Effectiveness of Augmented and Virtual Reality-Based Interventions in Improving Knowledge, Attitudes, Empathy and Stigma Regarding People with Mental Illnesses—A Scoping Review

Interventions adopting augmented and virtual reality (AR/VR) modalities allow participants to explore and experience realistic scenarios, making them useful psycho-educational tools for mental illnesses. This scoping review aims to evaluate the effectiveness of AR/VR interventions in improving (1) knowledge, (2) attitudes, (3) empathy and (4) stigma regarding people with mental illnesses. Literature on published studies in English up till April 2022 was searched within several databases. Sixteen articles were included. The majority of studies were conducted in the West (93.8%), within undergraduates (68.8%) but also amongst high school students, patients, caregivers, public including online community, and covered conditions including psychotic illnesses, dementia, anxiety and depression. A preponderance of these included studies which employed AR/VR based interventions observed improvements in knowledge (66.7%), attitudes (62.5%), empathy (100%) and reduction of stigma (71.4%) pertaining to people with mental illnesses. In the context of relatively limited studies, extant AR/VR based interventions could potentially improve knowledge, attitudes, empathy and decrease stigma regarding people with mental illness. Further research needs to be conducted in larger and more diverse samples to investigate the relatively beneficial effects of different AR/VR modalities and the durability of observed improvements of relevant outcomes of interests over time for different mental conditions.


Introduction
About 11% of the worldwide population suffer from a mental illness [1] and these mental illnesses remain the leading cause of substantial illness burden internationally in terms of disability adjusted life years [2]. Of note, people with mental illness often face challenges such as discrimination [3] and being literate in such conditions will allow people to have better understanding of people who suffer from mental illnesses [4].
Mental health literacy is defined as the knowledge and awareness of mental illness, including prevention, identification and management of these conditions [5]. Having a good level of mental health literacy can enhance the insight into mental illness, promote early help seeking, recovery and psychosocial functioning [6] and foster better attitudes towards patients with mental illness [7]. In addition, better awareness of mental illness has been associated with better employment [8], treatment adherence [9], stronger therapeutic alliance and lower clinical severity [10]. Regarding empathy, it is the ability to stand in the shoes of others and understand another's experiences [11]. Empathy is said to have destigmatizing effects and therefore enhance positive attitudes towards people experiencing mental illness [12]. Concerning stigma about mental illnesses, it can be viewed as a set of unwarranted and negative beliefs and attitudes about mental illness, which can potentially influence discrimination, exclusion and fear of people experiencing mental illnesses [13].
Augmented reality (AR) uses technology to combine real and digital information so that participants experience the virtual and real contexts as one [14] and AR was used in the prominent Pokémon GO game [15]. Conversely, virtual reality (VR) excludes stimulus from the real-world setting. Virtual reality consists of two types: (1) desktop virtual reality and (2) immersive reality [16]. The former allows participants to control the virtual surroundings on a computer screen while immersive reality requires the use of a headset, earphones and controllers, which detects body movements to fully immerse participants in the virtual world.
AR and VR (AR/VR) technologies are gaining popularity in the field of healthcare and health professions education [17] as they allow participants to immerse in realistic simulations thus serving as a useful tool in training and learning [18]. VR has also been utilized in psychotherapy for the past two decades [19]. Since then, the use of VR as a treatment modality has grown. Of note, there are recent studies examining the effectiveness of AR/VR-based therapeutic modalities in the management of patients with neurodevelopmental spectrum conditions (such as autism spectrum disorders, attention deficit hyperactivity disorders) [20][21][22][23], anxiety disorders (such as phobias) [24][25][26][27], obsessive compulsive disorder [28][29][30], post-traumatic stress disorder [31], and cognitive impairments in the elderly [32,33]. In comparison, there are fewer studies specifically elucidating the effectiveness of AR/VR based interventions as a psychoeducational tool such as in improving understanding of mental illnesses, engendering more positive attitudes regarding people with mental illnesses [34,35] and reduction of stigma [36,37].
In light of increasing interest in the use of AR/VR-based modalities within the mental healthcare setting, this scoping review aims to evaluate the effectiveness (as evidenced by improvements in ratings) of AR/VR-based interventions in improving (1) knowledge, (2) attitudes, (3) empathy and (4) stigma pertaining to people with mental illnesses.

