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    EARLY VALUE ASSESSMENT PROGRAMME

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    2 The technologies

    2.1

    Virtual reality is a simulated environment with scenes and objects that people can explore while wearing a headset or viewing a screen. This creates an immersive experience that can trigger emotional responses like those in real-world situations. Virtual reality may be used as a tool in therapy sessions or as a standalone intervention with the support of a mental health professional. It can help deliver techniques such as exposure therapy by allowing people to immerse themselves in real-world situations while being in the safety of their home or clinic. Virtual environments can be adjusted based on a person's needs and individual treatment plan. This could allow more gradual exposure to stressful situations and increased comfort in completing interventions.

    2.2

    NICE has assessed 3 virtual reality (VR) technologies for treating agoraphobia and agoraphobic avoidance. The criteria for including technologies in this assessment are in the topic scope on the NICE website. The technologies are:

    • Amelia Virtual Care (Amelia Virtual Care) for treating mental health conditions including agoraphobia. It is a software-only VR platform delivered using a VR headset. It is designed to be used by therapists as a tool to support treatment in clinics or at home.

    • gameChangeVR (Oxford VR) for treating agoraphobic avoidance in people with schizophrenia spectrum disorders or affective disorders with psychotic symptoms. It is a software-only VR therapy delivered using a VR headset. The intervention is delivered by an automated virtual therapist and is supported by a mental health professional.

    • XR Therapeutics (XR Therapeutics) for treating anxiety disorders including agoraphobia. It uses a fully immersive screen-based VR studio and is delivered in person by a therapist in combination with therapy.

    During scoping, NICE also identified Invirto (Invirto) for treating anxiety disorders including agoraphobia. The company did not respond to requests for information and no evidence was identified. So, this technology was not assessed and was excluded from recommendations.

    Care pathway

    2.3

    NICE's guideline on common mental health problems recommends a stepped-care approach for treating agoraphobia with any underlying panic disorder. The first step involves recognition and diagnosis, including identifying any comorbidities. This is used to develop a treatment plan that may involve lifestyle changes and unguided or guided self-help. If needed or preferred, more intensive treatments should be offered. NICE's guideline on generalised anxiety disorder and panic disorder in adults recommends that people with moderate to severe panic disorder with or without agoraphobia should be offered cognitive behavioural therapy (CBT) or an antidepressant. Antidepressants may be offered if the disorder is long-standing or if the person has not benefited from or has declined psychological intervention.

    2.4

    People with psychosis who have agoraphobia or agoraphobic avoidance should also be offered treatment in line with their treatment plan. NICE's guideline on psychosis and schizophrenia in adults recommends that people with psychosis are offered oral antipsychotic medication and psychological interventions including family intervention and individual CBT. Clinical experts advised that access to CBT is limited, so people are more likely to be offered antipsychotic medication with simple contact and monitoring from their mental health service.

    2.5

    Agoraphobia may further impact a person's ability to access mental health services and support. Clinical and patient experts advised that agoraphobia is often untreated or undertreated especially when it occurs with other mental health conditions. Some people with agoraphobia or agoraphobic avoidance may also stop treatment because of difficulty tolerating techniques such as exposure therapy. VR technologies may increase access to care by offering another treatment option for agoraphobia and agoraphobic avoidance. It would be used as an alternative or addition to standard care. It is not intended to replace treatment for comorbid mental health conditions.

    The comparator

    2.6

    The comparator is standard care for agoraphobia or agoraphobic avoidance. This may vary depending on a person's individual needs and preferences and may include guided self-help, CBT with exposure therapy, applied relaxation, antidepressants or simple contact and monitoring with mental health services.