Cognitive Behavioral Immersion for Depression in the Metaverse: Virtual Reality Outperforms Flat-Screens in Randomized Controlled Trial

Background: Depression is pervasive, debilitating, and increasingly prevalent. Although efficacious interventions exist, they are rarely delivered in accessible, scalable ways that retain their integrity. Cognitive Behavioral Immersion (CBI) is a metaverse-based, coach-led cognitive behavioral skills program that offers a potential solution.Objective: This web-based randomized controlled trial compared CBI delivered through virtual reality headsets (CBI-VR) or flat-screen devices (CBI-FS) to a delayed access control.Methods: Adults with elevated depressive symptoms (n = 306) were equally randomized to conditions. CBI consisted of 8 hour-long groups led by coaches who taught cognitive behavioral skills. The intervention period lasted 8 weeks. The follow-up period lasted 6 months. The primary outcome was depression symptoms. The secondary outcomes were anxiety symptoms and quality of life. All outcomes were assessed through self-report questionnaires. Hierarchical linear modeling was used to examine differences in the rate of change among conditions. We also explored sense of presence as a potential mediator of intervention response.Results: Of the participants randomized to CBI-VR and CBI-FS (n = 102 in each condition), participants attended an average of 5 intervention sessions. CBI-VR showed faster reductions and larger short-term improvements in depressive and anxiety symptoms than either CBI-FS or the control across the 8-week intervention, with improvements largely maintained over the 6-month follow-up. CBI-VR and CBI-FS showed greater improvements in quality of life than the control. The sense of physical presence in the environment mediated CBI-VR’s effects.Conclusions: Virtual reality appears to be more effective than flat-screens to deliver metaverse-based CBT coaching and may help close the depression-treatment gap.Trial Registration: ClinicalTrials.gov NCT06418997