Methodology
A scoping review is useful for exploring the literature broadly to identify the extant evidence on a specific topic of interest [38]. This scoping review was conducted according to the methodology of the Joanna Briggs Institute for scoping reviews [38]. We adopted a modified Arksey and O'Malley methodological framework for conducting scoping reviews updated by Levac et al. (2010) to guide the study. The first step involves identifying the main research question addressed by this review: what is the effectiveness (evidenced by improvements in ratings) of AR/VR based interventions on (1) understanding, (2) attitudes, (3) empathy and (4) stigma related to people with mental illness?
The second step involves identification of relevant studies [39]. We searched several databases (CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, Pubmed, Science Direct and Scopus) for relevant studies that examined the research question from database inception until April 2022. Keywords and combination of keywords for the literature search included: 'virtual reality' OR '(augment* reality)' AND 'knowledge', 'attitude', 'empathy', 'stigma'; '(virtual reality)' OR '(augment* reality)' AND 'knowledge' OR 'attitude' OR 'empathy' OR '(social distance)' OR 'stigma OR depression OR schizophrenia OR bipolar disorder. The inclusion criteria are as follows: (A) primary research studies on the effectiveness of AR/VR-based interventions with relevant outcomes of interest regarding people with mental illnesses, and (B) articles must be published in English. Studies were not limited by population. Studies were excluded if they were non empirical papers, opinion articles, dissertations or did not include primary outcomes of interest.
The third step involves study selection. We manually screened the abstracts of identified reports to evaluate whether they met the inclusion criteria, before reviewing full reports of these studies. Two independent reviewers simultaneously screened the titles and abstracts. In case of any inconsistency between reviewers, the disagreement was resolved by thorough discussion within the team and a third reviewer.
The fourth and fifth steps involve charting, collating and reporting the results. For each included study, we extracted variables including the author, year of publication, characteristics of participants, AR/VR based interventions, and the main findings. The preceding data were organized and summarized into a table to facilitate independent, critical assessment by the readers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart for this review is shown in Figure 1 [40].
were non empirical papers, opinion articles, dissertations or did not include primary outcomes of interest.
The third step involves study selection. We manually screened the abstracts of identified reports to evaluate whether they met the inclusion criteria, before reviewing full reports of these studies. Two independent reviewers simultaneously screened the titles and abstracts. In case of any inconsistency between reviewers, the disagreement was resolved by thorough discussion within the team and a third reviewer.
The fourth and fifth steps involve charting, collating and reporting the results. For each included study, we extracted variables including the author, year of publication, characteristics of participants, AR/VR based interventions, and the main findings. The preceding data were organized and summarized into a table to facilitate independent, critical assessment by the readers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart for this review is shown in Figure 1 [40].

Description of Studies
Overall, 16 studies were included in this review ( Table 1). The number of participants ranged from 16 to 579 in each group and included undergraduates (11 of 16 studies, 68.8%), high school students, patients, caregivers and the public, including online community. Four studies were randomized controlled trials [36,[41][42][43]. Ten studies adopted quasiexperimental design. One study was a descriptive study [44] and another a prospective cohort study [45]. Six studies were conducted in United States, three studies in Australia, two studies in Spain and one study each in Brazil, The Netherlands, Germany, Ireland and Hong Kong, respectively. Only one study examined AR-based intervention [46] while the remaining 15 studies examined the use of VR, with two utilizing a Virtual Dementia Tour intervention [47,48]. AR/VR interventions ranged from virtual interactions with characters (4 of 16 studies, 25%) [36,44,49,50], environments (4 of 16 studies, 25%) [34,41,51,52] and assuming a specific character within the study (2 of 16 studies, 13%) [43,53]. Some interventions (4 of 16 studies, 25%) also allowed the participants to experience perceptual or sensory disturbances such as auditory hallucinations [35,[46][47][48]. The other interventions (2 of 16 studies, 13%) allowed participants to view scenarios of characters suffering from mental illnesses [42,45]. Please see Appendix A for Cochrane's risk of bias rating for each study.

