Margot Paul: Treating Major Depressive Disorder Through VR
Faaizah Arshad and Jessica Hagen join Dr. Margot Paul, clinical psychology postdoctoral fellow at Stanford School of Medicine, to discuss her previous and ongoing research on using VR as a method of engaging in behavioral activation for individuals with depression.
BIO
Margot Paul graduated from the PGSP-Stanford Psy.D. Consortium in 2022, where she won the award for Outstanding Overall Student (2021). For her doctoral dissertation, Dr. Paul designed a feasibility study and three-arm pilot randomized controlled trial to examine the feasibility of using a VR headset as a way to administer behavioral activation therapy for participants with a diagnosis of major depressive disorder. She is currently a clinical psychology postdoctoral fellow at Stanford School of Medicine, where she is continuing her research on using VR as a method of engaging in behavioral activation for individuals with depression.
The following is a transcript of the episode:
Faaizah Arshad
Hi, everyone. Welcome back to Psychiatry XR, where we aim to inspire worldwide conversations around the use of extended reality in psychiatric care. I'm your host for this episode, Faaizah Arshad, and I'm joined by my co-host, Jessica Hagen.
Jessica Hagen
Hi. Nice to be here.
Faaizah Arshad
Same here, Jessica. We're really happy to have Margot Paul. Dr. Paul graduated from the PGSP-Stanford Psy.D. Consortium in 2022, where she won the award for Outstanding Overall Student (2021). For her doctoral dissertation, Dr. Paul designed a feasibility study and three-arm pilot randomized controlled trial to examine the feasibility of using a VR headset as a way to administer behavioral activation therapy for participants with a diagnosis of major depressive disorder. She is currently a clinical psychology postdoctoral fellow at Stanford School of Medicine, where she is continuing her research on using VR as a method of engaging in behavioral activation for individuals with depression. Dr. Paul, thank you so much for joining us.
Margot Paul
Thank you for having me.
Faaizah Arshad
So, we would love to start off by hearing about maybe why you chose the clinical psychology field. Did you always know that you wanted to pursue this route? And how did you get into the XR space?
Margot Paul
Yeah, great question. Coming from a medical family, I knew that I always wanted to engage in patient care. And I think a lot of people that are clinical psychologists would say that they were the person that a lot of people would come to with their problems growing up. And I noticed that I really enjoyed helping people. And I've always been interested in the human mind and why people do what they do. And I think growing up, there was a lot of stigma in mental health, and a lot of people were paying more attention to physical health and to medical care. And I think that mental health is just as important as physical health. And I wanted to be someone that attended to and helped those in need of mental health.
Faaizah Arshad
And so once you sort of figured out that you were really interested in the mental health space, how did you realize that you wanted to incorporate XR and VR into your work too?
Margot Paul
So in coming to the PGSP- Stanford, Psy.D. Consortium, where I received my doctorate in Clinical Psychology, I noted to my advisor that I was actually really interested in the interplay between physical and mental health. And I was interested in functional neurologic disorder, which Dr. Kim Bullock works with. So I was then introduced to Dr. Kim Bullock, who is the head of the Virtual Reality and Immersive Technology (VRIT) Clinic here at Stanford. So in working with her, she told me a little bit about it. And I became super interested and intrigued on how technology could impact and influence mental health care and augment care and provide access to those with barriers to care. And so I got involved in her clinic and the rest is history.
Jessica Hagen
So when you went to VRIT and you saw the different uses of XR, what was it that really captured your attention as far as using it within the medical field?
Margot Paul
I think XR is really just a great way for people to gain access to care and a way to de-stigmatize mental health. And especially during the COVID time where, for example, people couldn't come in, there were talks of maybe using virtual reality to be in the same room with other people, and to be able to communicate with other people in a way that just felt less isolating. And that potential capability was really intriguing to me.
Faaizah Arshad
And Dr. Paul, you actually defended your dissertation during the pandemic, is that right?
Margot Paul
Yes, that is correct.
Faaizah Arshad
And so with your paper on Virtual Reality Behavioral Activation for Adults with Major Depressive Disorder, can you talk about what made you want to dig into that topic specifically during the pandemic? And maybe you know, how you used virtual reality during that time to help patients with major depressive disorder?
