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Abstract

Purpose

This study evaluated the feasibility of incorporating Virtual Reality (VR) technology into meditation exercises and using Electrocardiogram (ECG) devices for emotion regulation assessment. It also explored changes in emotion regulation, depression, and anxiety among participants.

Design

A single-arm feasibility study.

Subjects

Psychiatric hospital inpatients diagnosed by physicians with major depressive disorder or generalized anxiety disorder in the Midwestern United States (n = 25).

Intervention

VR meditation exercises 3 times weekly for 10 weeks.

Measures

Physiological coherence, as an indicator of regulated emotional state, was assessed using ECGs, while depression and anxiety were measured through survey questionnaires.

Analysis

Paired t-tests were employed to analyze changes in emotion regulation, depression, and anxiety.

Results

After 10 weeks, significant increases were observed in physiological coherence, suggesting more regulated emotional states (M = −35.25, SD = 22.25, 95% CI [−40.63, −29.86], Cohen’s d = −1.58). Reductions were also noted in depression (M = 3.48, SD = 3.29, 95% CI [1.84, 7.51], Cohen’s d = 1.06) and anxiety (M = 3.12, SD = 4.03, 95% CI [1.45, 4.78], Cohen’s d = 0.77).

Conclusions

VR is a feasible technology for meditation exercises, with observed associations with more stable emotional states, and reductions in depression and anxiety symptoms, while the application of ECG-based assessment further addresses methodological shortfalls in this population. These results highlight the potential of applying VR technology in mindfulness exercises to leverage inherent digital healthcare strengths, such as user-centered care and tailored treatment.

Keywords

virtual reality mindfulness exercise emotion regulation depression anxiety

Purpose

Major depression and anxiety are mental health disorders that frequently co-occur in the United States (U.S.). Major depressive disorder (MDD) affects over 21 million adults, while generalized anxiety disorder (GAD) impacts 6.8 million adults in the U.S.^1,2 Both MDD and GAD are linked to impairments in emotion regulation, specifically in the modulation of the intensity and duration of positive or negative emotions necessary to achieve specific goals.³ Individuals with MDD and GAD are susceptible to entering a cycle of psychological distress in which emotional dysfunction exacerbates depressive and anxious symptoms, thereby accelerating these disorders.⁴ Consequently, public health guidelines emphasize therapeutic interventions whose goal is to enhance emotion regulation and effectively manage depression and anxiety.^5,6

Mindfulness is a psychological process that involves intentionally directing one’s attention to present-moment experiences with openness and non-judgment, supporting emotional flexibility and adaptive coping. Within cognitive behavioral frameworks, mindfulness enhances self-regulation by helping individuals decenter from automatic negative thoughts and respond more effectively to stress. It facilitates goal-directed behaviors, emotional recovery, and positive reappraisal, which are essential for managing mood and anxiety symptoms.^7-9 In this context, mindfulness serves as a foundation for therapeutic programs such as Mindfulness-Based Cognitive Therapy (MBCT), which is considered an effective non-pharmacological treatment designed to recover emotional regulatory function and improve behavioral health in individuals diagnosed with MDD and GAD.^10,11 Empirical studies have demonstrated the impact of MBCT in reducing emotional distress and behavioral disorders,^12,13 and highlighted the long-term benefits of alleviating symptoms of depression and anxiety over time.^14,15

Within MBCT programs, meditation exercises are considered effective for individuals with mental health challenges to improve emotion regulation and reduce depressive and anxious symptoms.^12,15 Techniques such as focused attention and body scanning cultivate present-moment awareness and nonjudgmental acceptance of thoughts, both of which are crucial for managing emotional regulation and psychological well-being.¹⁶ These practices support a mechanism in which mindfulness meditation operates as a gating process analogous to inhibitory and excitatory neuronal processes, and it modulates the flow of maladaptive thoughts and emotions between the unconscious and the conscious awareness. By regulating this transparent boundary, it can block or attenuate maladaptive content entering awareness and thereby reduce distress and the risk of recurrence. Long-term continuous practice is more effective than short or intermittent practice, and it progressively blurs this boundary to facilitate the processing and clearing of maladaptive material.¹⁷ Furthermore, regular engagement in these exercises has been associated with the autonomic nervous system (ANS) regulation, reductions in stress markers such as cortisol levels, and reductions in depressive and anxious symptoms.¹⁸ Over time, consistent meditation exercise use leads to structural brain changes, including increased gray matter in regions associated with emotional balance and psychological health that supports long-term well-being.¹⁹

