Integrating Metaverse in Psychiatry for Adolescent Care and Treatment (IMPACT)

Abstract

The integration of the metaverse in healthcare has been evolving, encompassing various areas such as mental health interventions, neurological treatments, physical therapy, rehabilitation, medical education, and surgical procedure assistance. For the adolescent population, growing in the digital era and witnessing the interaction of technology with daily life has made digitalization a second nature. Despite the potential of this technology in advancing adolescent mental health care and treatment, there is a notable gap in research and development. Thus, this commentary article aims to elucidate the current landscape of emerging technologies for adolescent mental healthcare in the metaverse, identify potential challenges with its implementation in this growing population, as well as provide recommendations to overcome these obstacles.

Introduction

The metaverse refers to a shared immersive digital environment created by the confluence of physical and virtual worlds. ¹ It is a complex, persistent, and continuous three-dimensional universe where social and commercial exchanges are carried out by virtual avatars; facilitated by the integration of various technologies such as artificial intelligence (AI), virtual reality (VR), augmented reality (AR), mixed reality (MR), blockchain, etc.^1,2 In theory, this refers to a world where users can interact seamlessly with each other and the digital environment via virtual avatars which mimic actual interactions in real time. ¹

The integration of this innovative technology and its components in the healthcare sector has been evolving, encompassing various areas such as mental health interventions, neurological treatments, physical therapy, rehabilitation, medical education, and surgical procedure assistance.^3–6 For example, a 2023 Korean study found higher levels of career decision-making self-efficacy among nursing students after delivery of a metaverse-based career mentoring program. ⁷ Beyond these applications, it has also revolutionized our approach to medical research, offering us exciting prospects in diagnostics, prediction, and testing, as exhibited by a 2023 systematic review which showed that VR was effective in diagnosing and treating patients suffering from psychotic disorders.^8–10

Focusing on adolescent psychiatry, it is crucial to note that one in seven 10 to 19-year-olds experiences a mental disorder, constituting 13% of the global burden of disease in this age group. ¹¹ According to the World Health Organization, depression, anxiety, and behavioral disorders such as attention-deficit/hyperactivity disorder (ADHD) are among the foremost causes of morbidity and disability in adolescents, with 3.6–4.6% and 1.1–2.8% of youngsters afflicted by anxiety and depression respectively. ¹¹ While ADHD is said to affect 2.4–3.1% of this population. ¹¹ Despite the positive shift in attitudes toward mental health and its growing acceptance, public stigma—which refers to negative or discriminatory attitudes of people towards mental illness—remains a significant challenge in this population. ¹²

Simultaneously, adolescents exhibit higher digital literacy, making them more adept at engaging with digital tools and platforms. ¹³ Growing in the current digital era and witnessing the interaction of technology with daily life has made digitalization a second nature. According to Deloitte's 2023 digital media trends study, 40% of adolescents in the United States (US) aged 12–27 years have already used VR technology in one shape or another. ¹⁴ Another US survey reported that Generation Z participants expected to spend an average of 4.7 hours in the metaverse every day by 2027. ¹⁵ While increasing digitalization has been shown to have its own harmful impacts on adolescent mental health, such as those associated with cyberbullying or social comparison via social media, the familiarity of this population with technology and its positive attitude towards emerging technologies like the metaverse also facilitates smoother integration into the mental healthcare sector.^16–18

Considering the above, the metaverse emerges as a highly adaptable three-dimensional space that could redefine our interaction with the internet and the physical world. It can be customized to provide specific solutions for advancing adolescent mental healthcare, by aiding broadly in diagnosis, treatment, and prevention. However, despite its potential, there is a notable gap in research and development in integrating the metaverse into adolescent mental health. A 2022 systematic review of the literature regarding the metaverse in healthcare found only one article related to mental health, and no studies concerning adolescents specifically. ¹ Thus, this paper aims to elucidate the current landscape of emerging technologies for adolescent mental health, identify important challenges in its implementation, and provide recommendations to overcome them.

Current innovations

Due to the limited studies available on adolescent mental healthcare in the metaverse, this section will highlight the applications of the immersive technologies that comprise the metaverse for mental healthcare generally, with their potential to expand to the metaverse for adolescents specifically.

Data collection and visualization

VR is a valuable tool for collecting specific functional data to shape therapies and present information in an engaging, visually appealing manner. ³ For example, the VR-based diagnostic methods developed by Professor Rizzo at University of Southern California have shown promise in assessing ADHD.^19,20 One such study involved the use of a head-mounted VR display to immerse adolescents with and without ADHD in a simulated classroom environment integrated with neuro-behavior sensors, finding that the VR classroom showed great clinical potential in the assessment of ADHD. ¹⁹ These methods are extended to ADHD coaching and social-emotional learning for neurodiverse users.^21,22

