Metaverse for mental health disorders: Opportunities and challenges

Abstract

Several articles on the mental health impact of the metaverse and the need to balance its potential benefits with the risks of metaverse use has recently published. The metaverse consists of a combination of immersive technologies and artificial intelligence algorithms. The metaverse differs from the preceding digital psychiatric interventions due to its complex structure and interactions between components. The diverse functions of the metaverse ensure that it may have a substantial impact on mental health. However, the evidence for its efficacy in treating mental health disorders is limited to a few trials. The mental health benefits of immersive technologies are well-documented and suggest that metaverse-based psychiatric treatment may be similarly efficacious. The mental health risks of the metaverse are largely unknown, and it is not clear whether they will be greater than other digital psychiatric interventions. Much more research is needed to determine whether metaverse-based psychiatric treatment will meet the standards of appropriate mental healthcare.

Key Words: Metaverse; Mental health; Benefits; Risks; Challenges

Core Tip: The metaverse is a complex digital technology with diverse functions. It differs from other digital psychiatric interventions because of its distinctive features. The unique features of the metaverse suggest that it can have a substantial impact on mental health. However, the evidence for its efficacy in treating psychiatric disorders is limited, and the potential mental health risks of the metaverse are unknown. Further research is needed to define the role of metaverse-based interventions in mental healthcare.

INTRODUCTION

The World Journal of Clinical Cases has recently published several articles on the impact of the metaverse on mental health. In their review, López del Hoyo et al[1] define metaverse as a combination of immersive technologies such as virtual reality (VR) and augmented reality (AR) coupled with artificial intelligence (AI) and highlight features such as the fusion of the virtual and physical world, interactive aspects, and the sense of presence. They mention the potential of the metaverse in preventing and treating mental health problems, noting that the evidence for its efficacy is limited. They end by reviewing the challenges and concerns involved in the use of metaverse for mental health disorders. Pandi-Perumal et al[2] suggests caution in balancing the potential benefits with the likely dangers of the use of metaverse for mental health. She concludes that “who will benefit and at what cost” is not certain. In their editorial, Chen et al[3] re-emphasize the technological imperfections and concerns about the unrestricted use of metaverse. Like the others, they suggest that it is not clear whether the mental health benefits of metaverse will prove to be superior to other modes of treatment.

BACKGROUND

The World Health Organization’s World Mental Health Report, 2022 found that 13% of the global population suffered from a mental illness in 2019[4]. These rates have increased since the coronavirus disease 2019 pandemic. Apart from their high prevalence, mental disorders are also significantly disabling. They account for about 5% of the global burden of illness-related disability and about 16% of the years lived with disability. The mental health burden is higher in low- and middle-income countries (LMICs). About 82% of those with mental illnesses live in these countries. Human, economic, and infrastructural resources for mental healthcare are limited in LMICs. This resource gap leads to a large treatment gap. Only 5%-15% of the people with mental disorders in LMICs receive the treatment they require. The report also endorsed using digital technologies to reduce the treatment gap and achieve universal mental health coverage. Over the past seven decades, digital technologies such as phones, computers, videoconferencing, and internet or mobile phone-based tools have delivered mental health services. The metaverse is the latest of these digital technologies with potential psychiatric applications.

The metaverse is an Internet-based digital platform that blends virtual environments with enhanced physical environments. Its components, VR, AR, mixed reality, extended reality (XR), and AI, enable users to experience the virtual environment in real-time, synchronously, interactively, continuously, and immersively[5-7]. The advent of the metaverse heralds the fourth industrial revolution and the next generation Internet[8-10]. It supersedes the third revolution of information communication technology by expanding the scope of digitization and automation at an unprecedented pace[8,11]. However, the metaverse is still evolving, and there is a lack of clarity about its eventual form, which gives rise to uncertainty about its positive and negative impacts on mental health[11-13]. The metaverse is perhaps the most complex and sophisticated digital technology thus far, with diverse functions that can impact daily lives, business, education, and healthcare (Table 1)[7,9,11,14,15]. The medical uses of the metaverse are particularly relevant for mental healthcare[9,10-12,16].

Table 1 Metaverse: Structure and functions[7,9,11,14,15].