There is growing interest in digital health technology applications that can be used to improve mental health across a broad diversity of clinical settings.^20-22 Substantial evidence indicates that the benefits of digital health include enhancement of the clinical efficacy of care services and improved accessibility through individualizable treatments.^23-25 Among available types of digital health technology applications, Virtual Reality (VR) is a user-centered and audiovisual intervention that delivers non-pharmacological mental health care in a standardized manner particularly when integrated with meditation exercises.^26,27 An Immersive Virtual Reality Meditation (IVRM) program provides numerous customizable options including various types of nature scenery, background music, and mindfulness exercises, improving retention in treatment program.^28-30 The integration of virtual reality into meditation has been suggested to enhance the therapeutic impact, as IVRM provides audiovisual stimulation through VR goggles and headsets, distinguishing it from traditional meditation exercises.^28-30 Accordingly, when applied to mindfulness meditation, immersive environments can intensify attentional focus, standardize delivery, and enable context-rich practice with real-time feedback, which may strengthen the inhibitory-excitatory gating processes of conscious awareness and support long-term adherence.¹⁷

Two shortcomings have been identified in previous studies. First, there is limited preliminary research on the health benefits of audiovisually stimulating meditation exercises, particularly in a VR environment, for individuals with MDD and GAD. While exploratory studies suggest that VR-facilitated meditation exercises have the potential to revolutionize mental health care delivery and improve health outcomes, the lack of feasibility studies in clinical settings has hindered the validation and application of these interventions among individuals with mental health disorders.^31-35 Second, measurement reliability has been a concern for individuals with mental health disorders. Self-reported assessments using survey questionnaires are often unreliable for this population due to inconsistent responses and potential biases, such as response bias, where participants may provide consistent answers regardless of their actual experiences or behaviors.^36,37 To overcome these limitations, utilizing Electrocardiogram (ECG) technology is essential for evaluating participants’ emotion regulation through sensor-based biofeedback assessment.^38,39 These gaps highlight the need for a preliminary evaluation of VR technology applications in meditation exercises, as well as ECG utilization as a biofeedback instrument in clinical settings. Thus, we tested the feasibility of an IVRM which is an audiovisual intervention for emotion regulation, depression, and anxiety, employing ECG with the aim of improving of reliability of assessments in inpatients with MDD and GAD.

Methods

Participants

We recruited participants at a behavioral healthcare unit in a community hospital in the Midwestern U.S. that provides residential psychiatric treatment for patients with mental health disorders (eg, schizophrenia, bipolar disorder, and dissociative disorders) and behavioral challenges (eg, substance abuse and suicidal ideation). The sole participant inclusion criteria of this study were that participants must have been diagnosed with MDD and/or GAD by the psychiatrists in the unit. Potential participants with schizophrenia, dissociative disorders, psychosis, or sensory challenges related to sight and hearing were excluded, as our study focused on patients with MDD and GAD, and aimed to prevent unexpected abnormal behaviors following the VR-facilitated intervention, based on consultations with attending physicians.

Study Design and Procedures

This study was a single-arm clinical trial in which participants experienced the intervention 3 times per week over a 10-week period (n = 25) (Figure 1). Of the 61 participants initially recruited, 39 met the eligibility criteria and were included in the study. Baseline measurements were taken 1 week prior to the intervention for these 39 participants. One week after the intervention concluded, endline assessments were conducted on 25 participants. Although 39 participants engaged in the program, endline assessments could not be conducted for 14 participants due to the following reasons: medication schedules (n = 1), seclusion and restraint (n = 3), and unnotified discharges (n = 10). The issue of unnotified discharges is related to the facility’s protocol, and the study was conducted in compliance with Health Insurance Portability and Accountability Act (HIPAA) guidelines. The research team was not granted access to information regarding the timing, reasons, or transportation associated with these discharges. Thus, this study is not able to provide detailed information about the 10 participants who were discharged without prior notice, as directed by their assigned physicians.

