May 19, 2023

Journal of Medical Internet Research This paper is in the following e-collection/theme issue: September 01, 2022 Physical Versus Virtual Reality–Based Calm Rooms for Psychiatric Inpatients: Quasi-Randomized Trial Authors of this article: 2Institute of Health Care Sciences, Centre for Person-Centred Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 3Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden 4University of Gothenburg Centre for Person-Centred Care, Gothenburg, Sweden 5Region Västragötaland, Forensic Psychiatric Department, Sahlgrenska University Hospital, Gothenburg, Sweden 6Section of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 7Mediary, Stockholm, Sweden Psychiatric Department Abstract Background: Interest in sensory rooms or so-called “calm rooms” in psychiatric inpatient care has increased significantly. In a hospital setting, their purpose is to introduce a relaxing environment to increase well-being as well as to decrease anxiety and aggressive behaviors. Calm rooms can also be used as a tool to provide self-help through a convenient environment for the patients and, at the same time, strengthen the therapeutic relationship between the patient and the professional. Recent developments in virtual reality (VR) have made virtual calm rooms possible, but these have not yet been evaluated in psychiatric inpatient care. Objective: This study aimed to compare the effects of VR and physical calm rooms on self-reported well-being and physiological markers of arousal. Methods: The study was conducted in 2 inpatient psychiatric wards specializing in bipolar disorder from March 2019 to February 2021. Patients who were already admitted were asked if they were interested in using a calm room and willing to provide ratings. This study relied on the quasi-randomized allocation of patients to the wards, which either had a physical or VR calm room. Self-assessment scales (Montgomery-Åsberg Depression Rating Scale-Self Assessment [MADRS-S], Beck Anxiety Scale, and Clinical Global Impression) were used to determine the participants' baseline level of depressive and anxiety symptoms before their use of the physical or VR calm room. The study determined the state of well-being measured using an 11-point visual analog scale (VAS) as well as arousal measured by blood pressure (systolic and diastolic) and heart rate before and after the use of the calm rooms. The primary end point was self-reported well-being using the VAS. Results: A total of 60 participants were included—40 used the VR calm room and 20 used the physical calm room. The mean age of participants was 39 years and the majority were women (35/60, 58%). Analysis of VAS measurement showed improved well-being at the group level from before to after the intervention (P<.05), with no statistically significant difference in effects between the 2 different interventions. Effects were not moderated by baseline depression levels (dichotomized as MADRS-S >20 or ≤20) despite an overall difference in reported well-being between subgroups. Conclusions: Although the power in this study was low, the findings of this first study indicate comparable effects with respect to well-being and arousal of a VR calm room and a physical calm room. This suggests that a VR calm room can be a viable alternative when the use of a physical calm room is not an option for logistic or other reasons. Trial Registration: ClinicalTrials.gov NCT03918954; https://clinicaltrials.gov/ct2/show/NCT03918954 J Med Internet Res 2023;25:e42365 Overview The main objective of this quasi-randomized study was to explore the effects of a physical calm room on self-reported well-being compared to a VR calm room for patients admitted to inpatient psychiatric intensive care. We did not find any statistically significant between-group differences in relaxation effects. However, both groups reported increased well-being and decreased HR, albeit with no effect on BP. Effects were not moderated by baseline depression levels despite an overall difference in reported well-being between subgroups. To our knowledge, this is the first study to compare the effects of a physical calm room to VR relaxation. Our findings are, however, in line with previous studies on both physical calm rooms [ 1 , 3 , 5 ] and VR relaxation [ 23 , 25 , 31 , 37 ]. Our results suggest that VR relaxation can be considered when there is no opportunity to have a physical calm room due to limitations of space, safety reasons, financial limitations, or similar. Designed VR environments used in clinical therapies, such as exposure therapies for phobias, can resolve many logistic issues [ 28 , 29 ] and support patient autonomy. In addition, VR supports the ability to relax by increasing the state of mindful awareness [ 38 ]. Both VR apps and physical calm rooms have shown an increased sense of “relaxation” [ 6 ]. In our study, participants reported that overall well-being was significantly increased. Relaxation is the state of calmness that fosters positive well-being including strategies, such as breathing exercises, meditation, and guided muscle relaxation. With these strategies, high BP and HR may be lowered [ 9 ]. Effects of VR calming rooms are not explored, but there is a couple of studies that show reduced distress levels and lower HR [ 39 , 40 ]. A previous study [ 41 ] supports that HR and some other physical signs of arousal reduced after the use of multisensory treatment as well that patients felt more relaxed, focused, calm, and comfortable aligned with the results of our study and allows to draw conclusion that sensory interventions are likely to reduce distress inducing the subjective well-being in psychiatric inpatient care. Limitations of this study include lower than the planned statistical power, as well as the quasi-random allocation to the different calm room interventions. According