Impact of virtual reality-based biofeedback on sleep quality among individuals with depression and anxiety: a 4-week randomized controlled study (Preprint)

BACKGROUND Depressive disorders, projected by the WHO to rank third in global disease burden by 2030, significantly impair quality of life, with over 300 million affected worldwide. Sleep difficulties, particularly insomnia, are closely linked to depression, exacerbating its severity. Biofeedback (BF) therapy, specifically heart rate variability biofeedback (HRV-BF), shows promise in treating insomnia and associated depressive symptoms. Recent studies suggest that integrating virtual reality (VR) into BF therapy could enhance its efficacy by creating immersive, calming environments that improve sleep quality. This study explores the potential of VR-based BF to improve sleep in individuals with depression and anxiety. OBJECTIVE To investigate impact of virtual reality-based biofeedback (VR-based BF) on sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) of individuals with depressive or anxiety symptoms. METHODS Between December 2019 and February 2022, 131 adult volunteers were recruited at Samsung Medical Center, Seoul, South Korea. Individuals with specific medical or psychiatric conditions were excluded. Those with depressive and anxiety symptoms (DAS) were randomized into VR (n = 40) and BF (n = 38) groups by computer-generated random number. A Healthy Control (HC, n = 40) cohort with sham intervention mirroring the DAS/VR group was also included. Over three visits, participants received VR-based BF or conventional BF with a therapist. Iterative baseline and 4-week follow-up PSQI assessments were performed. Following intervention, subcomponent scores of the PSQI decreased in both DAS/VR and DAS/BF groups. RESULTS After 4-week intervention, a decrease in global PSQI scores was observed across all groups. For Global PSQI score, the DAS/VR group demonstrated a substantial reduction from 9.70 (±2.49) to 7.20 (±2.46) (p<0.001), and the HC/VR group from 5.85 (±2.39) to 4.90 (±2.11) (p=0.007). Notably, improvements in sleep quality, latency, disturbance, and day dysfunction were statistically significant in the DAS/VR groups but not in sleep duration, efficiency, and sleep medicine uses. CONCLUSIONS This study provides evidence that VR-based BF can serve as effective psychological intervention for enhancing sleep quality of individuals experiencing symptoms of depression and anxiety, and also effective in health subjects.