Telehealth and specific interventions

VR clinics may become a reality as technology, privacy provisions, and regulatory frameworks mature. Currently, VR serves as an entry point for accessing well-researched VR-based interventions for specific conditions such as phobias, post-traumatic stress disorder (PTSD), affective disorders, addiction, and neurodiversity.^23,24 Virtual reality exposure therapy (VRET) has shown efficacy in treating specific phobias and PTSD. ²⁵ VRET involves the use of VR technology to accurately simulate fear-inducing stimuli and environments, such as those associated with specific phobias or traumatic memories. ²⁶ In contrast to in-vivo exposure therapy, VRET has the advantage of being able to closely mimic the distressing situation, in a safe and controlled artificial environment. ²⁶ Some surveys have shown that people may prefer VRET over traditional therapy. ²⁵ Especially in the context of younger patients, therapy with VR may be preferable because their fascination with this technology may persuade them to engage in treatment. ²⁶

There is an increasing interest and testing of using the metaverse as a telehealth platform. ⁹ A systematic review published in 2021 explored the effectiveness of VR applications for adolescents in hospital settings and found significant benefits in reducing pain and anxiety levels. Such applications were also found to be safe, fun, immersive, and engaging for adolescent users. ²⁷ Metaverse-based clinics are being utilized to enhance traditional telehealth for clinical consultations while introducing more immersive technologies for coaching and mentoring.^28,29 Figure 1 shows a metaverse mental health consultation in progress inside such a clinic. In its simplest form, the metaverse can serve as a psychoeducation and engagement portal. Engaging conversational AI avatars, such as those developed by Spiegel et al., can guide young people through managing their uncertainties, potentially preventing future escalations. ³⁰

Figure 1.

Mental health consultation in progress inside a metaverse-based clinic.

Cultural adaptability and social connection

Immersive technologies can be adapted to specific cultural groups, communities, and limitations, making them versatile in addressing youth mental health challenges. ³¹ They can provide global clinical and supportive interventions, overcoming geographical boundaries and effectively improving access to specialized care. ³² Acceptability and adoption of VR in this unique population is an integral component for creating future immersive experiences. A mixed-methods study at a cancer hospital involving 90 inpatients (7–19 years old) and their caregivers’ perceptions of the effectiveness of VR as a therapeutic intervention to improve psychological well-being showed high user satisfaction with ease of VR use in both populations, despite the presence of chronic and severe illness. ³³ VR has also demonstrated potential in combating feelings of displacement and loneliness, enabling young people to break the isolation pattern and build confidence to re-engage with the natural world. ³⁴ There is greater potential in utilizing such immersive communities in the development of rehabilitation programs for physiotherapy, mental health, and focus groups for adolescent patients. ³⁵

Implementation challenges

The twenty-first century has seen rapid progress in digitalization and the emergence of the metaverse has led to an accelerated growth in opportunities around how health providers can interact with clients. In tandem, these opportunities also create inherent challenges as these novel models of care can create new treatment approaches.

Privacy and security

Safety and supervision of vulnerable groups is a pressing concern with existing safeguards not yet enveloping metaverse use. This includes the critical issue of ensuring that patient health information is secure and its storage complies with data protection regulations. With well-researched digital services such as telehealth or mobile health applications, certain security measures for protection of patients are already in place. These include the use of encrypted and Health Insurance Portability and Accountability Act (HIPAA)-compliant telehealth platforms, multi-factor authentication for patients and providers, separating adolescent patient and parent portals, etc.^36,37 In contrast, the complex, immersive, and interconnected nature of the metaverse makes implementing security standards much more difficult. ³⁸

Stigma

Stigma is a major disabler for seeking mental health support in this age group, with a significant number of children and adolescents with mental health difficulties struggling to seek help. ³⁹ The perspective of youth viewing their parents as “gatekeepers” to mental health support can in turn create disabling clinical outcomes due to parental stigma. ⁴⁰ The fear of bullying among peers can further exacerbate the self-stigma experienced by children which prevents them from reaching out for mental health support on a face-to-face basis.

Accessibility

Another significant obstacle is that access to the metaverse may create a digital divide, and therefore inequalities of care. ⁴¹ Although the metaverse can help overcome common barriers to mental health services for youth—such as mobility, lack of available services and providers, and reluctance to engage in treatment—they still require access to digital infrastructure such as electricity, electronic devices, and a reliable internet connection. This would exacerbate inequalities in care, particularly among low-income groups.^2,42 Mejsner et al. explain that AI, VR, AR, the internet, robotics, and quantum computing undoubtedly have immersive, intimate, and personalized care applications useful for adolescent mental health. ⁴¹ However, there may be challenges relating to equality, as understood through the Social Determinants of Mental Health (SDMH). ⁴³ The SDMH are the non-medical factors influencing health outcomes and are associated with conditions in which people are born, grow, work, and live. The SDMH create an awareness that there is a need for healthcare providers to appreciate the client's social context and how it impacts their states of health and disease relating to mental health.^43,44 Therefore, the digital inequalities around cost may need immediate examination by governing health authorities to regulate the accessibility of the metaverse for adolescents who may not possess the financial resources to allow access. There is also a need to educate health workers on the presence of this possible inequality.