Margot Paul
Yeah, absolutely. So in working in the virtual reality and immersive technology lab with Dr. Bullock, my dissertation was coming up and I was really wanting to do a dissertation in the XR space. And in doing a literature review, I saw that there was a huge gap in the literature, in that a lot of XR was used in research for mental health disorders, and yet there wasn't research on depression specifically. And so I considered (and with Dr. Bullock) and we thought, “How could we use XR to treat people with depression?” This was actually before the COVID pandemic began when my dissertation topic was in the talks, and we thought about it. And one of the most evidence-based treatments for major depressive disorder is something called behavioral activation, which essentially tells people to do activities that they view as pleasurable or to give them a sense of mastery and accomplishment. And if they do that, then their mood can improve. And so we thought, you know, well, what if people used XR to do activities that they found enjoyable or XR to do things that may give them a sense of mastery or accomplishment? Could that lend to the same mood improvements as doing an activity in real life? And if so, then people who are older, and maybe can't really get out or can't do the physical things they used to do, maybe they could use it in VR — people in nursing homes, that, you know, are looking at the same four walls, and they could use VR and travel the world or go scuba diving and do things that they couldn't do before. Maybe that would give them the same mood gains. Or for individuals that maybe have physical limitations, or live in dangerous communities, or don't have the financial means to do certain things: if they could do these activities in XR, and it could elicit the same affective responses as doing them in real life, I think that would be a huge improvement.
Faaizah Arshad
I think it's so great that you realized that there was a need, and a gap in the literature, and you really tried to address that.
Margot Paul
Yeah, absolutely. And then what was so interesting is that then COVID happened, and we adapted the study to do it through Zoom. So individual were first going to come in person to Stanford. We did it through Zoom, where we sent the headsets out. And then during COVID, it became even more important to see because that showed a situation where people really couldn't get out. People really couldn't do activities. Depression increased. And so it's actually really fortuitous that that happened in that time, because it allowed people who were really socially isolated and just stuck in their own home in their own four walls to actually get out through XR.
Jessica Hagen
Since you started it before COVID, and it was kind of ongoing during COVID, did you see the big changes in your participants as far as depression goes as the pandemic progressed?
Margot Paul
Yeah, really great question actually. So the first participant enrolled, actually, during the COVID pandemic, so it would have been interesting to actually see if there were any discrepancies between people before and after. So I can't speak to that. What I can speak to is that we didn't have a large enough N, a large enough sample size to have a power study. It was primarily a feasibility, acceptability, and tolerability study, which is an important first step when using new technology like XR in a treatment. But what we can speak to is that there was signal showing that the people who had participated in the study and used XR, their moods did improve. And while it wasn't statistically significant, it was significant on the measure that we used. So it was clinically significant on the mood measure— the Patient Health Questionnaire-9 (PHQ-9), which is an evidence based measure for depression. So we found that people who used XR on average did have a clinically significant decrease in depression symptoms.
Faaizah Arshad
And what ages did you look at? Like was it both younger individuals and older adults?
Margot Paul
Yeah, so anyone over the age of 18, was eligible to participate in the study. So, it was only adults.
Faaizah Arshad
Did you find that there were any added challenges of using virtual reality? Like things that you maybe did not expect before-hand? Because of course, you were really excited about how beneficial extended reality could be used for psychiatric and behavioral care. When you were actually implementing it, what did you experience with your use? Did you feel like there were challenges or things that surprised you?
Margot Paul
It was important when doing this research, especially because anyone over the age of 18— and actually after COVID, and it became virtual, we decided to extend it to nationwide so individuals that may not be technologically savvy— so it was important for me to choose a headset that was easy for people to use. We ended up choosing a headset supplied by Limbix, which is now partnered with BehaVR— a Pico headset that didn't have anything to hold with your hands. It was only one button that you could press and you would look around and there'd be a laser pointer. And there were videos pre added on the headset, so 37 videos of “activities” that were added on the headset. So I purposely chose the headset that was relatively user friendly for that reason. I think there still definitely was a learning curve for some individuals in terms of using the headset. Also in through shipping the headset, we, there was one instance where one of the headsets had a blemish in the screen, which impacted the participants sense of presence. So that was a barrier. But overall, the main concern was cybersickness, which is like sea sickness or motion sickness. And there's different theories as to why cybersickness can happen, and we tried to do things to minimize that. But overall, there was no adverse effects. And it seemed to be acceptable and tolerable to the individuals who participated.
Jessica Hagen
What were some of the key findings of the study?