Figure 1.

Consort Diagram

Technology Application

Virtual Reality Meditation Program

We used the Meta Oculus Quest 2 and the Guided Meditation VR app (developed by Cubicle Ninjas, USA), an innovative VR meditation exercise designed to deliver immersive audiovisual experiences. IVRM provides a wide spectrum of immersive environments, including serene meadows, wooded forests, and tranquil deserts, to facilitate relaxation and inner equilibrium (Figure 2). IVRM is a personalized meditation exercises that uses immersive environments to deliver the benefits of meditation, such as positive mood, better sleep, and reduced stress.^28,29 Participants can create their preferred meditation environments using an extensive library of over 300 audio tracks, comprehensive meditation monitoring, and curated selections of contemplative settings. A 30-minute IVRM intervention was provided to participants during each session.

Figure 2.

Diverse Meditation Programs in Virtual Reality

Electrocardiogram

HeartMath, an ECG-facilitated measure, was used to assess coherence level, which reflects emotion regulation functionality. The coherence level represents the alignment of the sympathetic and parasympathetic activities of the ANS.^38,39 HeartMath measures the level of synchronization in the ANS, which encompasses the heart, brain, and other bodily systems. This synchronization refers to a measurable state where the heart rhythm displays increased orderliness and harmony, indicated by a distinct heart rate variability pattern characterized by smooth and rhythmic fluctuations in beat-to-beat intervals.⁴⁰

Measures

Emotion Regulation

HeartMath uses electrocardiography to assess physiological coherence, as an indicator of regulated emotional state, based on the alignment of the ANS. Coherence level is recalibrated every 5 seconds during a session, and these individual scores are summed to generate a total coherence level for the entire session.⁴⁰ Higher coherence scores indicate alignment between the sympathetic and parasympathetic nervous systems. A high coherence level indicates a serene emotional state, whereas a low coherence level signifies a more erratic emotional state.^38,39 Consequently, an increase in coherence level may indicate greater ANS alignment at the time of measurement, which is associated with a more regulated emotional state rather than necessarily reflecting improved emotion regulation ability. A 10-minute coherence level assessment was conducted 1 week before and 1 week after the participation in the study intervention.

Depression

Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), a widely validated tool.⁴¹ The PHQ-9 is comprised of 9 items, each rated on a four-point scale ranging from 0 (“not at all”) to 3 (“nearly every day”). An example item includes, “Feeling down, depressed, or hopeless.” Total scores range from 0 to 27, with a score of 20 or higher indicating severe depression, and higher scores reflecting higher levels of depression. The PHQ-9 assessments were conducted 1 week before and 1 week after participation in the study intervention. The scale demonstrated adequate internal consistency, with Cronbach’s α values of 0.71 at baseline and 0.74 at the conclusion of the intervention.

Anxiety

Anxiety was assessed using the Generalized Anxiety Disorder-7 (GAD-7) instrument, a validated measure that consists of 7 items designed to evaluate the psychological state of participants over the previous 2 weeks.⁴² Each item is rated on a four-point scale ranging from 0 (“not at all”) to 3 (“nearly every day”), measuring aspects such as nervousness, anxious feelings, excessive worrying, and irritation. An example item includes, “Not being able to stop or control worrying.” Total scores range from 0 to 21, with a score of 15 or higher indicating severe anxiety, and higher scores presenting higher levels of anxiety. The GAD-7 was administered 1 week before and 1 week after participation in the study intervention. The scale demonstrated a high level of internal consistency, with Cronbach’s α values of 0.88 at baseline and 0.88 at endline.