Knowledge about Mental Illnesses
Nine studies examined the effects of VR interventions on knowledge and awareness of mental illness with the majority (six of nine studies) showing increased knowledge about these conditions [34,44,45,47,48,51]. In terms of nature of mental conditions, three studies examined knowledge about a range of mental illnesses [36,45,49]. Five studies examined knowledge about specific disorders, namely, psychotic conditions [34,52], dementia [47,48] and one study evaluated knowledge about both depression and schizophrenia [44]. Another study examined the effects of VR intervention on medication adherence amongst patients with schizophrenia [51].
In terms of nature of intervention, the study by Formosa et al. (2018) allowed participants to interact within a virtual reality intervention that simulated danger, and found significant improvement in knowledge about the psychotic disorder. Stigma-Stop is a video game that allows players to interact virtually with characters with mental illnesses. After utilizing Stigma-Stop, more than 85% of the high school students in Spain could identify panic disorder, depression and schizophrenia, although only slightly more than half could identify bipolar disorder [36]. This was largely congruent with the findings amongst psychology undergraduates in Spain [49]. Second Life (SL) simulation, involving players in a virtual reality environment, as a teaching modality, was deemed moderately effective as a psycho-educational modality [44]. In an earlier study, participants indicated greater understanding of schizophrenia, auditory and visual hallucinations after using Second Life intervention [52]. Among nursing undergraduates in the United States, the intervention group assigned with the VR case study was less likely to rate 'do not know' when asked about the effectiveness of hospital admission and electroconvulsive therapy indicating better knowledge [45]. One study found that reminder notes and clock in the virtual environment aided in better understanding of medication adherence [51]. Two studies used Virtual Dementia Tours whereby participants experienced changes in sensory perception while engaging in everyday tasks [47,48] with conflicting findings of improved knowledge about dementia in one study [48], but not the other [47].

Attitudes toward People with Mental Illnesses
Eight studies examined the effects of AR/VR based intervention on attitudes towards people with mental illness and more than half (five of eight studies) showed improvement of attitudes following the intervention [34,35,41,46,47]. In terms of the nature of mental illness, three studies examined attitudes towards a range of mental illnesses [36,45,49], three related to psychotic disorders [34,41,46] and two studies examined attitudes towards people with dementia [35,47].
For qualitative findings that were conducted in two studies in Spain, at least half of the participants felt that they were able to help the character with schizophrenia or bipolar and more than 80% of them felt being able to help the character with depression or panic disorder after following Stigma-Stop intervention [36,49]. In a separate study by Liu et al. (2020), participants from both VR and control groups acknowledged the need for external help beyond self, thus suggesting no difference in attitudes between the two groups.

Empathy
Seven studies examined empathy towards people either with dementia [47,48,50,53] or psychotic conditions [34,41,46], and found improvements of empathy across all studies following the intervention. Specific empathy scales included the Clinical Empathy Scale [34], Comprehensive State Empathy Scale [50], and 12 item Empathy Scale [41]. In the study by Wijma et al. (2018), improvement in empathy was observed in the "Perspective-taking" subscale of Interpersonal Reactivity Index but not in the "Person centeredness" subscale.
Amongst medical students in Brazil, stigma levels were increased post-intervention [46], and students considered the VR characters with schizophrenia more dangerous than pre-intervention. Similarly, in Germany, VR intervention increased stigma when compared with both video and no intervention control groups [42].

Discussion
Overall, the majority of studies included in this scoping review were conducted in the West (93.8%), within undergraduates (68.8%) but also amongst high school students, patients, caregivers, public including online community, and covered conditions including psychotic illnesses, dementia, anxiety and depression. Amid the variety of AR/VR modalities employed within the included studies, the preponderance of these studies observed improvements in knowledge (66.7%), attitudes (62.5%), empathy (100%) and reduced stigma (71.4%) regarding people with mental illnesses.

Knowledge about Mental Illnesses
We found that the AR/VR interventions used in this review were beneficial in increasing knowledge of mental illness. The VR interventions employed in the included studies allowed participants to interact with virtual characters with mental illnesses or experience perceptual or sensory abnormalities that patients with schizophrenia or dementia experience. Such patient experiences made possible through AR/VR modalities allow the participants to gain insights into the relevant mental illnesses and could impact positively on learning outcomes [54]. For example, AR/VR modalities can enhance intrinsic motivation, engagement and facilitate deeper learning in the context of life such as scenarios [54][55][56]. These benefits have rendered learning using AR/VR more fruitful than traditional learning [57]. Of note, VR have been increasingly utilized in health professions education amongst medical students, nursing students, allied health and even patients and their caregivers [58][59][60][61]. Amongst healthcare students, virtual reality interventions have been observed to improve skill competencies, and better appreciation of symptom and illness [62]. Earlier studies have found that AR/VR interventions can be adopted to manage conditions such as specific phobias, autism spectrum disorder, psychotic conditions, substance related disorders, depression and eating disorders [23,24,63,64]. In our review, we observed that VR intervention could help to assess and enhance medication adherence amongst patients with schizophrenia (Baker et al., 2006).

