Impact of cybersickness and presence on treatment satisfaction and clinical outcomes in virtual reality-based biofeedback for depression and anxiety

Abstract

Virtual Reality-Biofeedback (VR-BF) has emerged as a novel digital intervention for reducing anxiety and depressive symptoms. This study aimed to assess the relationship between cybersickness, presence, treatment satisfaction, and symptom change following VR-BF. In this prospective clinical study, 80 drug-naive adults were enrolled and classified into two groups: those with subclinical depressive and anxiety symptoms (n = 40) and healthy controls (n = 40). All participants completed three sessions of a self-developed VR-BF intervention over four weeks. Clinical outcomes related to depression and anxiety symptoms were assessed using established psychological scales, along with post-intervention evaluations of presence, cybersickness, and treatment satisfaction. Higher presence was associated with greater reductions in anxiety (ΔSTAI: β = −0.24, SE = 0.06, P < 0.001), stress (ΔVAS: β = −0.37, SE = 0.13, P = 0.008), and depressive symptoms (ΔPHQ-9: β = −0.07, SE = 0.02, P = 0.008), and with greater treatment satisfaction (β = 0.07, SE = 0.01, P < 0.001). Cybersickness was inversely correlated with presence (ρ = −0.38, P < 0.001) and satisfaction (β = −0.11, SE = 0.04, P = 0.013) and was associated with smaller improvements in anxiety (ΔSTAI: β = 0.62, SE = 0.30, P = 0.044) and depressive symptoms (ΔPHQ-9: β = 0.28, SE = 0.12, P = 0.019). Female sex and older age were associated with greater clinical improvement and higher satisfaction. These findings underscore the relevance of experiential process factors in VR-BF and support further development of user-centered, tolerable, and clinically effective VR-based interventions.