Using a Virtual Reality CAVE-Based Mindfulness Intervention to Promote Mental Well-Being in Adolescents With Anxiety Symptoms: Pre-Post Mixed Methods Pilot Study.

An 8-week group-based mindfulness intervention delivered in a CAVE virtual reality environment was feasible and acceptable for adolescents with mild-to-moderate anxiety in Hong Kong. Attendance was high, with no dropouts or adverse events. No significant changes were found in self-reported distress, anxiety, depression, stress, or trait mindfulness. However, significant improvements in heart rate variability indices—standard deviation of normal-to-normal intervals and root-mean-square of successive differences—suggest preliminary enhancements in physiological stress regulation. Qualitative feedback indicated perceived benefits in emotional regulation, stress reduction, focus, and sleep, with the immersive environment and group format as key facilitators.

Study at a glance

Abstract

Adolescent anxiety is a growing public health concern associated with significant social and emotional impairment. Mindfulness-based interventions (MBIs) have shown promise in reducing anxiety and improving well-being; however, engagement remains challenging. Virtual reality (VR)-based delivery may enhance immersion and attention, potentially addressing barriers of traditional mindfulness formats. Evidence on VR-based mindfulness interventions for adolescents, particularly in Hong Kong, remains limited. This study aimed to evaluate the feasibility and acceptability of a VR-MBI delivered via a CAVE, an enclosed VR environment with three projected walls displaying immersive natural scenes and ambient sounds, for adolescents with mild-to-moderate anxiety symptoms in Hong Kong. Secondary aims were to explore preliminary effects on psychological outcomes and physiological stress regulation and to identify facilitators and barriers to engagement. A mixed methods, single-group pre-post study was conducted with adolescents experiencing mild-to-moderate anxiety symptoms, recruited from secondary schools and youth service organizations in Hong Kong. Participants completed an 8-week group-based VR-MBI. Feasibility and acceptability were assessed using recruitment, attendance, retention, homework practice frequency, dropouts, and adverse events. Psychological outcomes were measured using the Depression Anxiety Stress Scale-21 and the Mindful Attention Awareness Scale. Heart rate variability indices, including the standard deviation of normal-to-normal intervals and root-mean-square of successive differences, were collected at baseline and postintervention using a wearable device. Focus group interviews explored participants' experiences. Paired-sample t tests and Wilcoxon signed rank tests examined pre-post changes, and qualitative data were analyzed using thematic analysis, with findings integrated through triangulation. A total of 42 participants (mean age 14.88, SD 1.90 years; 20/42, 47.6% female; 22/42, 52.4% male) enrolled and completed both assessments. Attendance was high, with 73.8% (31/42) of participants attending at least 80% (8/10) sessions, and participants engaged in regular homework practice. No dropouts or adverse events were reported. No significant pre-post changes were observed in self-reported distress, anxiety, depression, stress, or trait mindfulness (all P>.05). However, significant improvements were observed in both heart rate variability indices, standard deviation of normal-to-normal intervals (mean difference 17.6 ms, 95% CI -33.88 to -1.32; P=.04; Cohen d=0.38) and root-mean-square of successive differences (mean difference 20.20 ms, 95% CI -38.76 to -1.65; P=.03; Cohen d=0.39), which may suggest preliminary enhancements in physiological stress regulation. Qualitative findings suggested perceived benefits in emotional regulation, stress reduction, focus, and sleep, with the immersive environment and group-based format identified as key facilitators. The CAVE-based VR-MBI was feasible and acceptable for adolescents with mild-to-moderate anxiety symptoms in Hong Kong. Despite no significant changes in self-reported outcomes, physiological improvements and positive qualitative feedback suggest early benefits not captured by self-report measures. These findings support further investigation of using controlled designs and longer follow-up periods.