Jurnal Jiwa Solo

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Research Paper

Ef cacy of the Virtual Reality-Based Stress Management Program

on Stress-Related Variables in People With Mood Disorders: The

Feasibility Study

Lubna Bte Iskhandar Shah a, Samantha Torres b, Premarani Kannusamy c, Cecilia Mui Lee Chng d,Hong-Gu He e, Piyanee Klainin-Yobas e,⁎a Institute of Mental Health, Singapore, Buangkok Green Medical Park, 10 Buangkok View, Singaporeb Faculty of Health and Social Care, Dearne Building, University Of Hull, UK c Assisi Hospice, Singapored Advanced Practice Nurses, Department of Psychological Medicine, National University Hospital, Singaporee

Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research Centre Block MD11, Singapore

a b s t r a c t

This study aimed to investigate the effect of a VR-based stress management program on people with mood dis-

orders. A quasi-experimental study was conducted in a tertiary hospital in Singapore, and a convenience sample

of 22 was recruited.The programcomprised three daily 1-hour sessions incorporating psychoeducation and VR-

based relaxation practice. Participants who completed the program had signicantly lowered subjective stress

(t = 6.91, p b 0.001), depression (t = 5.62, p b 0.001), and anxiety (t = 5.54, p b 0.001); and increased skin

temperature (F = 17.71, p b 0.001), perceived relaxation (F = 26.20, p b 0.001) and knowledge (F = 13.77,

p b 0.001). Participants' feedback on the program was positive. Findings from this study contribute to improving

clinical practice and serve as preliminary data to conduct more rigorous research in the future.

© 2014 Elsevier Inc. All rights reserved.

Across the world, stress has been cited as the second most frequent

health problem af icting individuals' health and well-being (World

Health Organization [WHO], 2005). Stress refers to individuals' physio-

logical responses to anydemand perceived to be threatening to the phys-

ical, emotional or psychological health (Varvogli & Darviri, 2011). At low

to moderatelevels,stress can be benecialto the individuals. However,at

high and persistent levels, stress becomes unhealthy, causing more harm

than benet and can contribute to poor mental health (Wilson, 2009).

Several studies show that stress can trigger mental disorders, especially

mood disorders (Danese & Pariante, 2008). In Singapore, major depressive

disorder (MDD)and bipolar disorder (BD) arecommonlyfoundwith a life-

time prevalence of 5.8% and1.2%, respectively (Chong et al., 2012). Individ-

uals with mood disorders often experience illness-related stress, which

furtheraggravates their mental health problems(Wilson,2009).As a result,

the persons may encounter relationship breakdowns, occupational disrup-

tions and even premature deaths through suicide (Walsh, 2011).

Stress management interventions, including psychoeducation and re-

laxation therapy, have been developed for people with mental disorders.

Evidently, psychoeducation was ef cacious in mitigating stress-related

outcomes and enhancing patients' knowledge (Bernhard et al., 2006;

Colom et al., 2003; Gamito et al., 2010; Oaz, Hatipoglu, & Aydin,

2008; Pratt et al., 2005), and relaxation therapy helped reduce depres-

sion among participants (Chen et al., 2009; Jorm, Morgan, & Hetrick,

2009; Knubben et al., 2007; Watkins & Moberly, 2008). Furthermore,

the combination of psychoeducation and relaxation therapy appears

to reduce depression among people with dysthymic disorder (Little,

Kligler, Homel, Belisle, & Merrel, 2009). Additionally, virtual reality

(VR) technology has been increasingly used in the mental health do-

main in the past 10 years.

The VR is a set of technology (such as graphical displays with sound)

that contains a convincing interface to stimulate the immersion and/or

interaction between users and created environments (Brooks, 1999,

November/December). The users may feel like “being there” in the VR

environment after experiencing vivid visual images and accompanying

audio materials. Forpeoplewith mood disorders, theVR devicecould be

used as an innovative tool to deliver psychoeducation. It may also serve

as a powerful visual imagery tool to induce relaxation and enhance pos-

itive emotions (Ku et al., 2007). However, there is limited empirical ev-

idence to support the effects of VR on people with mood disorders,

suggesting enormous knowledge gaps in the literature.

The utilization of VR in stress management interventions is an

emerging science with promising benets. A randomized controlled

trial tested the effectiveness of the interreality (VR-based stress man-

agement program) on teachers and nursing professionals (Pallavicini

et al., 2013). In this study, participants showed signicantly lower

Archives of Psychiatric Nursing 29 (2015) 6–13

⁎ Corresponding Author: Piyanee Klainin-Yobas, PhD, RN, Assistant Professor, Alice Lee

Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research

Centre Block MD11, 10 Medical Drive, Singapore 117597.

E-mail addresses: [email protected] (L.B.I. Shah),

[email protected] (S. Torres), [email protected]

(P. Kannusamy), [email protected] (C.M.L. Chng), [email protected]

(H.-G. He), [email protected] (P. Klainin-Yobas).

http://dx.doi.org/10.1016/j.apnu.2014.09.003

0883-9417/© 2014 Elsevier Inc. All rights reserved.

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

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perceived stress in comparison to controls (Pallavicini et al., 2013). An-

other study tested the ESCAPE (VR stress management program) on

university students and public of cers (Villani & Riva, 2012). Partici-

pants had signicantly lower heart rate than those in the control

group (Villani & Riva, 2012). Little is known about the effects of VR

stress management interventions on people with mental disorders.

The VR has been used as a tool to deliver exposure therapy,

psychoeducation, and relaxation therapy in people with anxiety

disorders. A quasi-experimental study tested the virtual reality-

incorporated psychoeducation intervention on ten participants with

posttraumatic stress disorder (PTSD) and found that the participants

in the experimental group had signicantly lower depression (Gamito

et al., 2010). Similarly, another quasi-experimental research reported

that the virtual-reality based psychoeducation helped reduce anxiety

and depression among 14 individuals with social anxiety disorder

(Yuen et al., 2013). Furthermore, a randomized controlled trial (RCT)

was conducted to compare the VR-guided combined psychoeducation

and relaxation therapy with cognitive–behavioral therapy (CBT) in 39

patients with anxiety disorders (Banos et al., 2011). Findings showed

that participants in the VR group had signicantly lowered depression

and greater relaxation intensity than controls. However, there were

no signicant differences in anxiety between these two groups.