Margot Paul
Yeah! So as I said, we looked at mainly the feasibility, acceptability, and tolerability. And so it was feasible in that it did seamlessly integrate into a behavioral activation for depression protocol. It was feasible to do even during a pandemic. It was acceptable to patients, meaning that when we asked patients questions on the Technology Acceptance Model, they rated it as overall acceptable, meaning that they would want to use it. They enjoyed using it. And they found it tolerable, meaning that there were no major events of simulator sickness and drop-out was unrelated to any type of physical or emotional intolerability using the headset. And then in terms of initial efficacy: though, it was a three arm, which was behavioral activation used in XR, behavioral activation treatment as usual, which would just be an in person, and then there was just a regular treatment as usual control group where people could be doing whatever they were doing, and they got no intervention by me. And so, what was found on the mood questionnaire (that PHQ-9 that I was talking about, which measures symptoms of depression), we found that overall, the people on that just no intervention treatment as usual, they remained the same in terms of their— relatively the same in terms of their— PHQ-9 score, which is to be expected. And then for the behavioral activation treatment as usual, there was a decrease. It wasn't clinically significant, because it was above three, and to be clinically significant on the PHQ-9, it has to be a five and above. And then on the XR, the behavioral activation protocol, it was considered clinically significant. So, there was a decrease of more than five on that scale. So again, this isn't statistically significant, because our power wasn't powered enough. There wasn't a large enough sample size, just based on recruitment and time constraints because it was my dissertation. But the signal did show that using behavioral activation with XR could be efficacious for people with depression.
Faaizah Arshad
What are you sort of focusing on in your current research? Are you using XR now as well, in any studies that you're doing? What is kind of ongoing for you now?
Margot Paul
Yeah, so we were really excited by the results of that dissertation research. And when we were talking about future directions, there were some talks of, “Okay, now, where do we go from here?” One was definitely getting that larger sample size, to look at power, now that we knew that it was feasible and acceptable and tolerable. And then the other was some, some participants said that they, they wanted to do something that was more immersive: to have the ability to be social or to interact in their environment. The initial study for my dissertation, as I said, I prioritized ease of use in terms of the headset, which meant that it was a VR video 360, meaning that you were in the virtual reality headset, and it was like you were watching a movie, but you could turn your head and see 360 degree views and the scene would move around you but you couldn't actually move and interact in the environment itself. Because at that time, I really wanted it to be as realistic as possible, and I thought, “What could be more realistic than, you know, seeing something like a movie screen and seeing the real world in that way?” And then I got participant feedback that they said, “I'd rather it actually look more game-y and have that interactive capability, then be more realistic looking, and not have that interactive capability.” So Dr. Bullock, and I thought, “Well, how can we expand upon this previous research?” So now currently, in my postdoctoral fellowship here at Stanford, I'm doing a four-arm RCT using the Meta Quest 2, which will allow people to have a lot of choices, nearly, you know, 1000s of different choices of different activities to do, social interactions, gaming, productivity, etc. So they can interact with their environment. It's more immersive. One of the arms would be doing that behavioral activation using that Meta Quest 2. Another arm is using behavioral activation and Meta Quest 2 actually with a mobile application that we're developing, which helps patients follow the behavioral activation protocol through the application. And then we're just doing behavioral activation treatment as usual, so in person, and then behavioral activation treatment as usual with that app as well. So, we're really excited because we're going to hopefully get more participants to have more statistical power. And we're going to see how their mood and affective responses differ using this more immersive technology.
Faaizah Arshad
First off, I think it's really nice that you sort of took the feedback that you got from your dissertation and, you know, tried to implement that. I think it's so interesting that a lot of the participants they wanted it to be more game-like and less realistic. Did you expect that or, you know, when you initially did this study, did you ever think of doing it to be more game-like?
Margot Paul
No, I was actually really surprised. Part of the reason why I did the study, as I initially did it was because I was inspired by previous research that had people either look at a scene of a lake and mountain range in real life and then rate different emotional responses. And then they had a different set of people look at that same scene, same time of day, same mountain, same lake, but in that virtual reality 360 that I was describing, and then rate their mood responses as well. And they found no significant differences in the effect of mood responses in those two situations. So, I thought that was super cool. And I thought, “Okay, well, that's cool. If video 360 looking at that same scene, in this video 360 elicited the same responses as looking at that scene in real life, then maybe doing an activity, you know, in video 360 could elicit the same mood responses as doing it in real life.” So that's where I got that idea of the video 360. And so, I was pretty, pretty surprised by that feedback, but also inspired. You know, I'm excited to see what this new study holds. We're currently recruiting now. And you know, the more participants the better. So we're definitely looking for people who are experiencing symptoms of depression and are currently in therapy and want free treatment— this treatment for depression, either in XR or just doing a behavioral activation in real life and with this cool, new mobile application.
Jessica Hagen
How would participants contact you to be able to, you know, join the study?
Margot Paul
They could definitely email me so it's mdpaul@stanford.edu.
Faaizah Arshad
Are you, for this study, looking at participants of all ages as well, like who are adults? Are there any criteria?