Attitude towards People with Mental Illnesses
It was observed that the AR/VR interventions improved participants' attitudes towards people with mental illness. AR/VR-based simulations have the ability to expose participants to realistic experiences such as visual and auditory hallucinations, enhance understanding of the unique journeys that people with mental illnesses undergo and thereby foster better patient engagement [65,66]. The current findings are in agreement with that of an earlier review of AR/VR-based interventions in dementia which found that such modalities can potentially enhance knowledge and attitudes of healthcare professionals and trainees towards people with neurocognitive disorders [67].

Empathy
It was found that the AR/VR-based interventions were largely effective in improving participants' empathy towards people with mental illnesses. This was consistent across all intervention types including viewing of immersive VR videos of characters with mental disorders and VR interventions that allowed participants to experience perceptual disturbances. This was also consistent with earlier findings that suggested that improvements in empathy were not dependent on the nature of VR intervention [68]. The affinity between the VR character and participant was more important than the specific VR design [42,69]. Likewise, the effectiveness of the VR intervention in enhancing empathy was not dependent on whether or not the VR intervention allowed participants to adopt the protagonist character as both types of VR interventions were equally effective in some studies [34,35,44,47,51,70].
Empathy allows the observer to stand in the place of the other person, and experience compassion and loving kindness towards others whilst preserving one's sense of identity, thoughts and emotions [71]. Training programs that have included the use of VR interventions have found increased empathy towards patients with specific conditions such as dementia [72], Alzheimer's disease [73], hearing and vision loss [73] among carers, medical and nursing students.

Stigma
The misconception that people with mental disorders are unpredictable, violent or aggressive has been seen across societies [74]. Within this review, various VR modalities proved effective in reducing stigma towards mental illnesses, for example, Stigma-Stop (for range of mental conditions), Visit with Viv (for dementia), simulated hallucinations using VR that allowed participants to experience psychopathology (for psychotic disorders) and immersive animation in which participants played a character with mixed depression and anxiety (for affective and anxiety conditions).
However, two interventions found an increase in stigma levels involving an AR modality with simulated hallucinations [46], and a VR intervention whereby a character spoke about his experiences with schizophrenia [42]. There are several possible reasons to explain the increase in stigma. First, mere simulation of schizophrenia may not reduce stigma unless participants can internalize such experiences and reflect on what people with mental disorders are truly experiencing [41]. Second, the construct of stigma is complex and influenced by various factors such as internalized perspectives (micro level), interactions with people with mental illnesses (meso level) and the integrated experience involving the milieu of the healthcare setting (macro level) [75]. Furthermore, these factors may also interact with other aspects such as knowledge, attitudes and aspects of empathy to affect stigma [12,76,77]. Third, the affinity between the VR character and the participants and the likeability of the VR character are likely to influence research findings [42]. Fourth, there may be participants who were uncomfortable with VR, which can overwhelm their senses. Such sensations can be intimidating, unpleasant, thus limiting the participant's ability to engage, reflecting an increase in stigma levels [42].

Limitations and Future Research Directions
This review had several limitations. First, there were limited studies which were mostly conducted in the West amongst undergraduates, hence more future studies are warranted especially in more diverse groups internationally including within Asia. Second, the majority of the included studies had small to modest sample sizes with variable measures of outcomes. Some studies had no control group, randomization and blinding. Third, this review did not limit papers according to population, which might have contributed to the heterogeneity of the findings of included studies. Fourth, the interventions varied in terms of the types of headsets and nature of AR/VR modalities. Future research can focus on the evaluation of AR/VR-based tools in larger samples of participants (such as residents in training and healthcare professionals across different disciplines) and comparison of different AR versus VR modalities. This can be performed across different sites and adopt a standard set of rating scales over time to better evaluate the impact of such AR/VR interventions in enhancing mental health literacy, positive attitudes, empathy and reduction in stigma towards people with mental illnesses.

Conclusions
In the context of limited studies, AR/VR based interventions were found to potentially improve knowledge, attitudes, empathy and reduce stigma related to people with mental illnesses. Further research is needed to investigate the relative beneficial effects of the different AR/VR modalities and the durability of observed improvements in outcomes of interests over time for different mental conditions.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest.