Keywords

1 Introduction

1.1 Depression: A Serious Problem

Worldwide, depression is among the leading causes of death [1]. Roughly 20% of people experience depression at some point in their lives [2]. Prevalence of depression is particularly high among college students [3, 4], who often do not seek professional psychological help [5], and leave the symptoms untreated [6]. The problem of not seeking help during depression is evident from the fact that almost 50% of young people who complete suicide had a diagnosable mood disorder, including depression [7].

1.2 Social Stigma and Help-Seeking for Depression

Social stigma is a significant barrier in help-seeking for people living with depression [10]. Giving such people an opportunity to tell their stories of illness helps them actively participate in improving their wellness [8] and empowering both story-tellers and listeners to seek and offer help [9]. Hearing others’ stories helps them cope with their own illness by realizing that they are not alone. Individuals with stigmatized health conditions, specifically individuals with depression are more inclined to suppress thoughts and keep the sufferings in themselves [11, 12]. Due to such discriminatory attitudes, even if an individual develops behavioral intention to seek help; stigma interferes to weaken caregiving relationship [13].

Help-seeking, through therapy and counseling, is a significant determinant for ones with stigma to recover from depression at an early stage. To facilitate these process, research on depression-related narratives has employed a method called ‘expressive writing’ [14]; a form of storytelling that involves journaling and diary writing. Expressive writing of one’s thoughts has shown to positively affect mental and physical health [15]. We envision that expressive storytelling can be effective to address depression. In this study, we enhance the benefits of expressive writing by introducing it in an immersive Virtual Reality (VR) environment. We propose that VR videos will result in a more interactive and engaged experience of expressing one’s depression-related thoughts and would in turn facilitate positivity and help-seeking behavior.

2 360-Degree Virtual Reality Videos

VR is defined as “an application allowing a user to navigate and interact in real time with a computer-generated three-dimensional environment” [16; p. 17]. Several studies have explored the benefits of VR-based interventions for social issues. For example, VR videos have been employed for educational setting [17], immersive story telling [18], virtual tourism [19], and learning a new language [20]. VR based interventions have shown positive results such as increased enjoyment [21], higher motivation [22], message retention [23], and positive mood induction [24]. The feasibility of VR interventions has surged due to the emergence of low cost headsets.

This study introduces two innovations. First, we produced VR videos, using 360-degree video camera, to provide a user with an immersive experience of listening to narratives of depression. Second, the VR video is made interactive by inviting participants to ‘speak-out’ and share their personal narratives of living with depression. This confidential and private nature of evoking depression-related narrative is hypothesized to result in positive emotions, reduced sadness, and positive attitude toward seeking professional psychological help (Fig. 1).

Fig. 1.
figure 1

Virtual reality 360-degree video showing a male individual sharing his story of living with depression while the participant listens and then shares her story. The people shown in this video are not real participants.

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Hypothesis and Research Question

As such, the study proposes the following hypotheses and a research question.

  • Hypothesis 1: Participants exposed to the interactive VR video will express more positive, and less negative emotions.

  • Hypothesis 2a: Participants exposed to the interactive VR video will express a positive attitude toward seeking a professional psychological help.

  • Hypothesis 2b: Participants exposed to the interactive VR video will express high behavioral intention to contact counseling center.

As discussed above, an important objective of the proposed approach is to provide participants with an opportunity to express their thoughts and feelings. Thus, in addition to the quantitative results, we will also administer a thought-listing exercise after watching the VR videos. Our research question is:

Research Question: What are the prominent themes emerging from the thought-listing exercise, expressed by the participants after watching the interactive VR video.

The research group comprise of an interdisciplinary team of professionals from computer science, psychiatry, interactive game design, health communication and information and media program at Michigan State University.

3 Method

3.1 Participants

Recruitment criteria and measurements for the study were developed and administered in collaboration with a clinical psychiatrist. The study was approved by institutional review board. Participants were recruited from a student subject pool. The recruitment criteria included scoring mild or moderate level of depression as per PHQ-9 scale. Additionally, respondents who are currently attending counseling or taking medications were excluded. Seven participants screened as a mild level of depression and five participants screened as moderate levels of depression. Overall, 12 participants (Male = 3, Female = 9) eventually participated in the main study. Most of the participants were single (n = 9), English as first language (n = 10), and in ages ranging from 18 to 26 years. The recruitment process started in October 2017. Figure 2 describes the inclusion and exclusion process.

Fig. 2.
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Process of including/excluding participants based on the recruitment criteria.

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3.2 Measurement

Positive and Negative Emotions.

The study measured ten positive and negative emotions selected from a battery of emotions provided in a study about hierarchical emotions in consumer behavior [25]. Participants were asked to rate their response on a seven-point scale. Positive emotions: Warm, Peaceful, Hopeful, Joyful, Relaxed, Purposeful, Secure, I can do it, Determined, and Helpful. Negative emotions: Sadness, Overwhelmed, Anxious, Hopelessness, Tense, Guilty, Tired, Helplessness, Unwanted, and Misunderstood. Higher score indicates more emotions evoked.

Attitude Toward Help Seeking.

Attitude toward help seeking was measured on a seven-point Attitude Toward Seeking Professional Psychological Help Scale (ATSPPHS) [26]. This is a shorter 10-item version of the original 29-item scale developed by Fischer and Turner [27]. Sample items include “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.” The revised scale strongly correlated with the longer version (.87) suggesting the measurement of the same construct [26].