Margot Paul
Yeah, so we're looking for people who are adults, so over 18, and we're looking for people who meet criteria for depression. That will be assessed once they express interest, and we do an initial assessment of eligibility. And then just to be able to speak and understand English just because the protocol is in English. And so it's important for people to be able to speak and understand English. So those are our main inclusion criteria. And we prefer for people to not be in therapy currently, just so that we can make sure that we know if the treatment works— it's because of our treatment and not because of some other treatment that they're receiving.
Faaizah Arshad
Yeah. Can you talk a little bit more about the app that you're using because that's not something that you used in the first study that you did with major depressive disorder, right?
Margot Paul
Yeah, exactly. So looking at another gap in terms of when we talk about technology, and why I was interested because it improves access to care, and as I said, I think it de-stigmatizes mental health. And that's where society's going. Society's going in that direction of just we're using our phones, we're using technology. So there are a lot of really great apps out there for mental health. And yet, we still haven't been able to find any specifically for this behavioral activation for depression. So the app isn't meant to use as like a standalone. It's meant to be a companion when working with a therapist, and it provides some brief education on depression, what behavioral activation is, a little bit of the research behind it, and it allows people to follow the protocol and track their activities and mood in the app, which research has shown can be really effective. It just is a treatment in itself that if people track their activities, they're more likely to do the activities. And if you can see like, “Wow, when I did four activities today, my mood was higher than when I only did one or zero activities,” that can be a huge incentive. And so for people, traditionally it was tracking through, you know, pencil / paper, and that can be difficult for people because when you're doing an activity, it's hard to be like, “Okay, now I'm going to pull out pencil and paper and track this.” So a lot of times people either forgot to do it, or they would do it at the end of the day, or they would do it only a few times a week and just guess at what their mood was in a given activity, which isn't as accurate as if you rate it in the moment. So, we thought if you had a mobile app, and you could just pull out your phone, because a lot of us are on our phones, for better for worse, and just rate it that way, write the activity down and just really user friendly, just very clickable, that that could be really effective and helpful to help people be more engaged in treatment.
Faaizah Arshad
Got it. So really emphasizing the accessibility and like user friendliness.
Margot Paul
Yes, yes exactly.
Jessica Hagen
As you’ve spent much of your time in XR and kind of exploring the use of XR, what are some things that you've found surprising about the technology and how possibly how participants react to the technology?
Margot Paul
I think one of the things that's really surprising is technology, it's amazing, and yet we have a lot further to go, which I think is really exciting to me, in that VR is so cool. And it can do so much. And we can be you know, in “the same room” as someone else as Avatars. And we can interact socially with other people and play tennis in XR, for example, and you know, do all these cool things. And yet, we still have so much further to go in terms of being in there and the sense of presence and, you know, movement and how realistic it is. And so, I think for some people, it can be frustrating if it doesn't feel like it's tracking your body in the exact same way. And then that can lead to symptoms of cybersickness, for example, if your visual field and your vestibular system, that inner ear, if it's perceiving movement, and it's not feeling movement, for example. So I think that there is further for technology to go. And that's exciting, too, because it leaves a lot of room for growth.
Jessica Hagen
Absolutely, I completely agree. I think it's very intriguing how XR is being used in different ways and being studied. And the technology even though it is incredibly impressive as to where it is now, it still has quite a ways to go to really give that immersive feeling. And I think that that's really cool that you've been studying it for a while and being able to kind of see how participants are reacting to it in, you know, physical and mental ways.
Margot Paul
Yeah, yeah, exactly. I'm super excited to see, you know, technology has come so far in such a short amount of time. And so I'm really excited to see where it goes. I think there's so many amazing possibilities and potential to use technology to help people with mental health and even physical health as well.
Faaizah Arshad
It's also really nice that you've had the chance to sort of lead some of these studies using extended reality for like psychiatric and behavioral health. Can you maybe give some advice to our listeners? Like if someone is interested in leading their own study? Or someone who's just starting out in this field? What is one piece of advice that you'd give them?
Margot Paul
Yeah, really great question. And I get this one frequently, I think I was really lucky and fortunate to have been introduced to Dr. Kim Bullock here at Stanford. I think in the Bay Area, there's just so many resources— the tech hub. So I was very fortunate in that way. If a person is interested in researching XR in mental health, or really in anything, really just reaching out, contacting people who are in the field and seeing how they can get involved, I think is just the best place to start.
Faaizah Arshad
Yeah.
Jessica Hagen
Yeah, I completely agree.
