using the VR device; however, the occurrence of such incidences is
rare and minimal (Stetz, Ries, & Folen, 2011). To ensure that the VR
would not post harmful effects on people with mood disorders, a pilot
study was conducted on ve healthy individuals. They were asked to
wear the VR device while viewing relaxation videos. During the VR sessions, none of participants in the pilot trial reported undesirable symptoms (such as discomfort, eye problems, headache, nausea, anxiety,
among others). In this study, the facilitator also monitored potential undesirable symptoms during the intervention. People with mood disorders were advised to inform the facilitator if they experienced
discomfort when using the VR device.
Measurements
Data were collected by physiological measurements and self-reported
questionnaire. Objective stress was obtained through physiological measurements of blood pressure, heart rate, and skin temperature. Blood
pressure and heart rate were measured using the Intelligence Blood Pressure Monitor Model T9P (OMRON Healthcare Singapore, 2013). During
the data collection, all participants were in a sitting position on a comfortable chair. A cuff was placed and tightened around their left upper arm
about 12 centimeters above the elbow. This T9P has an accuracy/calibration of +/4 mmHg for blood pressure and +/5% of reading for heart
rate (OMRON Healthcare Singapore, 2013).
Skin temperature was assessed using the SC 911 Stress Thermometer (Stress Market, 2011). While participants were sitting on a chair, a
thermometer lead wire was attached on a ngerprint side of the tip of
their index nger, where skin temperature is most sensitive. The

Table 1
Content Outline of the VR DE-STRESS Program.
Session
1 (1 hour)
2 (1 hour)
3 (1 hour)

Program
Psychoeducation: Stress, its causes, symptoms and effective management techniques
VR-guided relaxation practice: Abdominal breathing, muscle relaxation, and guided imagery (using a beach scenario)
Psychoeducation: Mood disorders & their relationship with stress
VR-guided relaxation practice: Abdominal breathing, muscle relaxation, and guided imagery (using a beach scenario)
Psychoeducation: Positive thinking & other relaxation techniques
VR-guided relaxation practice: Abdominal breathing, muscle relaxation, and guided imagery (using a beach scenario)

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

researcher waited for 1 minute to ensure that device fully captured the
nger temperature. The stress thermometer reads temperatures between
58 F and 158 F with higher scores indicating lower levels of objective
stress. The accuracy of the stress thermometer was +/0.1 F (Stress
Market, 2011). Concurrent validity of the stress thermometer was supported by its signicant correlation with the Numeric Stress Rating scale
on a Singaporean sample (Lim, Klainin-Yobas, & Chen, 2014).
To minimize possible confounding factors, all physiological instruments were assessed under controlled conditions. Firstly, the same participant was measured twice before and immediately after the
intervention, only 1 hour apart. This might help control individual factors (such as psychiatric diagnoses and treatments). Therefore, it
might be logical to conclude that any physiological changes result
from the intervention. Secondly, the same researcher (LS) collected
data across all participants across the two time points. Finally, all pretest
and posttest measurements were assessed under the same physical environment (such as venue and room temperature).
Depression, anxiety and subjective stress were measured with the
21-item Depression Anxiety Stress Scale (DASS-21) (Lovibond &
Lovibond, 1995). Participants rated on a four-point scale ranging from
0 (did not apply to me at all) to 3 (applied to me most of the time).
The DASS-21 has three subscales: depression (7 items), anxiety
(7 items), and stress (7 items). Each subscale has possible scores ranging from zero to 21, with higher scores indicating higher symptoms.
Alpha coefcients of 0.880.90 were reported for the depression,
0.820.84 for anxiety, and 0.860.90 for stress (Crawford et al., 2009;
Henry & Crawford, 2005; Mahmoud, Hall, & Staten, 2010). Furthermore,
alpha coefcients of the DASS-21 on Singaporean participants was 0.94,
suggesting excellent internal consistency reliability (Ang, 2012).
Relaxation levels were measured by the Perceived Relaxation Scale
(PRS), a single-item visual analogue scale (Lee, 2011). The PRS is a
numeric-visual analogue scale comprising a ten centimeter line with
calibration at every one centimeter. Participants were asked to rate
their perceived levels of relaxation from a scale of zero (very tensed)
to 10 (very relaxed). The Content Validity Index (CVI) of the PRS on cardiovascular patients in Singapore was 1.00 (Lee, 2011).
Participant knowledge was assessed by the Knowledge on Stress and
Stress Management Questionnaire (KSSMQ), which was developed by
the researchers for this study. The KSSMQ is a 15-item questionnaire
whereby every ve items were administered before and after each intervention session. The content of the KSSMQ was based on information
in the PEM. The questionnaire included 15 statements which can be
assessed as true, false or not sure. For every correct statement, a point
was given, making possible in the range of zero to 15 with higher scores
indicating more knowledge. Content validity of the KSSMQ was examined by two mental health nurses and one psychologist; and the CVI
of 0.98 was obtained.
Additionally, the program feedback form was administered at the
end of the third session to explore the participants' perception of the
overall VR DE-STRESS Program. Participants were asked to comment
on strengths and weaknesses; and to provide any other additional comments through three open-ended statements.

