Is virtual reality always better than 2D videos? A head-to-head randomized controlled trial for fear of flying with long-term follow-up.

Fear of flying affects up to 40 % of the global population, often leading to avoidance behaviors that significantly restrict personal and professional activities. Cognitive Behavioral Therapy is a well-established treatment, with exposure therapy as the gold-standard approach to reducing avoidance. Exposure therapy can be delivered through various methods, including virtual reality environments or traditional techniques such as two-dimensional (2D) videos, photographs, imagination, or real-life situations. While Virtual Reality Exposure Therapy (VRET) and 2D video exposure share similarities, VRET may provide a more immersive and realistic experience, potentially enhancing efficacy despite its higher cost and complexity. However, high-quality studies, particularly randomized controlled trials, remain scarce. Furthermore, no study has yet compared the effectiveness of VRET with an equivalent 2D video for treating fear of flying. We conducted the first head-to-head randomized controlled trial to address this gap by comparing the two methods. Twenty-six participants were randomly assigned to either VRET or 2D video. Assessments occurred at baseline, session 8, 6-, 12-, and 24-month follow-ups, measuring fear of flying severity, presence, simulator sickness, and symptoms of anxiety and depression. Both methods significantly reduced fear of flying post-treatment and across follow-ups (p< .01), with effects maintained two years later. However, VRET did not demonstrate superiority over 2D video at any of the assessed time points. These findings suggest that the choice between VRET and 2D video exposure should consider therapist's training requirements, equipment availability, potential for technical customization, simulator sickness risk, costs, and individual preferences. Clinical trial registration: REBEC RBR-7fqyy.