, results from the largest study of avatar therapy to date show.
The therapy allows patients to interact with a “digital embodiment” of the voice they hear, which is represented by a computer-generated face, also known as an avatar.
In the randomized, multisite, phase 2/3 AVATAR2 trial, patients who received AVATAR-Extended therapy, which included a personalized series of voiced dialogues based on their life history, plus treatment as usual (TAU) showed significantly greater improvement in distress and voice severity levels at 16 weeks vs those who received TAU only. They also had significant reductions in voice frequency at 16 and 28 weeks.
Patients in a third arm who were assigned to TAU plus AVATAR-Brief therapy, which included six sessions of a standardized version of the therapy, also showed improvements at 16 weeks, compared with TAU alone — but the clinical impact was stronger with the extended version.
“I was surprised at the extent to which the extended version seemed to be a more optimal version, and it should be the way forward with this therapy,” said study investigator Philippa A. Garety, PhD, professor emerita of clinical psychology at the Institute of Psychiatry, Psychology, and Neuroscience at King’s College, London, England.
With more than 300 participants, AVATAR2 is the largest trial to access avatar therapy to date, Garety noted.
“What’s unique about this work is that technology allows us to create safe face-to-face encounters with a representation of a person’s voice and allows them to relate to that voice in a new way,” she added.
The findings were published online in Nature Medicine.
A Decade of Research
Auditory verbal hallucinations are common in patients with schizophrenia, but currently available therapies can be ineffective, investigators wrote.
The therapy allows patients to customize how the avatar looks and sounds. Face-to-face dialogues are then conducted between the patients and avatars in order to build empowerment. A trained therapist provides support during these sessions.
As previously reported, the creator of avatar therapy, Julian Leff, MD, presented promising results from a pilot study of 26 patients at the International Congress of the Royal College of Psychiatrists in 2014.
“Opening up a dialogue between a patient and the voice they’ve been hearing is powerful,” said Leff, who was emeritus professor at the Institute of Psychiatry in London at the time.
In 2018, a randomized single-site study (AVATAR1) of 150 participants showed that the intervention was associated with a greater decrease in voice severity at 12 weeks vs supportive therapy. Past research led to the idea of incorporating personalization to better optimize the experience.
Garety noted that AVATAR2 is the largest trial to date of the therapy, as well as the first multisite trial to test the intervention, which was important in order to determine whether it could work outside of a research setting.
The study included 345 participants (61.4% men; mean age, 39.6 years) from three sites in England and one in Scotland. All were randomly assigned to receive TAU alone (n = 115), TAU plus AVATAR-Brief (n = 116), or TAU plus AVATAR-Extended (n = 114).
TAU typically included use of antipsychotics, as well as outpatient psychiatric visits and follow-up by case managers and care coordinators.
“We didn’t interfere with treatment as usual. We wanted to test whether adding this therapy to [TAU] would enhance effects and provide better treatment for their voices,” Garety noted.
AVATAR-Brief included a standardized process that focused on such things as self-esteem and assertiveness. AVATAR-Extended had two phases. In the first, participants received AVATAR-Brief therapy, whereas the second phase offered a more personalized intervention.