Ethical Consideration
Approval to conduct this study was received from the hospital ethics
committee. We explained the purpose of study to eligible patients, distributed patient information sheet (PIS), answered questions they
might have and seek their participation. All participants signed a written informed consent prior to participating in the study. They were
also informed that their information would be strictly condential and
that participation in this study was voluntary. The researchers also emphasized that their decision to participation or not to participate in this
study would not affect healthcare services they received from the
hospital.

Data Analyses
Data obtained in this study were entered into IBM SPSS (Version
20.0). Univariate analyses were used to describe participants' characteristics and study variables. Paired t-tests and repeated measures analysis
of variance (RMANOVA) were performed to test the effects of the intervention on outcome variables. Content analyses were used to analyze
open-ended questions.

RESULTS
A total of 26 patients were approached during the data collection period. However, four patients declined to participate in the study due to
disinterest or low mood. Hence, a total of 22 participants agreed to engage in the study, representing a response rate of 84.62%. Three had
early discharge before completing the intervention. These missing
data were handled by using intention-to-treat (ITT) analysis to minimize type I error. Participants in this study (Table 2) were diagnosed
with MDD (45.45%; n = 12) or BD with depressive episode (54.55%;
n = 10) with age ranging from 21 to 60. Most participants were Chinese
(63.64%; n = 14), female (72.73%; n = 16), and married (54.55%; n =
12) without children (50.00%; n = 11). All patients received standard
care (such as medications) prescribed by their physicians.

Table 2
Demographic Data of Study Participants (n = 22).
Characteristics
Clinical diagnosis
Bipolar Disorder
Major Depressive Disorder
Length of time since rst diagnosed
b 1 year
110 years
N10 years
Age (years)
2130
3140
4150
5160
Gender
Male
Female
Marital status
Single
Married
Widowed
Nationality
Singaporean
Singaporean-PR
Ethnicity
Chinese
Malay
Indian
Highest education level
Secondary
Certicate
Diploma
University
Post-graduate
Currently employed
Yes
No
Income level ($SGD)
b$1000
$1000$3000
$3001$6000
$6001$9000
N$12000
Undisclosed

Frequency (n)

Percentage (%)