THE CURRENT STUDY

Despite the encouraging ndings, it is not known if the VR technol-

ogy is benecial for individuals with mood disorders. Furthermore,

there is a dearth of studies exploring the effects of stress management

interventions on stress-related variables in individuals with mood dis-

orders, especially in Asian populations, reecting gaps in the literature.

Guided by existing empirical evidence, we developed the three-session

VR-based stress management (VR DE-STRESS) program for people with

mood disorders. This study then aimed to test the feasibility and initial

effects of the program in a hospital setting. Research questions were:

a) would the VR DE-STRESS Program mitigate objective stress, subjec-

tive stress, depression, and anxiety among people with mood disorder?

and b) would the program enhance participants' relaxation levels and

patient knowledge?

THEORETICAL FRAMEWORK

The Neuman System Model (Neuman & Fawcett, 2002) provided a

theoretical framework to guide this study. The model focuses on

stressors; and the interaction between people and their environment,

which is an integral aspect of mental wellbeing. The Neuman System

Model comprises four major domains; person, environment, health

and nursing (Fig. 1). In this study, person refers to individuals with

mood disorders, who constantly interact with environments to achieve

a state of health and wellbeing. Environment could be the source of

stressors for the person. In this study, stressors refer to undesirable

stimuli encountered by people with mood disorders (such as hospitali-

zation and relationship breakdowns). Without proper management,

stressors may disrupt the person's equilibrium, contributing to poor

health or delayed recovery. Health in this study was represented by

levels of subjective and objective stress, depression, anxiety, perceived

relaxation and knowledge. Stress refers to the person's bio-

physiological and psychological changes in response to stressors fromthe environments. Within the Neuman System model (Neuman &

Fawcett, 2002), nursing is a profession that assists persons to achieve

and/or resume their state of equilibrium. In this study, the VR DE-

STRESSProgram representeda nursing tertiary prevention intervention,

which aimed to maintain optimal wellness by restoring balance to the

client through reconstitution. Reconstitution is the process whereby

the client utilizes resources to prevent further stress. Through the VR

DE-STRESS Program, people with mood disorder learned skills to man-

age with their stress.

Stressors Persons withMood

Disorders

The VR DESTRESS

PROGRAM

Education

Relaxation

SubjectiveStress

Objective

Stress

Depression

Anxiety

PerceivedRelaxation

Knowledge

Environment Person Nursing Health

Internal

External

Created

PhysiologicalPsychological

Sociocultural

Developmental

Spiritual

Tertiary preventionintervention

Health-relatedvariables

Fig. 1. Research framework guided by the Neuman System Model ( Neuman & Fawcett, 2002).

7L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 6 –13


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METHOD

Research Design and Sample

A single-group, pretest–posttest, quasi-experimental research de-

sign and convenience sampling were used. This study was undertaken

at a mental health ward of a tertiary hospital in Singapore. Our target

population included inpatients diagnosed with MDD and BD (with de-

pressive episode). Patients were invited to the study if they: a) aged be-

tween 21 to 65 years, b) were procient at understanding and

communicating in English, and c) were diagnosed with MDD or BD by

their attending psychiatrist. Patients were excluded if they: a) had

acute psychiatric symptoms (such as suicidal ideations, an episode of

psychosis, intellectual disability or cognitive impairment) diagnosed

by their psychiatrist, b) were pregnant, and c) had uncontrolledmedical

conditions requiring hospitalization. These conditions were excluded

because they might confound research ndings.

Participant recruitment commenced following an approval from

hospital ethics committee and hospital administrators. One of the re-

searchers (LS) liaised with clinical staff (such as advanced practice

nurses, registered nurses, and psychiatrist) to identify potential partici-

pants based on the inclusion/exclusion criteria. Then, the researcher

approached eligible patients, explained the purpose of the study, dis-

tributed the participation information sheet, and invited them topartake in the study. Patients who agreed to participate were asked to

sign a consent form in the presence of clinical staff. Subsequently, the re-

searcher scheduled the VR DE-STRESS Program at patients' convenience.

The VR DE-STRESS Program

The individual-based VR DE-STRESS Program was developed for in-

dividuals with mood disorders. The program had three daily 1-hour

sessions comprising two major components: psychoeducation and re-

laxation practice (via VR-based relaxationvideos). The psychoeducation

covered information about stress, stress management, mood disorders,

positive thinking and relaxation techniques. Furthermore, participants

practiced three relaxation techniques: abdominal breathing, muscle re-

laxation and guided imagery using a beach scenario (Table 1). Contentof the psychoeducation as well as a step-by-step guide to the relaxation

exercises were consolidated in a participant education manual (PEM)

provided to the participant in the study. At the end of the program,

participants also received a relaxation audio CD for their optional

home practice.

At the beginning of each session, the researcher brought each partic-

ipant to a private room within the ward. The psychoeducation compo-

nent was delivered via face-to-face discussion. Then, the researcher

demonstrated how to carry out the relaxation exercise based on the in-

structions in the PEM. The participants practiced the technique with

guidance from the researcher. Subsequently, they practice relaxation

techniques while wearing the VR device and viewing instructional re-

laxation videos. When the relaxation component was completed, the

VR device was removed. Finally, the researcher provided a session sum-mary of learned knowledge and skills. Time was allowed for discussion

and questions before the end of each session.

The intervention procedure was repeated for the following two ses-

sions. The delivery of the VR DE-STRESS Program was standardized for

all participants to ensure the control of confounding variables such as

the environment, mode of measurements, facilitator style and treat-

ment adherence. All participants were brought to the same room and

were requested to sit on the same cushioned chair provided. The

room was air-conditioned with room temperature maintained at 23

degree Celsius acrossall sessions. Standardizedinstruments and devices

were used to obtain measurements for all outcome variables across

participants.

The same facilitator (LS) carried out the intervention for all partici-

pants. The Intervention Checklist was used to ensure that the facilitator

strictly adhered to the intervention protocol. Additionally, the facilitator

received threetraining sessions by performingthe intervention sessions

on three simulated patients (healthy volunteers) on 3 different days.

Two investigators specialized in mental health nursing (PKY and CC)

observed the simulated sessions and provided comments for improve-

ment. After the three training sessions, the two observers agreed that

the facilitator was able to perform according to the treatment protocol.

The VR Equipment and Relaxation Videos

The VR device is a lightweight, head-mounted display (model ITG-

PCX3), suitable for one viewer (Fig. 1). The device was used to guide

the relaxation practice in the VR DE-STRESS Program. Using this device,

the participant viewed relaxation videos showcasing three relaxationtechniques; abdominal breathing, muscle relaxation and guided imag-

ery. The relaxation videos contained visual presentations, soothing au-

ditory instructions (with female voice in English) and relaxing music.

A cyber-sickness is noted as a potential side-effect of interventions

using the VR device; however, the occurrence of such incidences is

rare and minimal (Stetz, Ries, & Folen, 2011). To ensure that the VR

would not post harmful effects on people with mood disorders, a pilot

study was conducted on ve healthy individuals. They were asked to

wear theVR device while viewingrelaxation videos. During theVR ses-

sions, none of participants in the pilot trial reported undesirable symp-

toms (such as discomfort, eye problems, headache, nausea, anxiety,

among others). In this study, the facilitator alsomonitored potential un-

desirable symptoms during the intervention. People with mood disor-

ders were advised to inform the facilitator if they experienceddiscomfort when using the VR device.

Measurements

Data were collected by physiological measurements and self-reported

questionnaire. Objective stress was obtained through physiological mea-

surements of blood pressure, heart rate, and skin temperature. Blood

pressure and heart rate were measured using the Intelligence Blood Pres-

sure Monitor Model T9P (OMRON Healthcare Singapore, 2013). During

the data collection, all participantswerein a sitting position on a comfort-

able chair. A cuff was placed and tightened around their left upper arm

about1–2 centimeters above the elbow. This T9P has an accuracy/calibra-

tion of +/ −4 mmHg for blood pressure and +/ −5% of reading for heart

rate (OMRON Healthcare Singapore, 2013).Skin temperature was assessed using the SC 911 Stress Thermome-

ter (Stress Market, 2011). While participants were sitting on a chair, a

thermometer lead wire was attached on a ngerprint side of the tip of

their index nger, where skin temperature is most sensitive. The

Table 1

Content Outline of the VR DE-STRESS Program.

Session Program

1 (1 hour) Psychoeducation: Stress, its causes, symptoms and effective management techniques

VR-guided relaxation practice: Abdominal breathing, muscle relaxation, and guided imagery (using a beach scenario)

2 (1 hour) Psychoeducation: Mood disorders & their relationship with stress


3 (1 hour) Psychoeducation: Positive thinking & other relaxation techniques


8 L.B.I. Shah et al. / Archives of Psychiatric Nursing 29 (2015) 6 –13


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researcher waited for 1 minute to ensure that device fully captured the

nger temperature. The stress thermometer reads temperatures between

58 °F and 158 °F with higher scores indicating lower levels of objective

stress. The accuracy of the stress thermometer was +/ −0.1 °F (Stress

Market, 2011). Concurrent validity of the stress thermometer was sup-

ported by its signicant correlation with the Numeric Stress Rating scale

on a Singaporean sample (Lim, Klainin-Yobas, & Chen, 2014).

To minimize possible confounding factors, all physiological instru-

ments were assessed under controlled conditions. Firstly, the same par-

ticipant was measured twice before and immediately after the

intervention, only 1 hour apart. This might help control individual fac-

tors (such as psychiatric diagnoses and treatments). Therefore, it

might be logical to conclude that any physiological changes result

from the intervention. Secondly, the same researcher (LS) collected

dataacrossall participants across the two time points. Finally, allpretest

and posttest measurements were assessed under the same physical en-

vironment (such as venue and room temperature).

Depression, anxiety and subjective stress were measured with the

21-item Depression Anxiety Stress Scale (DASS-21) (Lovibond &

Lovibond, 1995). Participants rated on a four-point scale ranging from

0 (did not apply to me at all) to 3 (applied to me most of the time).

The DASS-21 has three subscales: depression (7 items), anxiety

(7 items), and stress (7 items). Each subscale has possible scores rang-

ing from zero to 21, with higher scores indicating higher symptoms.Alpha coef cients of 0.88–0.90 were reported for the depression,

0.82–0.84 for anxiety, and 0.86–0.90 for stress (Crawford et al., 2009;

Henry & Crawford, 2005; Mahmoud, Hall, & Staten, 2010). Furthermore,

alpha coef cients of the DASS-21 on Singaporean participants was 0.94,

suggesting excellent internal consistency reliability (Ang, 2012).

Relaxation levels were measured by the Perceived Relaxation Scale

(PRS), a single-item visual analogue scale (Lee, 2011). The PRS is a

numeric-visual analogue scale comprising a ten centimeter line with

calibration at every one centimeter. Participants were asked to rate

their perceived levels of relaxation from a scale of zero (very tensed)

to 10 (very relaxed). The Content Validity Index (CVI) of thePRS on car-

diovascular patients in Singapore was 1.00 (Lee, 2011).

Participant knowledgewas assessed by the Knowledgeon Stressand

Stress Management Questionnaire (KSSMQ), which was developed bythe researchers for this study. The KSSMQ is a 15-item questionnaire

whereby every ve items were administered before and after each in-

tervention session. The content of the KSSMQ was based on information

in the PEM. The questionnaire included 15 statements which can be

assessed as true, false or not sure. For every correct statement, a point

wasgiven, makingpossible in the range of zero to 15 with higher scores

indicating more knowledge. Content validity of the KSSMQ was exam-

ined by two mental health nurses and one psychologist; and the CVI

of 0.98 was obtained.

Additionally, the program feedback form was administered at the

end of the third session to explore the participants' perception of the

overall VR DE-STRESS Program. Participants were asked to comment

on strengths and weaknesses; and to provide any other additional com-

ments through three open-ended statements.

Ethical Consideration

Approvalto conduct this study was received from the hospital ethics

committee. We explained the purpose of study to eligible patients, dis-

tributed patient information sheet (PIS), answered questions they

might have and seek their participation. All participants signed a writ-

ten informed consent prior to participating in the study. They were

also informed that their information would be strictly condential and

that participation in this study was voluntary. The researchers also em-

phasized that their decision to participation or not to participate in this

study would not affect healthcare services they received from the

hospital.

Data Analyses

Data obtained in this study were entered into IBM SPSS (Version

20.0).Univariate analyses were used to describe participants' character-

istics and study variables. Paired t-tests and repeated measures analysis

of variance (RMANOVA) were performed to test theeffects of the inter-

vention on outcome variables. Content analyses were used to analyze

open-ended questions.

RESULTS

A total of 26 patients were approached during the data collectionpe-

riod. However, four patients declined to participate in the study due to

disinterest or low mood. Hence, a total of 22 participants agreed to en-

gage in the study, representing a response rate of 84.62%. Three had

early discharge before completing the intervention. These missing

data were handled by using intention-to-treat (ITT) analysis to mini-

mize type I error. Participants in this study (Table 2) were diagnosed

with MDD (45.45%; n = 12) or BD with depressive episode (54.55%;

n = 10) with age ranging from21 to 60. Most participants were Chinese

(63.64%; n = 14), female (72.73%; n = 16), and married (54.55%; n =

12) without children (50.00%; n = 11). All patients received standard

care (such as medications) prescribed by their physicians.

Table 2

Demographic Data of Study Participants (n = 22).

Characteristics Frequency (n) Percentage (%)

Clinical diagnosis

Bipolar Disorder 12 54.54

Major Depressive Disorder 10 45.46

Length of time since rst diagnosed

b 1 year 6 27.27

1–10 years 14 63.64

N10 years 2 9.09

Age (years)21–30 5 22.73

31–40 6 27.27

41–50 7 31.82

51–60 4 18.18

Gender

Male 6 27.27

Female 16 72.73

Marital status

Single 9 40.90

Married 12 54.55

Widowed 1 4.55

Nationality

Singaporean 20 90.91

Singaporean-PR 2 9.09

Ethnicity

Chinese 14 63.63

Malay 5 22.73

Indian 3 13.64

Highest education level

Secondary 12 54.54

Certicate 2 9.09

Diploma 4 18.18

University 3 13.64

Post-graduate 1 4.55

Currently employed

Yes 12 54.55

No 10 45.45

Income level ($SGD)

b$1000 5 22.73

$1000–$3000 12 54.54

$3001–$6000 2 9.09

$6001–$9000 1 4.55

N$12000 1 4.55

Undisclosed 1 4.55



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Objective Stress

Objective stress was measured before and immediately after each

intervention session across 3 days to capture immediate physiological

changes, making up six measurements. RMANOVA was used to com-

pare mean differences across the six measurement points, and results

indicated signicant differences in skin temperature (F = 17.17,

p b 0.001) (Table 3). Post-hoc pair-wise comparisons suggested that

posttest scores of all sessions were signicantly higher than their re-

spective pretest scores. Posttest scores S1, S2 and S3 were also signi-

cantly higher than the baseline (pretest S1). Note that higher scores of

skin temperature signify lower levels of objective stress.

Unfortunately, there were no signicant differences in systolic blood

pressure (F = 2.12, p = 0.10), diastolic blood pressure (F = 0.22, p =

0.97) and heart rate (F = 1.91, p = 0.14) across six measurement points.

However, pair-wise comparison tests revealed that heart rate at posttest

session 3 was signicantly lower than its respective pretest ( X differ-

ence = 4.16, Se = 1.00, p = 0.007).

Subjective stress, anxiety, and depression

These three variables were measured two times; at baseline and

the completion of the 3-day program. T-tests were used to compare

means of pretest and posttest scores of stress, anxiety, and depres-sion (Table 4). Following the 3-day intervention, the participants

had signicantly lowered subjective stress ( X difference = 7.62,

SD = 5.17, t = 6.91, p b 0.001), depression ( X difference = 8.09,

SD = 6.75, t = 5.62, p b 0.001), and anxiety ( X difference = 5.64,

SD = 4.77, t = 5.54, p b 0.001).

Perceived Relaxation and Participant Knowledge

These two variables were measured before and immediately after

each the intervention session across 3 days (six measurement points).

There was a signicant difference in perceived relaxation across the

six time points (F = 26.20, p b 0.001) (Table 5). Posttest scores of per-

ceived relaxation of all sessions were signicantly higher than their re-

spective pretest scores. Furthermore, posttest S1, S2, and S3 weresignicantly higher than the baseline. Similarly, there was a signicant

difference in participants knowledge across the three time points

(F = 13.77, p b 0.001) (Table 6). Posttest scores S3 and S1 were signif-

icantly higher than their respective pretest scores. However, no signi-

cant difference score was observed in session 2.

Feedback on the VR DE-STRESS Program

Participants provided useful feedback on the program concerning its

strengths and weaknesses. Regarding the strengths, the participants

stated that the program helped them to be strong and determined,

think positively, see things in a bigger picture, open mind, look forward

to the future, learn to relax, manage insomnia, and cope with stress.

Most participants enjoyed the practice of relaxation; some liked the par-

ticipant education manual as it was easy to read, compact, and useful;

and some patients liked the VR device. Regarding the weaknesses, some

participants stated that the monitor screen of the VR device is too small;

some required a massage chair and aromatherapy during the relaxation

practice; some asked for a group-based intervention for the purpose of

exchanging ideas/opinion; some asked for additional relaxation tech-

niques; and some requested longer intervention sessions.

DISCUSSION

This study aimed to test thefeasibility and initial effect of theVR DE-

STRESSProgram on inpatients withmood disordersin a tertiary hospital

in Singapore. The program comprised two major components:

psychoeducation and relaxation practice guided by VR-based relaxation

videos.Evidently, it wasfeasible to deliver thethree daily 1-hour VR DE-

STRESS sessions to patients in the hospital setting. Findings from this

study provided empirical evidence to address the two research ques-

tions. For therst one, participants who attended the program reported

signicantly lowered objective stress (as indicated by skin tempera-ture), subjective stress, depression,and anxiety. For thesecondresearch

question, participants also had signicantly greater perceived relaxa-

tion and knowledge. Additionally, this study produced results that sup-

ported the Neuman System Model (Neuman & Fawcett, 2002).

Particularly, a tertiary prevention intervention (which was represented

by the VR DE-STRESS Program) could help individuals with mood disor-

ders manage stressors from environment, minimize stress-related

symptoms (such as depression and anxiety), and possibly return to

the state of equilibrium.

Under stressful circumstances, individuals' sympathetic nervous

system is activated, resulting in periphery vasoconstriction

(i.e., decreased blood ow to the surface of skin) and thus lowered

skin temperature (Chen et al., 2009). Conversely, when the body is in

a state of relaxation, it activates the parasympathetic nervous system,resulting in periphery vasodilation and then higher skin temperature.

In this study, participants reported lower levels of objective stress (evi-

denced by increased skin temperature) immediately at the end of each

intervention across 3 days. Participants also reported lowered objective

stress at the end of session two and three in comparison to the baseline.

