Feasibility and tolerability of virtual reality during esketamine treatment: A pilot study.

OBJECTIVE: Ketamine/esketamine produce rapid antidepressant effects, with growing interest in how acute subjective experiences and the surrounding set and setting shape clinical outcomes. Little is known about how audiovisual adjustments during ketamine/esketamine treatment influence comfort, tolerability, or patient experience, despite their common use in clinical practice. Virtual reality (VR) is one immersive approach being explored in this context. This study examines the feasibility and tolerability of integrating VR into maintenance ketamine/esketamine sessions. METHODS: Study 1 surveyed patients receiving ketamine/esketamine regarding their dissociative experience and openness to integrating virtual reality into treatment. In study 2, patients receiving esketamine integrated VR into clinical treatment. Participants were trained in the use of a VR headset and completed one esketamine session with VR. The primary objective was to assess safety, tolerability, and feasibility. RESULTS: Participants from Study 1 highlighted auditory (33%, 7/21) and visual (52%, 11/21) discomfort as common challenges during ketamine treatment; the majority (71%, 15/21) expressed openness to integrating VR into clinical treatment. In Study 2, five patients integrated VR into a single treatment session, with one using it throughout the session. Participants who wore glasses had difficulty integrating VR and reported nausea. All participants showed decreased altered experience as measured by the 5-Dimensional Altered States of Consciousness scale. CONCLUSIONS/RELEVANCE: This pilot study examines factors affecting the feasibility and tolerability of VR during ketamine treatment and highlights considerations for future research. The observed reduction in 5D-ASC scores raises questions about whether VR dampens dissociative intensity, with potential clinical implications warranting further exploration.