2 The technologies

2.1

Virtual reality (VR) is a simulated environment with scenes and objects that people can explore while wearing a headset or viewing a screen. This creates an immersive experience that can trigger emotional responses like those in real-world situations. Some VR technologies are designed to be used by a qualified therapist as a tool in therapy sessions to support the delivery of face-to-face or remote cognitive behavioural therapy (CBT). Other VR technologies are designed to be a standalone digital intervention that can be used with the support of a wider range of mental health professionals, such as assistant psychologists, peer support workers or therapists. VR technologies can help deliver treatments such as exposure therapy, by allowing people to immerse themselves in real-world situations while being in the safety of their home or clinic. Virtual environments can be adjusted based on a person's needs and individual treatment plan. This could allow more gradual exposure to stressful situations and increased comfort in completing interventions.

2.2

NICE has assessed 2 VR technologies for treating agoraphobia (Amelia Virtual Care and XR Therapeutics), and 1 VR technology for treating agoraphobic avoidance in people with psychosis (gameChangeVR). The assessment included VR technologies that are designed to be used as tools in therapy sessions and VR technologies that are standalone digital interventions. The criteria for including technologies in this assessment are in the final scope for this guidance on the NICE website. The technologies are:

  • Amelia Virtual Care (Amelia Virtual Care) for treating mental health conditions including agoraphobia. This is a software-only VR technology that delivers VR therapy using a VR headset. It is designed to be used by qualified therapists as a tool to support treatment in clinics or at home. Amelia Virtual Care helps therapists to deliver evidence-based treatment including gradual exposure, mindfulness-based cognitive therapy and desensitisation.

  • gameChangeVR (Oxford VR) for people with schizophrenia spectrum disorders or affective disorders with psychotic symptoms, who have agoraphobic avoidance (difficulties leaving home because of anxiety). This is a software-only VR technology that delivers VR therapy using a VR headset. The intervention is delivered in around 6 weekly 30‑minute sessions. There is an automated virtual therapist within the VR environment that guides the person through the treatment for agoraphobic avoidance using CBT techniques. This is supported by a mental health professional remotely or in person.

  • XR Therapeutics (XR Therapeutics) for treating anxiety disorders including agoraphobia. This uses a fully immersive screen-based VR studio and is delivered in person by a qualified therapist in combination with face-to-face CBT. It allows therapists to tailor digital scenes to a person's individual needs. Treatment can be adapted in real time, allowing therapists to manage the rate of exposure and the intensity of situations.

    During scoping, NICE also identified Invirto (Invirto) for treating anxiety disorders including agoraphobia. The company did not respond to requests for information, and no evidence was identified. So, this technology was not assessed and was excluded from recommendations.

Care pathway

The target population for this early value assessment is people aged 16 years and over with agoraphobia. This includes agoraphobia that occurs with other common mental health problems or severe mental illness, including psychosis with agoraphobic avoidance. More information on the target conditions and care pathways can be found in the final scope for this guidance on the NICE website.

Agoraphobia without complex or severe mental health conditions

2.3

In people aged 18 and over, agoraphobia without complex or severe mental health conditions is usually treated in primary care or in NHS Talking Therapies for anxiety and depression services. NICE's guideline on common mental health problems recommends a stepped-care approach for treating common mental health disorders in adults, such as panic disorder with or without agoraphobia. The first step is identification and assessment, including identifying any comorbidities. This is used to develop a treatment plan, which may involve lifestyle changes and guided self-help based on CBT that is delivered with the support of a practitioner or therapist. If needed or preferred, more intensive treatments should be offered. NICE's guideline on generalised anxiety disorder and panic disorder in adults recommends that adults with moderate to severe panic disorder with or without agoraphobia should be considered for referral for CBT or an antidepressant. Antidepressants may be considered if the disorder is long-standing or if the person has not benefited from or has declined psychological intervention. The NHS Talking Therapies for anxiety and depression programme offers evidence-based psychological therapies for adults, including CBT, guided self-help and counselling. Agoraphobia with co-occurring complex or severe mental health conditions would not be treated in primary care or NHS Talking Therapies for anxiety and depression services, but most likely in community mental health services or inpatient services. There is no NICE guideline on treating agoraphobia in young people aged under 18. Young people with symptoms of anxiety may be assessed and treated in a range of settings, including school mental health teams, single point of access teams, voluntary sector teams and children and young people's mental health services (CYPMHS).

Agoraphobic avoidance in people with psychosis

2.4

Treatment and care for psychosis in adults is usually managed in community mental health services including early intervention in psychosis services and community mental health teams. NICE's guideline on psychosis and schizophrenia in adults recommends that adults with a first episode or first presentation of psychosis should have an assessment and treatment in early intervention in psychosis services. Longer-term treatment and care are usually then provided by community mental health teams. NICE's guideline on psychosis and schizophrenia in children and young people recommends that young people with a first presentation of sustained psychotic symptoms should be urgently referred to child and adolescent mental health services or an early intervention in psychosis service. Longer-term treatment and care may then be provided in primary care or secondary care, including early intervention in psychosis services. The clinical experts advised that there is no established care pathway for agoraphobic avoidance within psychosis services. Treatment for agoraphobic avoidance in psychosis would be integrated within standard care treatment for psychosis. People with psychosis should be offered oral antipsychotic medicine and psychological interventions including CBT and family intervention. The clinical and patient experts advised that access to CBT for psychosis varies and is limited for some people. Most adults with psychosis who are having treatment outside of early intervention in psychosis services do not have the psychological treatment recommended by NICE's guideline on psychosis and schizophrenia. They are more likely to be offered antipsychotic medicine and monitoring from their mental health service.

Access to care

2.5

Agoraphobia and agoraphobic avoidance may further affect a person's ability to access mental health services and support. The clinical and patient experts advised that agoraphobia is often untreated or undertreated especially when its symptoms occur with other mental health conditions, such as agoraphobic avoidance in people with psychosis. Some people may also stop treatment because they have difficulty tolerating treatments such as exposure therapy. VR technologies may increase access to care by offering another treatment option for agoraphobia, or agoraphobic avoidance in people with psychosis. It would be used as an alternative or in addition to standard care. It is not intended to replace treatment for co-occurring mental health conditions.

The comparator

2.6

The comparator for Amelia Virtual Care and XR Therapeutics is standard care for agoraphobia, and for gameChangeVR, it is standard care for agoraphobic avoidance in people with psychosis. This may vary depending on a person's individual needs and preferences, comorbidities and the treatment setting. Standard care treatments for agoraphobia without complex or severe mental health conditions may include guided self-help, CBT or antidepressants. Standard care treatments for agoraphobic avoidance in people with psychosis may include CBT, antidepressants or monitoring from community mental health services. Clinical experts advised that VR technologies for treating agoraphobic avoidance in people with psychosis would not be offered instead of antipsychotic medicine. So, this was not a comparator in this assessment.