The signicant increase in skin temperature obtained is similar to the

ndings by Chen et al. (2009) who applied progressive muscle relaxa-

tion training (PMRT) on patients with schizophrenia. The positive nd-

ings obtained from the physiological measurement complemented and

strengthened the subjective measures of stress. Notably, participants in

ourstudy also reported reduced subjectivestresslevels (as measured by

the self-reported questionnaire) post-intervention.

Moreover, participants reported signicant increases in perceived re-

laxation levels after all three sessions of the VR DE-STRESS Program.This is consistent with research ndings from a previous study by Banos

et al. (2011). The relaxation response reduces the activity of the sympa-

thetic nervous symptom, thus undoing the stress response (Schaffer &

Yucha, 2004). These changes could have increased the perception of re-

laxation in the participants. In addition, we believe that the VR device

was a key feature in creating the overall relaxing experience during the

relaxation practice of the VR DE-STRESS Program. The VR device might

produce positive effects on auditory, visual and sensory receptors of the

person, and thus enhancing the relaxation experience (Banos et al.,

2011). The three relaxation techniques were incorporated into the VR-

based relaxation videos accompanied with peaceful music, soothing

narrator's voice and attractive visual sceneries. The personalized viewing

through the VR device grounded in a calm, quiet, and distraction-free en-

vironment contributes to the creation of a relaxing environment. These

Table 3

Scores of Skin Temperature in Fahrenheit Across Six Measurement Points (n = 22).

Skin temperature

(Fahrenheit)

Pretest mean

(SD)

Posttest mean

(SD) F-Test p value

Session 1 (S1) 85.01 (3.05) 90.58 (3.52) 17.17 b0.001

Session 2 (S2) 86.87 (3.82) 90.75 (3.90)

Session 3 (S3) 86.31 (3.05) 90.34 (3.03)

Post-hoc

comparisons

Mean difference

(SD)

95% C.I. p value

Lower Upper

Pretest S1 & posttest s1 5.58 (0.96) 2.40 8.76 b0.001





NOTE. a) Skin temperature was measured by the stress thermometer. b) Sphericity as-

sumed (Mauchly's W = 0.40; p = 0.239).



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factors might contribute to the positive ndings on perceived relaxation

among the study participants.

As anticipated, participants in this study had diminished levels of

depression and anxiety following the VR DE-STRESS Program. Such

positive ndings might be related to the content of the program,

which taught participants how to recognize and manage stress, de-

pression, and anxiety. Furthermore, the relaxation practice might

help reduce stress and enhance positive emotions. Similarly, previ-

ous studies found that the VR-based psychoeducation reduced de-pression among patients with PTSD and other anxiety disorders

(Banos et al., 2011; Gamito et al., 2010; Little et al., 2009; Yuen

et al., 2013). Nevertheless, conicting ndings were documented in

two studies where the VR-based program had no positive effect on

anxiety (Banos et al., 2011 & Blanaru et al., 2012). It is possible that

participants with PTSD in these studies had more severe and anxiety

symptoms, which required longer, more intensive, and more com-

prehensive interventions.

As expected, results from the study indicated a signicant in-

crease in patients' knowledge at the posttest session one and three.

These positive ndings are consistent with previous studies evaluat-

ing knowledge following the psychoeducation intervention

(Bernhard et al., 2006; Pratt et al., 2005). As recommended by Kinzie

(2005), effective strategies should be used during health educationto enhance positive outcome. We were in agreement with this rec-

ommendation. For the VR DE-STRESS Program, we selected topics

that directly related to the participants, divided and delivered

bulky information into 3 consecutive days to minimize participants'

exhaustion, offered individual-based sessions to facilitate patient–

facilitator interaction and optimal learning, used the VR technology

to guide relaxation practice, provided relaxation CD for optional

home practice, and administered the participant education manual

as (PEM) as a learning aid to enhance knowledge retention. Notably,

the contents in the PEM covered knowledge and skills taught in the

program. Patients could review the content based on their wish

and convenience.

Strengths and Limitations

This study had severalstrengths. First of all, this is the rst VR-based

stressmanagement program developed forpeoplewith mood disordersin Singapore. Empirical evidence from previous studies was utilized to

develop the VR DE-STRESS Program. Secondly, effortswere made to en-

sure the standardization of the delivery of the program across partici-

pants to enhance the integrity of the ndings. Adherence to the

intervention protocol was observed when carrying out the intervention.

Thirdly, both objective and subjective measurements of stress were ob-

tained to enhance the accuracy of ndings. Finally, a high response rate

was attained, which might help minimize response bias.

Several limitations must be highlighted for this study. Firstly, there was

no control group, and thus positive ndings might result from concurrent

treatments (such as medications) patients received during hospitalization.

Nevertheless, we measured skin temperature, perceived relaxation, and

knowledge before and immediately after each intervention session on

the same day under the same conditions, only 1 hour apart.Signicant im-provements on the three variables were consistently observed across

3 days. Hence, it might be logical to conclude that the VR DE-STRESS Pro-

gram had some benecial effects on the participants.

The second limitation was the lack of follow-up assessments after

the completion of the program. Therefore, it is still unclear if the effects

of the VR DE-STRESS Program persisted beyond the end of the interven-

tion. Lastly, the small sample size and the use of single-center recruit-

ment may impede the generalizability of nding to all individuals

withmood disorders(Polit & Beck, 2010). Furthermore,such small sam-

ple size might yield insuf cient statistic power to detect changes in

Table 4

Scores of Subjective Stress, Depression, and Anxiety (n = 22).

Outcome variables Mean (SD) Mean difference (SD) Lower Upper t -test p-value

Subjective stress

Pretest session 1 10.23 (5.43) 7.62 (5.17) 5.32 9.92 6.91 b0.001

Posttest session 3 2.61 (2.43)

Depression

Pretest session 1 9.77 (7.34) 8.09 (6.75) 5.10 11.08 5.62 b0.001


AnxietyPretest session 1 8.27 (5.56) 5.64 (4.77) 3.53 7.76 5.54 b0.001


NOTE. Subjective stress, depression, and anxiety were measured by the Depression Anxiety Stress Scale (DASS-21) (Lovibond & Lovibond, 1995).

Table 5

Scores of Perceived Relaxation Across Six Measurement Points (n = 22).