12
10

54.54
45.46

6
14
2

27.27
63.64
9.09

5
6
7
4

22.73
27.27
31.82
18.18

6
16

27.27
72.73

9
12
1

40.90
54.55
4.55

20
2

90.91
9.09

14
5
3

63.63
22.73
13.64

12
2
4
3
1

54.54
9.09
18.18
13.64
4.55

12
10

54.55
45.45

5
12
2
1
1
1

22.73
54.54
9.09
4.55
4.55
4.55

10

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

Objective Stress
Objective stress was measured before and immediately after each
intervention session across 3 days to capture immediate physiological
changes, making up six measurements. RMANOVA was used to compare mean differences across the six measurement points, and results
indicated signicant differences in skin temperature (F = 17.17,
p b 0.001) (Table 3). Post-hoc pair-wise comparisons suggested that
posttest scores of all sessions were signicantly higher than their respective pretest scores. Posttest scores S1, S2 and S3 were also signicantly higher than the baseline (pretest S1). Note that higher scores of
skin temperature signify lower levels of objective stress.
Unfortunately, there were no signicant differences in systolic blood
pressure (F = 2.12, p = 0.10), diastolic blood pressure (F = 0.22, p =
0.97) and heart rate (F = 1.91, p = 0.14) across six measurement points.
However, pair-wise comparison tests revealed that heart rate at posttest
session 3 was signicantly lower than its respective pretest (X difference = 4.16, Se = 1.00, p = 0.007).
Subjective stress, anxiety, and depression
These three variables were measured two times; at baseline and
the completion of the 3-day program. T-tests were used to compare
means of pretest and posttest scores of stress, anxiety, and depression (Table 4). Following the 3-day intervention, the participants
had signicantly lowered subjective stress (X difference = 7.62,
SD = 5.17, t = 6.91, p b 0.001), depression (X difference = 8.09,
SD = 6.75, t = 5.62, p b 0.001), and anxiety (X difference = 5.64,
SD = 4.77, t = 5.54, p b 0.001).
Perceived Relaxation and Participant Knowledge
These two variables were measured before and immediately after
each the intervention session across 3 days (six measurement points).
There was a signicant difference in perceived relaxation across the
six time points (F = 26.20, p b 0.001) (Table 5). Posttest scores of perceived relaxation of all sessions were signicantly higher than their respective pretest scores. Furthermore, posttest S1, S2, and S3 were
signicantly higher than the baseline. Similarly, there was a signicant
difference in participants knowledge across the three time points
(F = 13.77, p b 0.001) (Table 6). Posttest scores S3 and S1 were significantly higher than their respective pretest scores. However, no signicant difference score was observed in session 2.
Feedback on the VR DE-STRESS Program
Participants provided useful feedback on the program concerning its
strengths and weaknesses. Regarding the strengths, the participants
Table 3
Scores of Skin Temperature in Fahrenheit Across Six Measurement Points (n = 22).
Skin temperature
(Fahrenheit)

Pretest mean
(SD)

Posttest mean
(SD)

Session 1 (S1)
Session 2 (S2)
Session 3 (S3)

85.01 (3.05)
86.87 (3.82)
86.31 (3.05)

90.58 (3.52)
90.75 (3.90)
90.34 (3.03)

Post-hoc
comparisons
Pretest S1 & posttest s1
Pretest S1 & posttest s2
Pretest S1 & posttest s3
Pretest S2 & posttest s2
Pretest S3 & posttest s3

Mean difference
(SD)
5.58 (0.96)
5.74 (0.81)
5.34 (0.66)
3.88 (0.73)
4.03 (0.71)

F-Test

p value

17.17

b0.001

95% C.I.

p value

Lower

Upper

2.40
3.07
3.16
1.46
1.70

8.76
8.41
7.51
6.31
6.37

b0.001
b0.001
b0.001
b0.001
b0.001

NOTE. a) Skin temperature was measured by the stress thermometer. b) Sphericity assumed (Mauchly's W = 0.40; p = 0.239).

stated that the program helped them to be strong and determined,

think positively, see things in a bigger picture, open mind, look forward
to the future, learn to relax, manage insomnia, and cope with stress.
Most participants enjoyed the practice of relaxation; some liked the participant education manual as it was easy to read, compact, and useful;
and some patients liked the VR device. Regarding the weaknesses, some
participants stated that the monitor screen of the VR device is too small;
some required a massage chair and aromatherapy during the relaxation
practice; some asked for a group-based intervention for the purpose of
exchanging ideas/opinion; some asked for additional relaxation techniques; and some requested longer intervention sessions.