Analysis

The aim of this study was to evaluate the feasibility of applying VR technology in meditation exercises and using an ECG device for emotion regulation assessment, as well as to explore preliminary associations with emotional state coherence, depression, and anxiety. Prior to the main analysis, demographic characteristics of the study participants were explored to provide descriptive statistics for the variables. Paired t-tests were conducted to evaluate mean differences, t-values, 95% confidence intervals, and effect sizes for changes in the study variables before and after intervention participation. All analyses were conducted using SPSS Statistics version 29.0.

Ethical Consideration

This research protocol for this study was submitted to and approved by the Institutional Review Board (IRB: IU#17808) of the sponsoring institution. Before beginning data collection and the use of the study intervention, written consent was obtained from either the patients or their legally designated representatives. Participants were provided with information about the title, objectives, duration, type, and participation requirements of the study to ensure full comprehension of the study aims and procedures. All study research was conducted in strict accordance to the protocol approved by the institutional IRB.

Results

Table 1 presents the demographic characteristics including participant age, sex, marital status, educational level, and perceptions of health. A total of 25 participants were included in the study, with ages ranging from 18 to 71 years (M = 42.51, SD = 19.60). The sex distribution included 44.0% males (n = 11) and 56.0% females (n = 14). Regarding marital status, the majority of participants were widowed (64.0%, n = 16), followed by those who were never married (16.0%, n = 4), married (16.0%, n = 4), and separated (4.0%, n = 1). Educational level varied among participants, with 56.0% (n = 14) having graduated from high school, 24.0% (n = 6) possessing some college education, 16.0% (n = 4) having completed some high school, and 4.0% (n = 1) holding a college degree. In terms of general health status, 36.0% of participants reported their health as good (n = 9), 24.0% as fair (n = 6), 20.0% as very good (n = 5), and 12.0% as poor (n = 3). A small number of participants preferred not to disclose their health status (4.0%, n = 1), while another 4.0% reported excellent health (n = 1).

Table 1.

Demographic Characteristics

Characteristics	n	%
Age
18 to 71 years old (mean = 42.51 SD = 19.60)	25	100
Sex
Male	11	44.0
Female	14	56.0
Marital status
Married	4	16.0
Separated	1	4.0
Widowed	16	64.0
Never married	4	16.0
Education
Some high school or lower	4	16.0
High school graduate	14	56.0
Some college	6	24.0
College graduate	1	4.0
General health
Excellent	1	4.0
Very good	5	20.0
Good	9	36.0
Fair	6	24.0
Poor	3	12.0
Prefer not to answer	1	4.0

Table 2 presents the descriptive statistics of the study variables. We found that emotion regulation at the endline (M = 89.94, SD = 35.27) descriptively improved from the baseline (M = 54.69, SD = 22.95), that depression scores were lower at the endline (M = 26.16, SD = 2.56) compared to the baseline (M = 29.64, SD = 3.71) and that anxiety scores decreased from the baseline (M = 23.45, SD = 2.14) to the endline (M = 20.33, SD = 4.08).

Table 2.

Descriptive Statistics

Variables	Mean	SD	Cronbach’s α
Emotion regulation - baseline	54.69	22.95
Emotion regulation - endline	89.94	35.27
Depression - baseline	29.64	2.56	0.71
Depression - endline	26.16	3.71	0.74
Anxiety - baseline	23.45	2.14	0.88
Anxiety - endline	20.33	4.08	0.88

Total n = 25.

The paired t-test analyses (Table 3) revealed significant differences in emotion regulation, depression, and anxiety means before and after the intervention. Based on the ECG assessment results, we found significant change in emotion regulation (M = −35.25, SD = 22.25, 95% CI [−40.63, −29.86], t = −13.05, Cohen’s d = −1.58), demonstrating increased physiological coherence, which may reflect more regulated emotional states. These results showed increased synchronization between sympathetic and parasympathetic activities in the ANS, which may be associated with more stable emotional health. Further, the self-reported assessment results revealed significant changes in depression (M = 3.48, SD = 3.29, 95% CI [1.84, 7.51], t = 3.40, Cohen’s d = 1.06) and anxiety (M = 3.12, SD = 4.03, 95% CI [1.45, 4.78], t = 3.86, Cohen’s d = 0.77) following the participation in the IVRM intervention.