Core technologies	Features	Functions
Virtual reality involves immersion of the user in real-life like virtual environments employing headmounted displays, haptic device simulators and computerbased simulations. It creates a sense of presence and allows interaction with the environment	Three-dimensional experience. Virtual environment- non-tangible and digitally created. Immersive experience - complete transportation to and sensory engagement in virtual environments. Multimodal representations, content, and interactions involving all types of sensory stimuli. Interoperable network - the ability of components to work together and exchange information. Multi-user capability - in theory, unlimited number of users. Scalable – ability to expand to meet demands of users. Shared, interactive and collaborative. Decentralized - control lies in the hands of users. Avatars – digital representations of the user, controlled by users. Embodiment – sensing and feeling of ownership of avatars. Real-time - events are portrayed at the same rate at which the characters experience them. Integrity and data security – provided by blockchain technology. “Mirror world” – a virtual world that reflects an expanded version of the real world. “Virtual world” - a metaverse world peopled by avatars that is separate from reality. Fusion of the physical and virtual worlds – real and virtual world actions impact each other. Synchronous experience. Sustainable and persistent experience. Continuity – identity, experience, functions remain the same. “Lifelogging” – captures and shares daily life experiences of users. Individual sense of presence – sense of being there. Socially meaningful content- content that incorporates social values, which promotes user immersion	Basic functions: Socialization - social networking, social connectedness, social influence. Learning – social and other forms of digital learning. Cognitive and physical activation. Emotion regulation. Self-determination – autonomy, self-efficacy, sense of achievement and competence, self-awareness, control of self and environment
Augmented reality superimposes digital information on to the physical world using smartphones, smart glasses, or head-mounted displays. It allows users to interact with virtual objects in the real world
Mixed reality fuses elements from both the physical and digital worlds and allows interactions between these worlds during immersion. It enables greater control over the virtual objects than augmented reality
Extended reality includes virtual, augmented and mixed realities
Artificial Intelligence, machine learning, and big data analysis create dynamic, interactive, and user-responsive environments, predict user behavior, and guide user choices
Blockchain technology refers to secure storage of data in blocks linked together in a chain. The stored information is accessible but cannot be changed		Functions that impact mental health: Stress reduction. Social acceptance and support. Induces positive affect and improves life satisfaction. Improves wellbeing. Improves coping skills. Improves behavioral and social skills. Group interactions improve self-expression, understanding of self and others, communication and social skills
Edge/cloud computing: The process of bringing computation and storage elements closer to the network edge using cloud architecture
Internet of Things refers to the collective network of connected devices and the technology that facilitates communication between these devices and the cloud
Digital twin technology establishes a virtual twin of a real-world object, connects the digital representation to the real object, and predicts the behavior of the real-world object by real-life simulations
Non-fungible tokens are digital certificates of ownership and authenticity for digital or physical assets
Digital economy includes digital wallets and cryptocurrency to carry out secure digital transactions
Fifth generation internet with high bandwidth and low latency enables rapid and secure access and transactions

There is a lack of consensus regarding the relative contributions of immersive technologies and AI. With the availability of generative AI, which is a new form of AI, both technologies are equally important for the metaverse. Immersion and its accompaniments, a sense of presence, and embodiment are essential components of the metaverse experience. The AI and machine learning algorithms improve the efficiency of the metaverse, predict the outcome of behavioral choices, and personalize the metaverse experience[9,11,14,16,17]. The more pertinent issue is how the metaverse differs from earlier technologies such as VR, AR, and AI. The consensus is that the metaverse differs from the preceding digital technologies because of the additional components of mixed reality and XR, blockchain technology, and the Internet of Things. The metaverse is unique because the combined effect of all components is greater than the sum of their parts or the contribution of individual technologies[7,9,11,16,18]. The degree of immersion, the sense of presence, and the fusion of the physical and virtual worlds are greater in the metaverse due to features such as embodiment, digital twin technology, and personalization afforded by AI algorithms (Table 1)[19-21]. An influential neuroscientific theory (“predictive coding”) proposes that the metaverse resembles the mind more closely than other technologies in its ability to predict the consequences of events and the users’ actions. Lastly, the metaverse prioritizes social aspects such as social content, interaction, and collaboration more than its predecessors[7,9,15,16,20].