Behavioral Intentions to Seek Help.

The scale to measure behavioral intention to seek help is adopted from Park and Smith [28]. The scale employs a 7-point response format (1 = strongly disagree, 7 = strongly agree). Example item: “I intend to contact the counseling center when experiencing a personal or emotional problem in the future.” Higher score indicates more behavioral intention. Descriptive and correlation matrix of all scales is presented in Table 1.

Table 1. Correlation matrix and descriptive statistics for positive emotion, negative emotion, attitude toward help seeking, behavioral intention to contact counseling center
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3.3 Procedure

For the screening phase, participants first completed an online survey using Qualtrics survey platform. Based on the recruitment criteria adopted for this study, the respondents were screened and then invited to participate in an hour-long study. Participant was first provided a consent form. After providing consent, the participant wore the Oculus Rift VR headset and watched the interactive VR video produced specifically for this study. The video first showed a 360-degree video with a calm and soothing lake scene to familiarize the participants with the 3D environment. The participant could interact with the contents using a gaze pointer which was placed as a red dot at the center of the screen. Using the pointer, the participant moved to the next scene that introduced the study purpose while showing another scene of campus life. Next, the participant proceeded to an indoor scene where they see a person sitting in front of them. A voiceover explains (Appendix) the next steps of the video that includes clicking on a button through the gaze pointer to listen to his experience of living with depression, and then click on the record button to share participants’ own experience.

Overall, five different main scenes were designed to engage participants. At the end of each scene, participants were invited to express their personal experience which was recorded through an audio recorder and later transcribed.

After completing all main scenes, the participant took off the VR headset and completed an online survey using Qualtrics platform. Finally, the participant completed demographic scales and concluded the study. At the end of study, the participant received a debriefing form to provide information about the study purpose as well as the contact information of campus counseling center and other helpful sources to seek help during depression. The participant then received a course credit and left the lab.

4 Results

After going through the VR session, participants expressed more positive emotions (M = 4.89, SD = .81), compared with negative emotions (M = 2.34, SD = .66), thus supporting hypothesis 1. Additionally, participants expressed a considerably high positive attitude toward help seeking behavior (M = 4.34, SD = .96), supporting hypothesis 2a. However, participants reported below average behavioral intentions to seek help (M = 2.86, SD = 1.59), i.e., not supporting hypothesis 2b. A linear regression analysis entering positive emotions as predictor variable and attitude toward help seeking as criterion variable showed that positive emotions predicted a positive attitude toward help seeking behavior with marginal significance (R = .57, SE = .82, F (1,10) = 4.89, p = .052). This effect was absent in predicting behavioral intentions to seek help.

The research question stated: what are the prominent themes emerging from the thought-listing exercise, expressed by the participants after watching the VR video. To answer this question, we present here quotes from the thought-listing exercise written by participants after watching the VR videos. Our objective here is to understand the usefulness of the interactive VR videos and identify any signs of distress caused by the sharing experience. One participant expressed this as:

“I love the idea to express my story in a virtual context rather than a real counselor center, as I think psychological counselors are listening to me and taking good care of me because they are professional, but what I want more is to express what I am going through in a more natural context. This might be my biased view rather than a fact.”

Another participant talked about how the videos may help in improving help seeking intentions in the future:

“I think these videos were very helpful in making me feel like I am not alone in this work dealing with depression and there are ways to make things easier. The visuals and audio were great and really made me feel like I was in a room talking with someone also dealing with these issues.”

Another participant stated the same as:

“I think this study has encouraged me to talk to someone else about my depression.”

Specifically, talking about the use of VR for this purpose, one participant said:

“VR is the coolest new technology that many people can use. That entire experience was so cool. Being in a different place talking to someone that isn’t real. I know this sort of tech can be used for more serious things like mental health.”

Another participant, elaborating on the 360-degree aspect of the videos said:

“I thought the videos were cool through the headset because it was more than just a video. You knew about a real person who had similar issues and outlooks.”

Another participant elaborated the need for such interventions to improve counseling or help-seeking behavior and said:

“I thought talking about what depression is and looks like was an interesting idea and something more people could consider. I think it is easy to glance over depression, anxiety or panic that you might have but talking through it or acknowledging it in some way is helpful and can be a therapeutic experience.”

However, the study is not without its limitations as expressed by one participant who felt the whole experience weird, thus pointing towards further modifications and testing of the study.

“It was kind of uncomfortable to talk out loud about depression. I think having the other person share experiences first helped, but overall it felt weird.”

5 Discussion

To the best of our knowledge, this is a new study to experimentally test the effectiveness of VR videos to encourage self-disclosure and expression from individuals living with mild and moderate levels of depression. This study, by no means, claims to replace the counseling session, instead, it proposes VR as a medium to motivate individuals who avoid seeking help and promote help-seeking attitudes and behaviors. In other words, the VR may serve as a foot-in-the-door technique to increase help-seeking intentions while respecting users’ privacy and self-esteem. In terms of ecological validity, the VR approach is viable because of the easy access and availability of smartphones and cost-effective VR headsets now available off-the-shelf. In addition, the users can experience the VR sessions in the comfort of their homes without having to visit a counseling center. Based on this initial experience, they may feel more efficacious to seek professional help from a real counselor or seek social support from friends and family. Finally, the proposed approach is expected to result in a more immersive experience with better retention of messages and higher engagement.