Participants were recruited between July and November 2023 through multiple channels, including flyer distribution at Yokohama University Hospital, nearby clinics, local universities, high schools, community support organizations, and announcements on social media platforms. Recruitment materials briefly described the study as an opportunity to experience a metaverse-based psychiatric consultation and to share feedback about the experience. Interested individuals contacted the research team directly and were screened for eligibility.

All participants received written and verbal explanations of the study procedures, potential risks, and the voluntary nature of participation. Written informed consent was obtained prior to study participation; for participants younger than 18 years, consent was also obtained from legal guardians in accordance with institutional review board requirements. Participants were compensated with a gift card valued at approximately US $35 (¥5000).

The target sample size was determined based on the exploratory aims of a qualitative descriptive feasibility design rather than statistical power considerations. A total of 33 individuals expressed interest in participation. Of these, 1 individual did not meet the inclusion criteria, 5 were lost to contact prior to providing informed consent, and 1 was unable to participate due to their condition on the scheduled day. Consequently, 26 participants completed the metaverse-based consultation and postconsultation interview.

Recruitment and data collection were concluded when thematic convergence was observed during qualitative analysis, and no substantially new themes emerged in later interviews, indicating that the sample size was sufficient for the aims of this feasibility study.

Eligible participants were individuals aged 16 to 25 years at the time of consent, who were aware of their mental health conditions and able to provide written informed consent in Japanese. Individuals currently receiving treatment at a psychiatric medical institution without permission from their primary physician were excluded from participation.

The study was conducted in a meeting room on the Yokohama City University campus.

As a baseline assessment, the participants completed a self-administered questionnaire consisting of 4 parts: (1) mental and physical conditions, (2) living conditions over the past 3 months, (3) internet usage, and (4) perceptions of mental health and psychiatry.

After the baseline assessment, the participants entered the metaverse environment under the guidance of technical staff, wearing VR goggles and using a controller. Since the participants were unfamiliar with metaverse operations, the technical staff provided detailed instructions for fitting the goggles, launching the application, and logging in.

For this study, experimental worlds and avatars were set up on commercially available metaverse applications, VRChat and Workrooms. VRChat is a social VR platform that allows users to create, share, and explore user-generated virtual worlds through customizable avatars, fostering social interaction and creative expression in immersive settings. In contrast, Workrooms is a virtual collaboration tool designed for professional and educational use, enabling users to hold virtual meetings in shared spaces with avatars and facilitating interactive discussions, presentations, and collaborative tasks. These applications provided structured and flexible virtual spaces suitable for the purposes of this study.

The virtual environments included 3 distinct spaces: an outer space environment, a hospital examination room, and a meeting room with selectable views of a beach or mountains. The avatars included both human and nonhuman fictional characters, providing participants with diverse ways of interacting and expressing themselves. Figure 1 illustrates one of the settings and avatars used in the study.

The metaverse consultations were conducted one-on-one in private virtual rooms with a psychiatrist, who also wore VR goggles and appeared as an avatar from a remote location. The psychiatrists included both male and female professionals with an average of 19 years of clinical experience.

Each consultation lasted 30 to 40 minutes and followed a semistructured framework resembling a standard initial psychiatric consultation. The consultation consisted of 5 phases. First, the psychiatrist introduced themselves via their avatar and explained the goals and structure of the session, allowing time to establish rapport and ensure that the participant felt comfortable in the virtual environment. Second, the psychiatrist reviewed the participant’s medical and life history, including prior diagnoses, treatments, daily routines, relationships, and environmental stressors. Third, the session focused on symptom observation and assessment, during which participants described their current mental health concerns while the psychiatrist observed verbal and nonverbal cues through avatar-mediated interaction. Fourth, tailored guidance and recommendations were provided, including coping strategies, lifestyle adjustments, and referrals to additional mental health resources when appropriate. Finally, the session concluded with a summary of the discussion and an opportunity for the participant to ask questions or provide feedback.

The consultations were designed to balance structure and flexibility, providing participants with a supportive environment to explore their mental health concerns in a novel virtual setting. During the session, the participants navigated the 3 distinct spaces within the metaverse environment alongside the psychiatrist and interacted via various types of avatars. Technical staff members were available to assist as needed, ensuring a seamless and accessible experience.

After the metaverse consultation, participants were individually interviewed to explore their experiences and perceptions of the metaverse consultation. The semistructured interview guide used in this study was developed specifically for this project. An English version of the interview form is provided in Multimedia Appendix 1 for reference. The interviews explored several key areas, including the usability of the metaverse devices, any physical or psychological discomfort experienced, acceptance compared with face-to-face consultations, perceptions of individuals or situations in which metaverse consultations may be beneficial, and implementation-related requirements or concerns.

Following the participant interviews, the psychiatrists who conducted the consultations, along with members of the research team—including psychiatric social workers and a nurse—engaged in structured discussions regarding usability, expectations, and implementation challenges. These discussions addressed the functionality and user experience of the metaverse platform, technical considerations, perceived differences between metaverse and face-to-face consultations, compatibility with participant characteristics and symptom profiles, and additional observations noted during the study.

The reporting of this study conforms to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines (Checklist 1) [21].

The interview data were analyzed via thematic analysis following established qualitative research methodologies. First, all interviews were transcribed verbatim to ensure accuracy. The transcripts were then reviewed multiple times to facilitate familiarity with the data and identify potential patterns.

All interview transcripts were reviewed in full by the first author (MI), who performed line-by-line coding to identify meaningful units of text. Codes were generated inductively from the data and iteratively refined in consultation with 2 coauthors (JF and NT) to enhance credibility. Codes were clustered into categories, and higher-order themes were developed through repeated team discussions until consensus was reached.