Table 3.

Changes in Emotion Regulation, Depression, and Anxiety (Baseline – Endline)

Variables	Mean	SD	t	Sig	95% CI		Cohen’s d
Variables	Mean	SD	t	Sig	Lower	Upper	Cohen’s d
Emotion regulation	−35.25	22.25	−13.05	.00*	−40.63	−29.86	−1.58
Depression	3.48	3.29	3.40	.00*	1.84	7.51	1.06
Anxiety	3.12	4.03	3.86	.00*	1.45	4.78	0.77

Total n = 25, 95% CI = 95% Confidence Interval.

*P < .05.

Discussion

This study evaluated the feasibility of incorporating VR technology into meditation exercises and integrating ECG devices to assess emotion regulation. It also explored changes in emotion regulation, depression, and anxiety among inpatients diagnosed with MDD and GAD. The results showed that participants experienced reduced levels of depression and anxiety and an increase in physiological coherence, suggesting more regulated emotional states after participating in the IVRM intervention. These preliminary findings suggest that VR technology in meditation exercises may have potential as a therapeutic tool associated with reduced depression, anxiety, and more stable emotional states among individuals with mental health issues. This suggests that VR-based mindfulness programs have the potential to be a novel treatment for enhancing the emotional and mental health of patients with MDD and GAD.

The inherent strengths of VR technology make IVRM an advanced therapeutic intervention for mental health rehabilitation among individuals with MDD and GAD, even though feasibility evaluations of digital healthcare devices still need to be conducted.^26,27 Digital health technologies are designed as user-centered experiences tailored to individual preferences and are also referred to as innovative applications of MBCT programs, aimed at reducing psychological distress in individuals with mental health challenges.^26-28 For example, while the feasibility of health technology remains unproven, a VR-based meditation exercise accommodates participant preferences by offering a wide range of meditation techniques, background music, remote learning options, and immersive environments.^43,44 Building on this foundation, our study evaluated a VR-based meditation exercise, revealing its preliminary health benefits in reduced depression and anxiety, and increased physiological coherence reflecting more regulated emotional states in patients with MDD and GAD, similar to the traditional therapeutic benefits of MBCT programs.^12-16 These evaluation results provide evidence supporting the use of VR technology in meditation exercises as a feasible therapeutic tool, with preliminary evidence of associations with improvements in emotion regulation, depression, and anxiety in this population.

Previous studies have raised concerns about the reliability of self-reported data, including surveys and interviews, collected from individuals with mental health issues.^36,37 These studies emphasized the importance of using biofeedback devices to assess mental health in this population due to limited responses and potential response biases. To address these methodological issues, our study tested the feasibility of biofeedback devices to objectively assess emotion regulation, thereby strengthening assessment reliability and addressing research gaps related to the lack of objective assessments in prior studies. Through this study, we found that ECG is a feasible instrument for assessing emotion regulation, which can contribute much-needed measurement rigor for individuals with mental health issues.