Faaizah Arshad
And then how would you like to see extended reality being used 20 years from now. Like, we talked about how, you know, it's such an impressive thing, and it's exciting that we can use this for patient care. What are some ways that you envision it, like a few years from now?
Margot Paul
Yeah, and I was thinking about this, because sometimes I get pushback of like, “Oh, you know, technology can be detrimental for people, and people aren't going to be interacting with you know each other in real life.” And for me, that isn't how I conceptualize it. I think that at least for depression, XR can be an important first step to elevate people's moods. When people are depressed a lot of times, it's really hard for them to do things like even just get out of bed or leave their house and do those types of behaviors. And so, to me, the way I was viewing XR is it could be an in-between step to just put on your headset and get that little mood boost enough to maybe want to go out and do activities in real life. And I actually did get that feedback from participants that using XR inspired them to do other things in real life that they used to do and they weren't doing like volunteering or, you know, doing certain sports, which I thought was really great. And so where I see it— right now, I think the largest barrier is affordability for some of these higher end more immersive headsets. And so in 20 years, I really would like to see both the environments themselves to become more varied and more realistic and more immersive, but also just more accessible for the general population as well.
Faaizah Arshad
Yeah, I think that's so important, like making sure that people in the population who can really benefit from this do have access to it, because it's such an amazing thing to have all of this technology being generated and made in the Bay Area, just like you said, but getting it in the hands of patients and providers who can give that help is so key.
Margot Paul
Yeah, yeah, exactly. That would be my hope, my hope for the future. Just so that people who really do have these barriers to access to care, maybe are waiting to see a provider or, you know, they're just not ready to see a provider yet, that they could read about these studies and say, like, “Hey, if I just use this headset a few times a day, and then it could help me feel better, and then inspire me to go out and to do other things.”
Faaizah Arshad
Yeah, I definitely hope to see that vision come true, too.
Jessica Hagen
Yeah. And then also including clinicians within that, you know. Having that, that interaction with clinicians that can say, this is how you use it well, and this is how you're going to get the best possible outcomes from it. So really, there's an education as far as the patient aspect, but then there's an education as far as clinicians go as well. So like “This can benefit you, and this can benefit your patients,” to really improve what's being offered.
Margot Paul
Yeah, I think that's really a great point. And to that point, as well, I think that it could increase access to care in terms of decreased driving. So right now I know the Zoom is a really popular modality for, it's called like, telehealth. A lot of times people will prefer now to do therapy over Zoom just because it decreases travel time. And if in the future, you could actually do a therapy session in VR, where it's not just avatars, but you could see yourself and your therapist or you could do group therapy in Zoom—I also think that would be a really great use of XR as well.
Jessica Hagen
Absolutely.
Faaizah Arshad
I absolutely agree. Is there anything else that you'd like to share with our listeners, Dr. Paul?
Margot Paul
I just want to thank everyone for listening. And if you're interested in XR, and how XR can be applied to mental health, and specifically depression, or if you're interested in a study I did for my dissertation or the current study, again, just please feel free to reach out to me and I'm happy to answer any questions.
Faaizah Arshad
Thank you so much, Dr. Paul, for your time. We are so happy to get the chance to hear about your research. And I think everything that you've had to say about accessibility and improving like user friendliness, and just the ways that this technology can improve patient care— it just seems so promising. And I'm really excited to hear more about the work that you are doing and the current study that is ongoing.
Jessica Hagen
Yes. Dr. Paul, thank you so much for joining us.
Margot Paul
Thank you so much for having me.
Faaizah Arshad
That's it for this episode of Psychiatry XR. We hope you gained a new perspective on the use of extended reality in healthcare. And thank you very much for listening! We're also very grateful for the support of the International Virtual Reality Healthcare Association, who is offering, you, our listeners 50% off when you register for the 7th annual Virtual Reality and Healthcare Global Symposium taking place on March 3rd – 5th at Penn Medicine in Philadelphia. To learn more about the conference and to register to attend, visit health23.ivrha.org and use the discount code psychiatry XR when registering to receive 50% off. This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. For more information about Psychiatry XR, visit our website at psychiatryxr.com. Be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR’s use in psychiatric care. You can join us monthly on Apple Podcasts, Twitter, Spotify, or wherever you get your podcast. Psychiatry XR was produced by Dr. Kim Bullock, Faaizah Arshad, and Jessica Hagen. Please note that this podcast is distinct from Dr. Bullock's clinical teaching and research roles at Stanford University. The information provided is not medical advice and should not be considered or taken as a replacement for medical advice. We credit and are very grateful to David Bell for audio editing and Austin Hagen for music production. See you next time.