to the initial trial design, the sample was set to include 100 participants with a diagnosis of bipolar disorder. Due to the COVID-19 pandemic, the study was paused between January 2020 and July 2020, making it unfeasible to recruit the target sample size during the study timeframe. In addition, the hospital had a lack of beds, and patients who were diagnosed with other than bipolar disorder were included in the study. The achieved sample size of 60 (40+20) allowed us to detect with 80% power, a between-group difference of d>0.78 postintervention compared to d>0.57 as originally planned. Moreover, the lack of a predefined, clinically anchored, noninferiority limit precludes us from analyzing the study using this approach. Regarding the quasi-random allocation, this was a necessity stemming from running the study at a psychiatric inpatient clinic. Allocation, in this fully naturalistic trial, was based by necessity on clinic prerequisites (eg, bed availability and staffing) and not on study-specific allocation; thus, because it was not fully randomized, allocation was nonetheless seemingly independent of participant factors that could risk confounding results. For example, patients were not allocated to the different wards (and therefore interventions) due to severity of distress. Difference in achieved sample size ratio, as well as some differences in patient characteristics and baseline measures, indicate that the allocation was not completely free of systematic influences. Moreover, almost all the physical calm room group were female (16/29, 80%) compared to an even gender distribution in the VR room group. Furthermore, patients have not had any option to choose the room they wanted to experience, but they were allocated to the respective wards. The gender imbalance considers as a limitation because we cannot report if the intervention equal associated with an induced well-being because of gender as a factor. We may assume that the gender imbalance exists toward the physical sensory room due to different preferences between women and men. Alternatively, supervising personal may assume that women prefer a sensory room. The personal have had the responsibility to check the inclusion and exclusion criteria as well as the clinical characteristics and may have excluded more male patients than females or became influenced by social norms which indicate that males not seeking help [ 42 ]. In addition, length of stay was determined for the 2 calm rooms; however, this should not be considered an outcome in itself. The importance of measuring time spent in the intervention is hard to interpret in a quantitative study and should rather be explored in a qualitative way. A previous study shows that the greater amount of time spent in sensory room did not necessarily related with stress-relieving outcomes [ 43 ]. A further limitation is that the calm modalities of VR and a physical calm room are not the same; however, the comparison of using these 2 methods for relaxation should not be affected in a serious manner. Future research could examine whether VR relaxation can decrease the use of sedatives as well as aggressive behavior in the ward. Some studies have found no link between seclusion and aggressive behavior with the use of physical calm rooms. One small study did not find a decreased frequency of self-harm during the test period, although there was a low level of participation [ 2 ]. The same applies to another small study that did not find a reduction in the rate of seclusion for 13 participants [ 44 ]. The wards included in our study primarily receive patients with a diagnosis of bipolar disorder. Therefore, when the study was planned, patients with schizophrenia were excluded due to the practical reason of them being very few in these units. However, patients with a psychotic diagnosis need to be included in future studies. Due to small sample size and lack of controlled trials, research on physical calm rooms remains inconclusive, albeit promising. However, VR technology has become affordable and more accessible, which has led to its increasingly widespread use in psychiatric care [ 45 ]. Conclusions In conclusion, both VR and physical calm rooms were associated with an improvement in overall well-being and appear to be feasible self-relaxation methods for use in psychiatric inpatient care. Furthermore, no significant differences were found between the 2 different interventions, although power was low in this first study of a VR calm room in psychiatric inpatient setting. Acknowledgments The authors want to thank all the participants. The authors also gratefully acknowledge the contribution of the participating Psychiatry Affective Departments, their managers, and in particular the area manager, Mathias Alvidius, for their support and assistance in conducting the study. The authors would also like to thank Peter Todd (Tajut Ltd, Kaiapoi, New Zealand) for third-party editorial assistance in the drafting of this manuscript, for which he received financial compensation. The Stiftelsen Psykiatriska Forskningsfonden provided partial financing for the project. Data Availability Due to local regulations, we are not able to share the data freely but raw data can be provided from the corresponding author on reasonable request. Conflicts of Interest WH founded and served as CTO of Mimerse, the company that developed the Calm Place app. Mimerse is no longer an active company and had no role in collecting or analyzing data. PL reports having consulted for Mimerse. All other authors declare no conflict of interest. References Champagne T, Stromberg N. Sensory approaches in inpatient psychiatric settings: innovative alternatives to seclusion and restraint. J Psychosoc Nurs Ment Health Serv 2004;42(9):34-44. [ CrossRef ] [ Medline ] Sivak K. 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