Cognitive Behavioral Immersion for Depression in the Metaverse: Exploring the Feasibility of an ‘A La Carte’ Manualized Group Intervention

Abstract

Background: Despite the availability of effective treatments, the rising prevalence of depression is largely driven by barriers to access including cost, stigma, and provider shortages. Cognitive Behavioral Immersion™ (CBI), delivered by lay coaches via an avatar-based metaverse platform (Innerworld), presents one scalable solution. This study evaluated the feasibility of an eight-session CBI for Depression course and compared two delivery models: a sequential weekly "Serialized" format versus a flexible, user-driven "A La Carte" format developed via Community-Based Participatory Research (CBPR). Methods: A mixed-methods quality improvement pilot study was conducted within the Innerworld platform. Participants were Innerworld users (N=229 with baseline PHQ-9 ≥ 10). Data included quantitative measures (PHQ-9 scores, session attendance logs) and qualitative interviews (N=12) analyzed using an adapted Consensual Qualitative Research method incorporating artificial intelligence (“aiCQR”). Analyses compared engagement patterns and initial symptom trajectories between the Serialized and A La Carte delivery models and explored predictors of symptom change. Results: Delivering the CBI for Depression course proved feasible, although participants only attended two sessions on average. Participation was associated with modest reductions in depressive symptoms over time, albeit with larger drops for highly engaged users presenting with mild to severe baseline symptoms. Within the initial 56-day period, no significant difference was found in the total number of sessions attended between the Serialized and A La Carte groups. However, significant differences emerged in engagement patterns. Serialized participants largely adhered to the linear sequence, whereas the attendance of A La Carte participants was evenly distributed attendance across all sessions. A La Carte participants utilized sessions over longer periods and attended some sessions repeatedly, aligning with preferences for flexibility. Qualitative data highlighted key mechanisms including psychological safety, anonymity, accessibility of CBT tools, peer support, and the impact of guide interaction. Conclusion: The CBI for Depression course, delivered by lay coaches in a metaverse environment, is a scalable and feasible approach for depression support that is associated with a modest reduction in symptoms of depression that approaches clinically meaningful levels among mild to severely depressed participants with greater engagement. The flexible A La Carte delivery model may better accommodate user preference for autonomy and on-demand access, although engagement continues to be a problem for many. This novel approach, developed through direct feedback from individuals with lived experience, may confer unique benefits to individuals with depression. These findings present an alternative to conventional "once-per-week" structures and suggest user-centric, flexible models warrant tests of efficacy through randomized controlled trials.