Perceived relaxation Pretest mean (SD)Posttest mean

(SD) F-test p value

Session 1 (S1) 4.86 (2.66) 7.64 (1.79) 26.20 b0.001

Session 2 (S2) 5.50 (2.02) 7.50 (1.62)

Session 3 (S3) 5.79 (1.70) 8.32 (1.21)

Post-hoc

comparisons

Mean difference

(SD)

95% C.I.

p valueLower Upper



Pretest S1 & posttest s3 3.45(0.51) 1.77 5.13 b0.001



NOTE. a) Perceived relaxation was measured by the Perceived Relaxation Scale.

b) Greenhouse–Geisser Correction Model used as sphericity violated (Mauchly's

W = 0.22; p = 0.011).

Table 6

Scores of Stress Management Knowledge Across Six Measurement Points (n = 22).

Stress management

knowledge

Pretest mean

(SD)

Posttest mean

(SD) F-test p value

Session 1 (S1) 4.00 (0.82) 4.95 (0.21) 13.77 b0.001

Session 2 (S2) 3.86 (0.77) 4.57 (0.58)

Session 3 (S3) 3.79 (0.66) 4.47 (0.72)

Post-hoc

comparisons

Mean difference

(SD)

95% C.I.

p valueLower Upper




NOTE. a) Stress management knowledge was measured by the Knowledge on Stress and

Stress Management Questionnaire. b) Greenhouse–Geisser Correction Model used as

sphericity violated (Mauchly's W = 0.13; p b

0.001).



7/8

heart rate andblood pressure.The limitations in thestudy could serve as

a platform for the expansion of knowledge on stress management inter-

ventions through the implementation of true experimental designs in

future studies with a larger sample size.

Implications for Clinical Practice

Despite the aforementioned limitations, our study has demonstrated

the potential effects of the VR DE-STRESS Program in reducing stress,

depression and anxiety; while increasing perceived relaxation andstress management knowledge in people with mood disorders. Conse-

quently, the VR DE-STRESS Program could be incorporated into stan-

dard care in mental health settings. Given the shortage of health care

providers, the use of VR technology is a promising method in value-

adding therapeutic interventions. Furthermore, VR can be a new psy-

chotherapeutic tool, which is more appealing to patients in the mental

health setting and may increase adherence to treatment (Gaudiano,

Weinstock, & Millier, 2008). It is reported that participants in VR-

based studies in mental health settings expressed high levels of support

and interest in the use of VR for their care ( Banos et al., 2011). In

Singapore, most people with mood disorders are in age range 31–50

years. We believed that people in this age range are familiar with ad-

vanced technology, and thus they would be more open to the imple-

mentation of VR technology.

Recommendations for Future Research

More studies concerning psychoeducation and relaxation interven-

tions should be undertaken to expand the limited literature in areas of

VR-based interventions for people with mood disorders. Virtual reality

could be used as a psychotherapeutic tool to carry out future interven-

tions. More rigorous studies (such RCT) with a larger sample size should

be carried out to test the ef cacy of the interventions. Next, since the

PEM and an audio relaxation CD was provided to the participant so they

could benet from the intervention beyond the duration of the program,

it might be worth investigating theoutcomevariablesat follow-up assess-

ments to determine longer-term effects of the intervention.

In summary, ndings from this study provide empirical evidence to

inform the two research questions. TheVR DE-STRESSProgram wasfea-

sible and had some positive effects on individuals with mood disorders.

This empirical evidence contributes to body of knowledge concerning

stress management interventions for people with mood disorders in

Singapore.

ROLE OF THE FUNDING SOURCE

This study wassupported by theStart-up Grant, Yong Loo Lin School

of Medicine, National University of Singapore. Dr. Piyanee Klainin-Yobas

is a principal investigator.

CONFLICT OF INTEREST

All authors declare no conict of interest for this study. No compet-

ing nancial interests exist.

References

Ang, S. G. M. (2012). Testing the ef cacy of “ Stress Management for Stoma Patients” (SMSP) programme for patients following colostomy or ileostomy surgery: A pilot study. Unpub-lished Honour thesis. Alice Lee Centre for Nursing Studies, Young Loo Lin School of Medicine, National University of Singapore.

Banos, R. M., Gullen, V., Quero, S., Garcia-Palacios, A., Alcaniz, M., & Botella, C. (2011). Avirtual reality system for the treatment of stress-related disorders: A preliminaryanalysis of ef cacy compared to a standard cognitive behavioral program.International Journal of Human-Computer Studies, 69, 602–613, http://dx.doi.org/ 10.1016/j.ijhcs.2011.06.00.

Bernhard, B., Schaub, A., Kummler, P., Dittmann, S., Severus, E., Seemuller, F., et al. (2006).Impact of cognitive-psychoeducational interventions in bipolar patients and theirrela-tives. European Psychiatry, 21, 81–86, http://dx.doi.org/ 10.1016/j.eurpsy.2005.09.007.

Blanaru, M., Bloch, B., Vadaz, L., Arnon, Z., Ziv, N., Kremer, I., et al. (2012). The effects of music relaxation and muscle relaxation techniques on sleep quality and emotionalmeasures among individuals with posttraumatic stress disorder. Mental Illness, 4(13), 59–65, http://dx.doi.org/ 10.4081/mi.2012.e13.

Brooks, F. P. (1999, November/Decemberr). What’s real about virtual reality? IEEE Computer Graphics and Applications, 16–27.

Chen, W., Chu, H., Lu, R., Chou, Y., Chen, C., Chang, Y., et al. (2009). Ef cacy of progressivemuscle relaxation training in reducing anxiety in patients with acute schizophrenia.

Journal of Clinical Nursing , 18, 2187–2196, http://dx.doi.org/ 10.1111/j.1365-2702.2008.02773.x.

Chong, S. A., Abdin, E., Vaingankar, J. A., Heng, D., Sherbourne, C., Yap, M., et al. (2012). A

population-based survey of mental disorders in Singapore. Annals of Academic Medicine Singapore, 41, 49–66 (Retrieved from http://www.annals.edu.sg/pdf/ 41VolNo2Feb2012/V41N1p49.pdf ).

Colom, F., Vieta, E., Reinares, M., Martinez-Aran, A., Torrent, C., Goikolea, J. M., et al.(2003). Psychoeducation ef cacy in bipolar disorders: Beyond compliance enhance-ment. Journal of Clinical Psychiatry, 64(9), 1101–1105 (Retrieved from http://www.psychiatrist.com/default2.asp).

Crawford, J. R., Garthwaite, P. H., Lawrie, C. J., Henry,J. D., MacDonald,M. A., Sutherland, J.,et al. (2009). A convenient method of obtaining percentile norms and accompanyinginterval estimates for self-report mood scales (DASS, DASS-21, HADS, PANAS, andSAD). British Journal of Clinical Psychology, 48(2), 163–180, http://dx.doi.org/ 10.1348/014466508X377757.