Initial coding was conducted by systematically highlighting recurring phrases, concepts, and key statements. These codes were grouped into broader categories that represented emerging themes. To enhance rigor, the themes were independently reviewed and refined by multiple researchers to ensure consistency and reduce bias.

The analysis focused on 3 primary domains: the usability of the metaverse platform, the acceptance of metaverse consultations in comparison with face-to-face interactions, and the identification of participant characteristics or conditions for which metaverse consultations may offer particular advantages, such as social anxiety or sensory sensitivities.

To ensure trustworthiness, we maintained an audit trail of coding decisions, documenting how codes were generated, refined, and grouped into themes. Triangulation was achieved through iterative discussions among the research team, allowing for verification and consensus in data interpretation. Representative quotations were included in the Results section and labeled with participant numbers to illustrate key themes and to provide transparency between the participants’ voices and the researchers’ interpretations.

Data collection was concluded when data saturation was reached, defined as the point at which no new themes or insights emerged from the interviews. No substantially new themes emerged in the latter part of the interviews. Thus, we consider the sample size sufficient for the exploratory aims of this qualitative feasibility study.

This study was conducted and reported in accordance with the APA Journal Article Reporting Standards for qualitative research [22].

Participants expressed a range of views regarding usability. Approximately 46% reported positive experiences, describing the device as intuitive or comparable to gaming interfaces. About 23% expressed neutral views, noting that while manageable for short sessions, prolonged use might be physically demanding. In contrast, 31% reported negative experiences, primarily related to physical discomfort, device fit, or technical complexity.

Participants who reported positive experiences noted that they “quickly got used to the controls” (Participant 10, 19, 20), and found the device “easy to use due to regular use of gaming devices” (Participant 9, 13, 16, 22). Optimism for future accessibility was evident in comments such as “I would like to use it when it becomes easier” (Participant 4) and “more affordable” (Participant 23, 24).

Participants with neutral views indicated that although they adapted to the operations, more complex tasks might require assistance. One participant commented,

Those expressing negative views raised concerns about the device’s physical fit and comfort. Nine participants experienced issues such as the goggles feeling “too tight” (Participant 18), “too loose and slipping” (Participant 13, 14), or challenging to fit over glasses. Five participants reported mild physical discomfort, including VR-related discomfort or head heaviness, although no psychological discomfort was noted. A participant remarked, “It might be difficult to connect and operate remotely without staff assistance” (Participant 18), highlighting barriers to independent use.

Responses regarding the acceptance of metaverse consultations revealed a range of perspectives.

Thirty-eight percent of participants expressed a preference for metaverse consultations over face-to-face sessions, citing benefits such as reduced psychological pressure and convenience. The comments included, “It’s a big help not having to leave home when I’m feeling too unwell to go out” (Participant 12) and “Meeting a new doctor is less nerve-wracking through an avatar” (Participant 3). Another participant noted,

Another 38% of participants expressed neutral responses, describing the content and quality of metaverse consultations as comparable to face-to-face consultations. Many noted that their preference would depend on their condition at the time. For example, one participant remarked,

Others suggested that

The remaining 24% preferred face-to-face consultations, emphasizing the reassurance of observing facial expressions and body language. One participant shared,

Another added,

Participants also shared insights into specific scenarios where metaverse consultations might be beneficial. One participant stated,

Another remarked,

Participants highlighted several key requirements and concerns regarding implementation. Security and privacy were frequently emphasized, particularly the need for a secure and private consultation environment. The participants requested assurances that psychiatrists understood them accurately. One participant commented,

Concerns about information security for private consultations were also raised.

Customizability of avatars and virtual spaces was another recurring theme. Participants frequently emphasized the importance of customizable settings, using terms such as “relaxing,” “free from distractions,” and “self-selectable.” Twelve participants expressed a preference for avatars that felt authentic to them, with one stating,

Preferences for human avatars (6 participants) and nonhuman characters (6 participants) were evenly split.

The psychiatric team provided valuable insights into the potential benefits and challenges of metaverse consultations.

Team members noted that individuals with sensory hypersensitivity, such as those with traits associated with autism spectrum disorder, appeared to focus more effectively in the immersive VR environment. They also reported that individuals with significant social anxiety or tension seemed to relax more quickly, enabling broader and deeper conversations.

At the same time, concerns were raised regarding the suitability of metaverse consultations for participants with pronounced symptoms, as certain clinical cues may be less observable in virtual settings. Suggestions included simplifying metaverse operations for easier access and expanding the range of avatars and room settings to allow for more personalized consultations. They also recommended developing diagnostic support tools to enhance the consultation experience.

This is the first observational trial to explore the feasibility of psychiatric consultations in a metaverse setting, offering novel insights into how digital environments can be leveraged to support youth mental health. The study benefited from a youth-centered design, the involvement of experienced psychiatrists, and the incorporation of diverse participant feedback. This design enabled a nuanced understanding of how metaverse-based consultations may meet the psychological and logistical needs of underserved youth populations, including those with interpersonal anxiety, sensory sensitivities, or barriers to in-person care.

Several limitations should be noted. First, the sample size was modest, and participants were primarily recruited from urban or institutional settings, which may limit the generalizability of the findings to broader or more diverse populations. Second, the study focused solely on avatar-based communication within VR platforms, without evaluating broader features of the metaverse, such as social engagement spaces, gamified environments, or decentralized user governance structures such as DAOs. Third, populations such as nonnative speakers or individuals with speech impairments were not included, which may limit the inclusivity of the findings. Future studies should explore comparative modalities (eg, light vs heavy metaverse), include more diverse participants, and assess additional functional elements of digital environments to further understand the potential of metaverse-based mental health support.