DISCUSSION
This study aimed to test the feasibility and initial effect of the VR DESTRESS Program on inpatients with mood disorders in a tertiary hospital
in Singapore. The program comprised two major components:
psychoeducation and relaxation practice guided by VR-based relaxation
videos. Evidently, it was feasible to deliver the three daily 1-hour VR DESTRESS sessions to patients in the hospital setting. Findings from this
study provided empirical evidence to address the two research questions. For the rst one, participants who attended the program reported
signicantly lowered objective stress (as indicated by skin temperature), subjective stress, depression, and anxiety. For the second research
question, participants also had signicantly greater perceived relaxation and knowledge. Additionally, this study produced results that supported the Neuman System Model (Neuman & Fawcett, 2002).
Particularly, a tertiary prevention intervention (which was represented
by the VR DE-STRESS Program) could help individuals with mood disorders manage stressors from environment, minimize stress-related
symptoms (such as depression and anxiety), and possibly return to
the state of equilibrium.
Under stressful circumstances, individuals' sympathetic nervous
system is activated, resulting in periphery vasoconstriction
(i.e., decreased blood ow to the surface of skin) and thus lowered
skin temperature (Chen et al., 2009). Conversely, when the body is in
a state of relaxation, it activates the parasympathetic nervous system,
resulting in periphery vasodilation and then higher skin temperature.
In this study, participants reported lower levels of objective stress (evidenced by increased skin temperature) immediately at the end of each
intervention across 3 days. Participants also reported lowered objective
stress at the end of session two and three in comparison to the baseline.
The signicant increase in skin temperature obtained is similar to the
ndings by Chen et al. (2009) who applied progressive muscle relaxation training (PMRT) on patients with schizophrenia. The positive ndings obtained from the physiological measurement complemented and
strengthened the subjective measures of stress. Notably, participants in
our study also reported reduced subjective stress levels (as measured by
the self-reported questionnaire) post-intervention.
Moreover, participants reported signicant increases in perceived relaxation levels after all three sessions of the VR DE-STRESS Program.
This is consistent with research ndings from a previous study by Banos
et al. (2011). The relaxation response reduces the activity of the sympathetic nervous symptom, thus undoing the stress response (Schaffer &
Yucha, 2004). These changes could have increased the perception of relaxation in the participants. In addition, we believe that the VR device
was a key feature in creating the overall relaxing experience during the
relaxation practice of the VR DE-STRESS Program. The VR device might
produce positive effects on auditory, visual and sensory receptors of the
person, and thus enhancing the relaxation experience (Banos et al.,
2011). The three relaxation techniques were incorporated into the VRbased relaxation videos accompanied with peaceful music, soothing
narrator's voice and attractive visual sceneries. The personalized viewing
through the VR device grounded in a calm, quiet, and distraction-free environment contributes to the creation of a relaxing environment. These

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

11

Table 4
Scores of Subjective Stress, Depression, and Anxiety (n = 22).
Outcome variables
Subjective stress
Pretest session 1
Posttest session 3
Depression
Pretest session 1
Posttest session 3
Anxiety
Pretest session 1
Posttest session 3

Mean (SD)

Mean difference (SD)

Lower

Upper

t-test

p-value

10.23 (5.43)
2.61 (2.43)

7.62 (5.17)

5.32

9.92

6.91

b0.001

9.77 (7.34)
1.68 (0.60)

8.09 (6.75)

5.10

11.08

5.62

b0.001

8.27 (5.56)
2.63 (2.49)

5.64 (4.77)

3.53

7.76

5.54

b0.001

NOTE. Subjective stress, depression, and anxiety were measured by the Depression Anxiety Stress Scale (DASS-21) (Lovibond & Lovibond, 1995).