Danese, A., & Pariante, C. M. (2008). Mood (affective) disorders. Medicine, 36 (8), 410–414(http://dx.doi.org.libproxy1.nus.edu.sg/10.1016/j.mpmed.2008.05.005).

Gamito,P., Oliveira, J., Rosa, P., Morais, D., Duarte, N., Oliveira, S., et al. (2010). PTSD elder-ly war veterans: A clinical controlled pilot study. Cyberpsychology, Behavior and SocialNetworking , 13(1), 43–48, http://dx.doi.org/ 10.1089/cyber.2009.0237.

Gaudiano, B. A., Weinstock, L. M., & Millier, I. W. (2008). Improving treatment adherencein bipolar disorder: A review of current psychosocial treatment ef cacy and recom-

mendations for future treatment and development. Behavior Modi cation, 32(267),267–301, http://dx.doi.org/ 10.1177/0145445507309023.

Henry, J. D., & Crawford, J. R. (2005). The short-form version of the Depression AnxietyStress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology, 44(2), 227–239, http://dx.doi.org/ 10.1348/014466505X29657.

Jorm, A. F., Morgan, A. J., & Hetrick, S. E. (2009). Relaxation for depression. Cochrane Databaseof Systematic Reviews, 4, 1–79, http://dx.doi.org/ 10.1002/14651858.CD007142.pub2.

Kinzie, M. B. (2005). Instructional design strategies for health behavior change. Patient Education and Counseling , 56 (1), 3–15, http://dx.doi.org/ 10.1016/j.pec.2004.02.005.

Knubben, K., Reischies, F. M., Adli, M., Schlattmann, P., Bauer, M., & Dimeo, F. (2007). Arandomized, controlled study on the effects of a short-term endurance training pro-gramme in patients with major depression. British Journal of Sports Medicine, 41,29–33, http://dx.doi.org/ 10.1136/bjsm.2006.030130.

Ku, J., Han, K., Lee, H. R., Jang, H. J., Kim, K. U., Park, S. H., et al. (2007). VR-based conversationtraining program for patients with schizophrenia: A preliminary clinical trial.CyberPsychology & Behavior , 10(4), 567–574, http://dx.doi.org/ 10.1089/cpb.2007.9989.

Lee, S. (2011). Developing a stress management intervention for adults patients with hyper-tension and ischemic heart disease: A pilot study. Unpublished honours dissertation.Singapore: National University of Singapore.

Lim, Y.C., Klainin-Yobas,P., & Chen, H.C. (2014).Ef cacyof therelaxation interventiononpain, self-ef cacy, and stress-related variables among patients following total kneereplacement surgery. Pain Management Nursing , http://dx.doi.org/ 10.1016/j.pmn.2014.02.001.

Little, S. A. S., Kligler, B., Homel, P., Belisle, S., & Merrel, W. (2009). Multimodal mind/bodygroup therapyfor chronicdepression: A pilot study. Explore, 5(6),330–337, http://dx.doi.org/ 10.1016/j.explore.2009.08.004.

Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales(2nd ed.). Sydney: Psychology Foundation.

Mahmoud, J. S. R., Hall, L. A., & Staten, R. (2010). The psychometric properties of the 21-Item Depression Anxiety and Stress Scale (DASS-21) among a sample of youngadults. Southern Online Journal of Nursing Research, 10(4), 21–34.

Neuman, B., & Fawcett, J. (2002). The Neuman Systems Model (4th ed.). New Jersey: Pear-son Education Inc.

Oaz, F., Hatipoglu, S., & Aydin, H. (2008). Effectiveness of psychoeducation interventionon post-traumatic stressdisorder and copingstyles of earthquake survivors. Journalof Clinical Nursing , 17 , 677–687, http://dx.doi.org/ 10.1111/j.1365-2702.2007.02047.x.

OMRON Healthcare Singapore (2013). Intellisense Blood Pressure Monitor- Model T9P.Retreived from. http://www.omronhealthcare.com.sg/products_bloodpressure_t9p.htm.Pallavicini, F., Gaggioli, A., Raspelli, S., Cipresso, P., Serino, S., Vigna, C., et al. (2013).

Interreality for the management and training of psychological stress: Study protocolfor a randomized controlled trial. Trials, 14(191), 1–14, http://dx.doi.org/ 10.1186/ 1745-6215-14-191.

Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research: Appraising evidence for nurs-ing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

Pratt, S. I., Rosenberg, S., Mueser, K. T., Brancato, J., Salyers, M., Jankowski, M. K., et al.(2005). Evaluation of a PTSD psychoeducational program for psychiatric inpa-tients. Journal of Mental Health , 1 4(2), 121–127, http://dx.doi.org/ 10.1080/ 09638230500066356 .

Schaffer, S. D., & Yucha, C. B. (2004). Relaxation and pain management: The relaxation re-sponse can play a role in managing chronic and acute pain. American Journal of Nursing , 104(8), 75–82.

Stetz,M. C., Ries, R. I., & Folen,R. A. (2011). Virtual reality supporting psychological health. Advanced Computational Intelligence Paradigms in Healthcare, 6 (337), 13–29.

Stress Market (2011). Stress Thermometer SC 911. Retrieved from. http://www.cliving.org/SC911/SC911instr.pdf.