Digital literacy

This point raises the next identified challenge, namely the competency and confidence of the current mental health workforce around digital literacy. The authors suggest that these emerging technologies provide an additional dimension to contemporary skillsets, and education providers need to consider an inclusive curriculum design that demonstrates learning outcomes focusing on the metaverse. Given this specialized topic area, universities may need to share resources and expertise to create discursive learning opportunities for interpersonal learning. ⁴⁵ Embedding metaverse health into healthcare training will allow learners to integrate patient-centered skills into therapeutic engagement with their clients.

Research and funding

Lastly, the authors highlight the challenge of the lack of research and funding for resources to build metaverse infrastructure. Donkin et al. argue that action on the SDMH is required to reduce inequities. ⁴⁶ This would suggest that concerning inequalities, this could be realized as an over-reliance on traditional hospital settings and, therefore, a need to further research and establish comprehensive mental health services inclusive of the metaverse through a commitment to a new digital healthcare strategy.

Recommendations

A multifaceted approach is required to address the challenges in implementing metaverse-based mental healthcare, particularly among the child and adolescent population.

Ensuring security and safeguarding

The role of health regulatory bodies is paramount in ensuring the safety of the users reaching out for accessible mental healthcare. This has been showcased by having the virtual presence of the Ministry of Health and Prevention (MOHAP) from the United Arab Emirates’ customer happiness center inside the metaverse. ⁴⁷ Such virtual authority hubs have the potential of understanding and tackling unique challenges that may arise during the patient care experience. On another level, the role of advanced verification of user accounts in ensuring safety is critical and can be further enhanced by connecting user accounts to national identity numbers, which will allow for ease in integrating unified medical records. Furthermore, utilizing blockchain technology is an innovative way to ensure these medical records and sensitive patient health information is stored and shared securely. ¹ With its decentralized, immutable, and encrypted nature, blockchain allows patients to control access to their information via smart contracts, while also maintaining transparency and traceability to ensure accountability and audits. ⁴⁸

Parental supervision and consent to participating in treatment is of the utmost importance, and will not only provide a safe but holistic environment for families to be included in the virtual development space. This can be ensured via additional security measures for adolescents such as parent-managed accounts which allow parents to configure supervision settings and filter content. ⁴⁹ Verified parent accounts can be considered to sign digital consent forms before their child can access or receive mental healthcare inside the metaverse. To further increase the confidence of parents of children accessing mental healthcare in the metaverse, educational courses can be focused on exposure to the metaverse experience, supported by mental health professionals’ counseling on the risks and benefits of being a part of healthcare in the metaverse. Simultaneously, in order to assist children facing challenges with parental consent for mental health treatment, metaverse-based support groups can be created which would allow adolescents to connect with peers experiencing similar issues for advice and guidance. Children could also be given communication training within the metaverse, designed to aid them in approaching the subject of mental health treatment with their caregivers. And finally, the presence of mental health hotlines where children can securely communicate with social workers and counselors, who can then facilitate communication between parents and children, could also be a valuable tool in navigating the complicated issue of parental consent. The role of “youth circles” can be explored to guide younger patients to create communities for self-help and supportive groups, which can be guided by a professional to allow for regulated information-sharing in a safe space. ⁵⁰

Increasing digital awareness initiatives

This brings us to a more crucial task of upskilling the current mental health workforce on metaverse adoption through Continued Medical Education (CME) courses, and by hosting key events related to child mental health advancements using the metaverse platform. One example is a training session offered by Stanford University on the “Application of VR and Metaverse Technology in Education for Healthcare Professionals.” ⁵¹ Harvard Medical School also offers a CME course on Digital Mental Health, aiming to familiarize healthcare providers with the technologies involved in this upcoming field. ⁵² Further educational initiatives are needed with a particular focus on adolescent mental health in order to better equip practitioners with an understanding of the unique challenges faced by this population.

Prioritizing research and funding

On a stakeholder level, this calls for increased funding for developing the digital infrastructure to allow for cloud-based linking to healthcare networks. This can facilitate remote consultations and narrow the digital divide for access and cost efficiency to seek child and adolescent mental healthcare. Lastly, research on the benefits of metaverse-based interventions is vital to understand its feasibility as an augmentation to traditional approaches, while empowering the youth to seek support without associated stigma.

Conclusion

The innovative tools comprising the metaverse present promising potential solutions to ongoing issues in adolescent psychiatry. Not only can it aid in diagnosis and treatment, but it also has the potential to assist in prevention by facilitating social support, reducing stigma, and decreasing isolation among young people. However, the current healthcare landscape appears unprepared for its implementation. Further robust studies are necessary to explore the sustainability and applicability of the metaverse in the adolescent healthcare sector. In order for its benefits to be fully realized, the obstacles concerning its application must be addressed through initiatives such as inclusion of curricula-specific training and education in digital literacy for healthcare providers, active allocation of institutional resources and funding towards research and infrastructure; while ensuring patient security, and parity in accessibility and quality of care for all.