OPPORTUNITIES: THE ROLE OF THE METAVERSE IN ASSESSMENT AND TREATMENT OF PSYCHIATRIC DISORDERS

The potential of the metaverse: The unique features of the metaverse and the diversity of its functions can substantially impact mental health and mental health disorders[14,15,20]. Metaverse-based interventions can improve treatment access and engagement, empower users, deliver efficacious and cost-effective care, reduce stigma, and overcome other barriers to treatment similar to the existing digital psychiatric interventions[11,13,14,16,21]. Metaverse-based interventions can diagnose mental disorders, deliver pharmacological and psychotherapeutic interventions, promote early intervention, and implement preventive measures. The metaverse can improve psychiatric education and research.

Efficacy of immersive technologies: The evidence base for the efficacy of metaverse interventions in psychiatric disorders is limited[9,13,16,22]. The lack of evidence for the effectiveness of metaverse-based interventions has led to projections from the evidence on the mental health benefits of VR, AR, and XR-based interventions[1]. VR is effective for the diagnosis and assessment of psychiatric disorders such as attention deficit hyperactivity disorder (ADHD), psychosis, substance use disorders, eating, and body-image disorders[16,23-26]. The most common VR-based interventions for psychiatric disorders are VR-based exposure therapy and cognitive behavioral therapy[27]. These psychological treatments are effective in the treatment of anxiety, phobic, and post-traumatic stress disorders, and to a lesser extent for ADHD, autism, eating disorders, depression, and substance use disorders[13,16,17,21,24]. Additionally, VR is an effective tool for teaching psychiatric trainees[13]. However, the evidence base for VR and other immersive technologies has several methodological flaws. There are few randomized-controlled trials, findings are heterogeneous, and the chances of publication bias are high[12,13,15,16,24]. The risks of VR and XR-based treatments are unclear, and the application of these treatments in clinical settings is limited[13].

The evidence for the efficacy of the metaverse: López del Hoyo et al[1] have pointed out that the therapeutic potential of the metaverse for psychiatric disorders has not been realized yet because of the lack of evidence for the efficacy of metaverse-based interventions. Although the reports on the healthcare uses of the metaverse have grown in the past few years, most of them are reviews rather than clinical trials[9]. Very few trials have examined the effectiveness of the metaverse in disorders such as autism, female sexual dysfunction, social anxiety disorder, depression, and psychotic disorders[9,13,16,18,22]. Table 2 includes some examples of metaverse-based treatments[28-34].

Table 2 Metaverse-based interventions in psychiatric disorders: Examples.

Ref.	Study	Findings
Yellowlees and Cook[28], 2006	Pilot study using the Second Life metaverse platform to simulate auditory and visual hallucinations of patients with schizophrenia. Five hundred seventy-nine users competed the tour and recorded their responses	The majority of users reported that the virtual tour improved their understanding of hallucinations and that they would recommend it for others
Hoch et al[29], 2012	Mindfulness and relaxation-based resiliency training using the Second Life metaverse platform in 24 healthy participants	The intervention was feasible and acceptable to the participants. It led to reduction in stress, depression, and anxiety. The effects were comparable to in-person interventions
Yuen et al[30], 2013	Feasibility, acceptability, and efficacy of an acceptance-based therapy using the Second Life metaverse platform in 14 people with social anxiety disorder	Participants and therapists rated the intervention as feasible and acceptable. The intervention led to improvements in social anxiety, depression, disability, and quality of life
Matsangidou et al[31], 2022	Feasibility trial of a “Multi-User Virtual Reality”-based remote psychotherapy in 13 participants with eating disorders	Feasibility, acceptability, and the usefulness of the application was demonstrated. High levels of immersion and sense of presence were the key to success
Lee et al[32], 2023	Open-label, single-center, pilot parallel randomized controlled trial of 15 children with high-functioning autistic spectrum disorder. Treatment consisted of a metaverse-based social skills intervention delivered via the metaverse platforms (Roblox) and Zoom	The intervention was significantly more effective than the control treatment in improving social interaction, social cognition, social communication, and autistic mannerisms. The intervention enhanced mental health, reduced emotional and behavioral problems in children, and distress among parents
Vila et al[33], 2024	Randomized controlled trial of avatar-based psychotherapy using the Second Life metaverse platform in 31 women with female orgasmic disorder. The intervention consisted of 12 weekly sessions based on cognitive behavioral and acceptance and commitment therapy	Compared to the control group, participants in the avatar-based intervention showed a significant improvement in reduction of a sexual disorder diagnosis, improved sexual satisfaction, sexual function, initiative and sexual communication, and sexual self-esteem, reduced guilt about sex, and sexual anxiety, and enhanced adherence
Vila et al[34], 2024	Qualitative analysis of attitudes to metaverse-based psychotherapy for psychiatric and sexual disorders among 21 participants of either gender	Attitudes towards metaverse-based treatment were favorable for both psychiatric and sexual disorders. The main reason was improved access to psychological treatments through the metaverse