factors might contribute to the positive ndings on perceived relaxation

among the study participants.
As anticipated, participants in this study had diminished levels of
depression and anxiety following the VR DE-STRESS Program. Such
positive ndings might be related to the content of the program,
which taught participants how to recognize and manage stress, depression, and anxiety. Furthermore, the relaxation practice might
help reduce stress and enhance positive emotions. Similarly, previous studies found that the VR-based psychoeducation reduced depression among patients with PTSD and other anxiety disorders
(Banos et al., 2011; Gamito et al., 2010; Little et al., 2009; Yuen
et al., 2013). Nevertheless, conicting ndings were documented in
two studies where the VR-based program had no positive effect on
anxiety (Banos et al., 2011 & Blanaru et al., 2012). It is possible that
participants with PTSD in these studies had more severe and anxiety
symptoms, which required longer, more intensive, and more comprehensive interventions.
As expected, results from the study indicated a signicant increase in patients' knowledge at the posttest session one and three.
These positive ndings are consistent with previous studies evaluating knowledge following the psychoeducation intervention
(Bernhard et al., 2006; Pratt et al., 2005). As recommended by Kinzie
(2005), effective strategies should be used during health education
to enhance positive outcome. We were in agreement with this recommendation. For the VR DE-STRESS Program, we selected topics
that directly related to the participants, divided and delivered
bulky information into 3 consecutive days to minimize participants'
exhaustion, offered individual-based sessions to facilitate patient
facilitator interaction and optimal learning, used the VR technology
to guide relaxation practice, provided relaxation CD for optional
home practice, and administered the participant education manual

as (PEM) as a learning aid to enhance knowledge retention. Notably,

the contents in the PEM covered knowledge and skills taught in the
program. Patients could review the content based on their wish
and convenience.
Strengths and Limitations
This study had several strengths. First of all, this is the rst VR-based
stress management program developed for people with mood disorders
in Singapore. Empirical evidence from previous studies was utilized to
develop the VR DE-STRESS Program. Secondly, efforts were made to ensure the standardization of the delivery of the program across participants to enhance the integrity of the ndings. Adherence to the
intervention protocol was observed when carrying out the intervention.
Thirdly, both objective and subjective measurements of stress were obtained to enhance the accuracy of ndings. Finally, a high response rate
was attained, which might help minimize response bias.
Several limitations must be highlighted for this study. Firstly, there was
no control group, and thus positive ndings might result from concurrent
treatments (such as medications) patients received during hospitalization.
Nevertheless, we measured skin temperature, perceived relaxation, and
knowledge before and immediately after each intervention session on
the same day under the same conditions, only 1 hour apart. Signicant improvements on the three variables were consistently observed across
3 days. Hence, it might be logical to conclude that the VR DE-STRESS Program had some benecial effects on the participants.
The second limitation was the lack of follow-up assessments after
the completion of the program. Therefore, it is still unclear if the effects
of the VR DE-STRESS Program persisted beyond the end of the intervention. Lastly, the small sample size and the use of single-center recruitment may impede the generalizability of nding to all individuals
with mood disorders (Polit & Beck, 2010). Furthermore, such small sample size might yield insufcient statistic power to detect changes in

Table 5
Scores of Perceived Relaxation Across Six Measurement Points (n = 22).

Perceived relaxation

Pretest mean (SD)

Posttest mean
(SD)

Session 1 (S1)
Session 2 (S2)
Session 3 (S3)

4.86 (2.66)
5.50 (2.02)
5.79 (1.70)

7.64 (1.79)
7.50 (1.62)
8.32 (1.21)

Post-hoc
comparisons
Pretest S1 & posttest s1
Pretest S1 & posttest s2
Pretest S1 & posttest s3
Pretest S2 & posttest s2
Pretest S3 & posttest s3

F-test

p value

26.20

b0.001

95% C.I.