http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://dx.doi.org/10.1016/j.ijhcs.2011.06.00http://dx.doi.org/10.1016/j.ijhcs.2011.06.00http://dx.doi.org/10.1016/j.eurpsy.2005.09.007http://dx.doi.org/10.1016/j.eurpsy.2005.09.007http://dx.doi.org/10.4081/mi.2012.e13http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://dx.doi.org/10.1111/j.1365-2702.2008.02773.xhttp://dx.doi.org/10.1111/j.1365-2702.2008.02773.xhttp://www.annals.edu.sg/pdf/41VolNo2Feb2012/V41N1p49.pdfhttp://www.annals.edu.sg/pdf/41VolNo2Feb2012/V41N1p49.pdfhttp://www.psychiatrist.com/default2.asphttp://www.psychiatrist.com/default2.asphttp://dx.doi.org/10.1348/014466508X377757http://dx.doi.org/10.1348/014466508X377757http://dx.doi.org/http://dx.doi.org/10.1089/cyber.2009.0237http://dx.doi.org/10.1177/0145445507309023http://dx.doi.org/10.1177/0145445507309023http://dx.doi.org/10.1348/014466505X29657http://dx.doi.org/10.1002/14651858.CD007142.pub2http://dx.doi.org/10.1002/14651858.CD007142.pub2http://dx.doi.org/10.1016/j.pec.2004.02.005http://dx.doi.org/10.1136/bjsm.2006.030130http://dx.doi.org/10.1136/bjsm.2006.030130http://dx.doi.org/10.1089/cpb.2007.9989http://dx.doi.org/10.1089/cpb.2007.9989http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://dx.doi.org/10.1016/j.pmn.2014.02.001http://dx.doi.org/10.1016/j.pmn.2014.02.001http://dx.doi.org/10.1016/j.pmn.2014.02.001http://dx.doi.org/10.1016/j.explore.2009.08.004http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0095http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0095http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0105http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0105http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0105http://dx.doi.org/10.1111/j.1365-2702.2007.02047.xhttp://dx.doi.org/10.1111/j.1365-2702.2007.02047.xhttp://www.omronhealthcare.com.sg/products_bloodpressure_t9p.htmhttp://dx.doi.org/10.1186/1745-6215-14-191http://dx.doi.org/10.1186/1745-6215-14-191http://dx.doi.org/10.1186/1745-6215-14-191http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0120http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0120http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0120http://dx.doi.org/10.1080/09638230500066356http://dx.doi.org/10.1080/09638230500066356http://dx.doi.org/10.1080/09638230500066356http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://www.cliving.org/SC911/SC911instr.pdfhttp://www.cliving.org/SC911/SC911instr.pdfhttp://www.cliving.org/SC911/SC911instr.pdfhttp://www.cliving.org/SC911/SC911instr.pdfhttp://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0130http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://refhub.elsevier.com/S0883-9417(14)00138-1/rf1295http://dx.doi.org/10.1080/09638230500066356http://dx.doi.org/10.1080/09638230500066356http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0120http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0120http://dx.doi.org/10.1186/1745-6215-14-191http://dx.doi.org/10.1186/1745-6215-14-191http://www.omronhealthcare.com.sg/products_bloodpressure_t9p.htmhttp://dx.doi.org/10.1111/j.1365-2702.2007.02047.xhttp://refhub.elsevier.com/S0883-9417(14)00138-1/rf0105http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0105http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0100http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0095http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0095http://dx.doi.org/10.1016/j.explore.2009.08.004http://dx.doi.org/10.1016/j.pmn.2014.02.001http://dx.doi.org/10.1016/j.pmn.2014.02.001http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0195http://dx.doi.org/10.1089/cpb.2007.9989http://dx.doi.org/10.1136/bjsm.2006.030130http://dx.doi.org/10.1016/j.pec.2004.02.005http://dx.doi.org/10.1002/14651858.CD007142.pub2http://dx.doi.org/10.1348/014466505X29657http://dx.doi.org/10.1177/0145445507309023http://dx.doi.org/10.1089/cyber.2009.0237http://dx.doi.org/http://dx.doi.org/10.1348/014466508X377757http://dx.doi.org/10.1348/014466508X377757http://www.psychiatrist.com/default2.asphttp://www.psychiatrist.com/default2.asphttp://www.annals.edu.sg/pdf/41VolNo2Feb2012/V41N1p49.pdfhttp://www.annals.edu.sg/pdf/41VolNo2Feb2012/V41N1p49.pdfhttp://dx.doi.org/10.1111/j.1365-2702.2008.02773.xhttp://dx.doi.org/10.1111/j.1365-2702.2008.02773.xhttp://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0170http://dx.doi.org/10.4081/mi.2012.e13http://dx.doi.org/10.1016/j.eurpsy.2005.09.007http://dx.doi.org/10.1016/j.ijhcs.2011.06.00http://dx.doi.org/10.1016/j.ijhcs.2011.06.00http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165http://refhub.elsevier.com/S0883-9417(14)00138-1/rf0165


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Varvogli, L., & Darviri, C. (2011). Stress management techniques: evidence-based proce-dures that reduce stress and promote health. Health Science Journal, 5(2), 74–89 (Re-trieved from http://www.hsj.gr).

Villani, D., & Riva, G. (2012). Does interactive media enhance the management of stress?Suggestions from a controlledstudy. Cyberpsychology, Behavior and Social Networking ,15(1), 24–30, http://dx.doi.org/ 10.1089/cyber.2011.0141.

Walsh, R. (2011). Lifestyle and mental health. American Psychological Association, 66 (7),579–592, http://dx.doi.org/ 10.1037/a0021769.

Watkins, E. R., & Moberly, N. J. (2008). Concreteness Training reduces dysphoria: A pilotproof-of-principle study. Behaviour Research and Therapy, 47 , 48–53, http://dx.doi.org/ 10.1016/j.brat.2008.10.014.

Wilson, D. (2009). Anxiety and depression: It all starts with stress. IntegrativeMedicine, 8 (3), 42–44 (Retrieved from http://www.imjournal.com/index.cfm).

World Health Organization (2005). Mental health: Facing the challenges, building solution. Report from the WHO European Ministerial Conference (Retrievedfrom http://www.euro.who.int/__data/assets/pdf_le/0008/96452/E87301.pdf ).

Yuen, E. K., Herbert, J. D., Forman, E. M., Goetter, E. M., Comer, R., & Bradley, J. C. (2013).Treatment of social anxiety disorder using online virtual environments in secondlife. Behaviour Therapy, 44 (1), 51–61 (http://dx.doi.org.libproxy1.nus.edu.sg/10.1016/j.beth.2012.06.001).

http://www.hsj.gr/http://dx.doi.org/10.1089/cyber.2011.0141http://dx.doi.org/10.1089/cyber.2011.0141http://dx.doi.org/10.1037/a0021769http://dx.doi.org/10.1016/j.brat.2008.10.014http://www.imjournal.com/index.cfmhttp://www.imjournal.com/index.cfmhttp://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://dx.doi.org/http://dx.doi.org/http://dx.doi.org/http://dx.doi.org/http://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0008/96452/E87301.pdfhttp://www.imjournal.com/index.cfmhttp://www.imjournal.com/index.cfmhttp://dx.doi.org/10.1016/j.brat.2008.10.014http://dx.doi.org/10.1037/a0021769http://dx.doi.org/10.1089/cyber.2011.0141http://www.hsj.gr/

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