Limitations and Future Studies

The findings of this study are subject to several limitations inherent to its design. First, we used a single-arm design with inherent biases and errors. Selection bias arising from pre-existing differences in participant characteristics limits the generalizability of the study findings beyond the population included in this study.^45-47 Despite these limitations, this study provides preliminary evidence supporting the application of VR technology in MBCT programs, as well as the use of ECG devices to increase assessment reliability. The lack of a control condition further limits the ability to draw causal conclusions about the intervention’s effects. Future studies should incorporate a randomized controlled trial design to better account for potential confounding variables and strengthen the validity of findings.⁴⁸ Second, the characteristics of the study population and facility may have introduced bias. This study was conducted in a behavioral health unit that provides scheduled mental health care, including psychiatric medication and seclusion. The withdrawal of 14 out of 39 participants during the intervention period prevented an endline assessment of these individuals. The dropout rate of 35% among participants may have introduced bias defined as the unfair influence on participants, which could potentially affect the validity of the results. To address these limitations, employing statistical methods such as intention-to-treat analysis can account for missing data and minimize potential bias introduced by dropouts. Comparing the characteristics of participants who remained with those who left can further ensure the accuracy and reliability of the study results. Third, this study did not include technology acceptance in the analysis. However, as technology acceptance is closely linked to the perceived benefits of VR-based interventions, its absence is a noted limitation. Assessing technology acceptance is necessary for evaluating the clinical impact of IVRM use, as low levels of participant acceptance may hinder full immersion in VR environments.¹⁸ Future studies should account for baseline VR technology acceptance levels to better understand the benefits of therapeutic interventions. Lastly, while our findings showed increased coherence levels during the intervention, we acknowledge that this should not be interpreted as direct evidence of improved emotion regulation ability. Rather, these results reflect a more regulated emotional state at the time of measurement, and do not necessarily indicate an enhanced capacity for emotion regulation. Future research should incorporate additional independently validated measures, beyond HeartMath-based assessments, to strengthen interpretation and avoid conflating observed physiological indicators with underlying latent psychological constructs.

Conclusion

This study found that VR technology is feasible for use in meditation exercises for individuals with MDD and GAD, while also demonstrating the feasibility of sensor-based biofeedback devices to address methodological shortfalls for this population. The results indicated that the participants reported improvements in emotional health and with reductions in depression and anxiety symptoms observed after 10 weeks of IVRM participation. Furthermore, the ECG-based assessment approach was shown to be a reliably feasible method for measuring emotional changes during the intervention. These results underscore the potential of applying VR technology in MBCT to leverage inherent digital healthcare strengths, such as user-centered care and tailored treatment for individuals with MDD and GAD, as well as highlight the need for larger-scale studies with control groups to establish causal conclusions.

So What?

What is Already Known on This Topic?

Meditation exercises are impactful in enhancing emotion regulation and reducing depressive and anxious symptoms in individuals with mental health challenges. Virtual Reality (VR) provides a user-centered, audiovisual, non-pharmacological intervention that standardizes mental health care, particularly when integrated with meditation practices.

What Does This Article Add?

We found that using VR technology in meditation exercises is a feasible therapeutic tool, providing preliminary evidence of associations with improved emotion regulation and reduced depression and anxiety in this population. Furthermore, we found that electrocardiogram-based assessment devices are applicable instruments for assessing emotion regulation, providing much-needed measurement rigor for individuals with mental health issues.

What are the Implications for Health Promotion Practice or Research?

This suggests that VR-based mindfulness programs could serve as innovative therapeutic interventions, leveraging inherent digital healthcare strengths, such as user-centered and tailored treatments for patients with mental health issues.

Footnotes

Author’s Note

This manuscript has not been published or will not be submitted elsewhere for publication while being considered by the American Journal of Health Promotion.

ORCID iDs

Jungjoo Lee

Junhyoung Kim

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research project was carried out with the support of the “Research Grant Program: The Effect of Virtual Reality Meditation on Emotional Regulation: A Pilot Study” provided by the National Council for Therapeutic Recreation Certification (NCTRC).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data supporting the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and/or ethical restrictions.*

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Applying Virtual Reality in Mindfulness Exercises for Emotion Regulation and Mental Health Among Inpatients With Behavioral Issues: A Feasibility Study

Abstract

Purpose

Design

Subjects

Intervention

Measures

Analysis

Results

Conclusions

Keywords

Purpose

Methods

Participants

Study Design and Procedures

Technology Application

Virtual Reality Meditation Program

Electrocardiogram

Measures

Emotion Regulation

Depression

Anxiety

Analysis

Ethical Consideration

Results

Discussion

Limitations and Future Studies

Conclusion

So What?

What is Already Known on This Topic?

What Does This Article Add?

What are the Implications for Health Promotion Practice or Research?

Footnotes

Author’s Note

ORCID iDs

Funding

Declaration of Conflicting Interests

Data Availability Statement

References