Mean difference
(SD)

Lower

Upper

p value

2.77 (0.48)
2.64 (0.52)
3.45(0.51)
2.00 (0.25)
2.53 (0.31)

1.20
0.90
1.77
1.16
1.51

4.35
4.37
5.13
2.84
3.54

b0.001
b0.001
b0.001
b0.001
b0.001

NOTE. a) Perceived relaxation was measured by the Perceived Relaxation Scale.

b) GreenhouseGeisser Correction Model used as sphericity violated (Mauchly's
W = 0.22; p = 0.011).

Table 6
Scores of Stress Management Knowledge Across Six Measurement Points (n = 22).
Stress management
knowledge

Pretest mean
(SD)

Posttest mean
(SD)

Session 1 (S1)
Session 2 (S2)
Session 3 (S3)

4.00 (0.82)
3.86 (0.77)
3.79 (0.66)

4.95 (0.21)
4.57 (0.58)
4.47 (0.72)

Mean difference
(SD)
0.96 (0.17)
0.71 (0.24)
0.68 (0.13)

Post-hoc
comparisons
Pretest S1 & posttest s1
Pretest S2 & posttest s2
Pretest S3 & posttest s3

F-test

p value

13.77

b0.001

Lower

Upper

p value

0.40
0.08
0.25

1.51
1.50
1.12

b0.001
b0.001
b0.001

95% C.I.

NOTE. a) Stress management knowledge was measured by the Knowledge on Stress and
Stress Management Questionnaire. b) GreenhouseGeisser Correction Model used as
sphericity violated (Mauchly's W = 0.13; p b 0.001).

12

L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 613

heart rate and blood pressure. The limitations in the study could serve as
a platform for the expansion of knowledge on stress management interventions through the implementation of true experimental designs in
future studies with a larger sample size.
Implications for Clinical Practice
Despite the aforementioned limitations, our study has demonstrated
the potential effects of the VR DE-STRESS Program in reducing stress,
depression and anxiety; while increasing perceived relaxation and
stress management knowledge in people with mood disorders. Consequently, the VR DE-STRESS Program could be incorporated into standard care in mental health settings. Given the shortage of health care
providers, the use of VR technology is a promising method in valueadding therapeutic interventions. Furthermore, VR can be a new psychotherapeutic tool, which is more appealing to patients in the mental
health setting and may increase adherence to treatment (Gaudiano,
Weinstock, & Millier, 2008). It is reported that participants in VRbased studies in mental health settings expressed high levels of support
and interest in the use of VR for their care (Banos et al., 2011). In
Singapore, most people with mood disorders are in age range 3150
years. We believed that people in this age range are familiar with advanced technology, and thus they would be more open to the implementation of VR technology.
Recommendations for Future Research
More studies concerning psychoeducation and relaxation interventions should be undertaken to expand the limited literature in areas of
VR-based interventions for people with mood disorders. Virtual reality
could be used as a psychotherapeutic tool to carry out future interventions. More rigorous studies (such RCT) with a larger sample size should
be carried out to test the efcacy of the interventions. Next, since the
PEM and an audio relaxation CD was provided to the participant so they
could benet from the intervention beyond the duration of the program,
it might be worth investigating the outcome variables at follow-up assessments to determine longer-term effects of the intervention.
In summary, ndings from this study provide empirical evidence to
inform the two research questions. The VR DE-STRESS Program was feasible and had some positive effects on individuals with mood disorders.
This empirical evidence contributes to body of knowledge concerning
stress management interventions for people with mood disorders in
Singapore.
ROLE OF THE FUNDING SOURCE
This study was supported by the Start-up Grant, Yong Loo Lin School
of Medicine, National University of Singapore. Dr. Piyanee Klainin-Yobas
is a principal investigator.
CONFLICT OF INTEREST
All authors declare no conict of interest for this study. No competing nancial interests exist.
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