It is not clear how metaverse-enabled psychiatric interventions will add to currently available VR or XR-based interventions[12,13,16]. Although metaverse-based interventions are likely to be helpful in disorders that respond to VR-based treatments, the specific advantage of the metaverse in treating these conditions is uncertain[16]. The metaverse differs from the existing digital technologies in its diversity and sophistication. Therefore, it has the potential to provide more comprehensive, effective, and accessible mental health care than the existing digital interventions[13,16,17]. Additionally, metaverse-enabled interventions could be more advantageous in areas like digital phenotyping, neuromodulation treatments such as repetitive transcranial magnetic stimulation, and psychiatric education[13]. However, the existing literature on metaverse-enabled interventions does not support these possibilities.

CHALLENGES

Apart from the uncertainty regarding the efficacy of the metaverse in treating psychiatric disorders, the negative impact of the metaverse on mental health is also unclear due to the lack of evidence. The existing literature suggests that the adverse effects of the metaverse are similar to other digital interventions. They include negative psychological and physiological consequences and the technical, social, and economic challenges of implementing metaverse-based treatments[12,35,36]. Similar concerns about inequalities in access, privacy, security, confidentiality, costs, technological barriers, and lack of regulations governing the metaverse exist for metaverse-based psychiatric interventions[13,35-37]. The list of potential harms is also a long one. It includes addiction, loneliness, social isolation, burnout, fatigue, sleep disturbances, sedentary lifestyles, and harassment and bullying[18,21,24,35,38]. The ethical concerns about the use of metaverse for psychiatric disorders are also comparable to the concerns expressed about the existing digital technologies. They include widening the digital divide, the conflict between commercial interests and patient welfare, the propagation of false information, and the protection of vulnerable groups such as children[18,35,39,40].

The detrimental consequences of digital technologies arise from the gap between the rate of technological change and the users’ ability to adapt to the change[41]. Since this gap is wider with the metaverse than existing digital technologies, its negative impact may be more extensive. However, this may not be always true. For example, a recent study found that the addictive potential of the metaverse was similar to VR and social media interventions[38]. The contrary findings indicate that the mental health impact of the metaverse is likely to vary depending on cognitive development, sociodemographic influences, and past mental health[20].

RECOMMENDATIONS

Although the metaverse-delivered mental health treatment is still in its early stages, recommendations about its use have been made based on the research on the existing digital psychiatric interventions.

Entrepreneurs/innovators: There should be further research on protecting the users’ rights such as privacy, security, and freedom from harassment[12,24]. Any information on the positive or negative effects of the metaverse should be made public. There is a need to adequately examine the new applications of the metaverse before and after they are marketed.

Providers/practitioners: The need for further research into the effects of the metaverse is clear. Both positive effects and negative impacts of the metaverse need to be examined[9,38]. Randomized controlled trials with sufficient sample sizes are required to investigate the efficacy of the metaverse in different psychiatric disorders. Studies on adverse effects will also require large samples, which can determine the magnitude and causal direction of these effects. Studies examining the implementation and integration of metaverse-based interventions in mainstream mental healthcare services are required. The research on the mental health effects of the metaverse should include all stakeholders, corporations, researchers, providers, users, and governments[20].

Policymakers: The principal suggestion is to classify metaverse-enabled psychological interventions as medical devices so that all the standards regarding the utility and safety of these interventions can regulated and monitored[12]. Educational measures to improve the awareness of the users about metaverse-based psychiatric treatment should be introduced[24].

CONCLUSION

The mental health effects of the metaverse are largely unknown. The claims about its transformative potential often arise from the tendency to overestimate the impact of any digital technology early in its development[12,24]. Metaverse-based interventions have a long way to go to meet the standards of appropriate mental healthcare such as access, equity, effectiveness, quality, and respect for the patient’s rights[37]. Further research will provide some answers, but similar to other digital technologies, the metaverse’s eventual role will probably be as a gateway or adjunct to in-person psychiatric care.