Computer-based treatment helps people with schizophrenia

"Avatar therapy 'reduces power of schizophrenia voices'," BBC news reports. The headline is prompted by a study where people with schizophrenia received a new type of treatment to help them reduce the effect of auditory hallucinations.

Symptoms of schizophrenia include hallucinations, confused thinking and thoughts that are not based in reality (delusions).

This trial involved 150 people in the UK with schizophrenia or related psychosis conditions who experienced auditory hallucinations in the form of hearing voices. This is a widespread symptom in people who have schizophrenia.

Half of the participants were given conventional talking therapy sessions ("supportive counselling"). The other half received a treatment which involved creating a computerised face ("avatar") to represent the voice they were hearing. The therapist then worked with them to challenge the avatar, in an attempt to reduce the influence it was having.

After 12 weeks, the people in the avatar-based therapy group showed a greater improvement in their symptoms than those receiving conventional therapy. But it’s difficult to say how much of a difference this improvement would make to the person's daily life without further research.

At 24 weeks there was, however, no longer any greater benefit for the group having the avatar-based therapy compared to the control group.

This is a promising piece of research into an innovative treatment. The next step will be to see if the benefits are still found when the therapy is trialled in more people at other centres.

Where did the story come from?

This study was carried out by researchers from King's College London, University College London, and the University of Manchester. It was funded by the Wellcome Trust. Two of the researchers have filed patents on the AVATAR system used in the research.

The research was published in the peer-reviewed journal The Lancet Psychiatry.

BBC News' coverage of the study was accurate and balanced.

What kind of research was this?

This was a randomised controlled trial (RCT) to assess the effect of avatar therapy for auditory hallucinations.

Because of the nature of the therapy, it was not possible to hide from the doctors or the participants whether they had been allocated to the avatar treatment or the control (supportive counselling).

However, the people who carried out the assessments before and after the treatment did not know which treatment was used, so the assessment was less prone to bias.

An RCT is the best way of comparing two different treatments, though as an early stage study this included people from a single location who had a varied mix of diagnoses. This can make it difficult to work out who could benefit most from the treatment. It's also difficult to know how this treatment could be positioned alongside or in the place of standard treatment which includes both therapy and medication.

What did the research involve?

The study was based at a single centre in the South London and Maudsley NHS Trust. Adults (aged over 18) were invited to participate if they had been experiencing auditory verbal hallucinations (voices) for at least 12 months beforehand.

This included people with a mix of diagnoses, including mainly schizophrenia and related disorders, but also bipolar disorder and unspecified psychosis. Everyone participating had tried taking antipsychotic medication to control their hallucinations but with no or limited success.

They were not allowed to take part if they were already receiving psychological therapy for psychosis, were refusing medication, had brain disease or a learning disability, or were dependent on non-medical drugs.

Participants were randomised to either the intervention (avatar therapy) or the control (supportive counselling):

• AVATAR therapy was delivered by experienced clinicians. Using the AVATAR system, staff helped participants to create a computerised face (avatar) which represented the characteristics of the voice they were hearing. During the sessions, the therapist then worked with the participants to challenge the avatar.
• Supportive counselling was delivered by graduate assistant psychologists, supervised by a therapy co-ordinator. This involved structured, face-to-face sessions that were adapted to reflect the person's situation and experiences.

People received weekly 50-minute sessions for six weeks. Participants were assessed at the start of the study, and then again 12 and 24 weeks later.

They were asked about their hallucinations using a standardised tool, the Psychotic Symptom Rating Scales, auditory hallucinations subscale (PSYRATS-AH). This measures symptoms on a scale of zero to 44 with lower numbers meaning a less severe problem.

What were the basic results?

Just over 80% of people in both groups completed assessments at 12 weeks. This fell to around 75% at 24 weeks.

The main outcome the trial set out to examine was score change on the PSYRATS-AH scale at 12 weeks. The starting scores in both groups were about 30 on the 44-point scale.

At 12 weeks, people in the avatar-therapy group showed a greater improvement than the people who received supportive counselling, with a mean (average) score 3.82 points lower than that of the control group (95% confidence interval -6.70 to -0.94).

At 24 weeks, the people in the supportive counselling group showed improvement compared to their scores at 12 weeks (scores reducing from 28 at 12 weeks to 25), while the people who received avatar therapy stayed the same (about 22 at both assessments). This meant there was no longer a difference between the groups at 24 weeks (mean difference -1.55, 95% confidence interval -5.09 to 1.98).

No harms were observed from treatment in either group.

How did the researchers interpret the results?

The researchers conclude: “This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size.”

They caution that future multi-centre studies are needed to establish the effectiveness of AVATAR therapy, but say if proven effective “we think it should become an option in the psychological treatment of auditory verbal hallucinations.”

Conclusion

This is said to be the first trial to investigate the effects of avatar therapy on hallucinations. It benefits from a good sample size with fairly good participant follow-up rates for this type of study.

The people in this study had previously tried medication, without success. Therefore, as the researchers say, the fact that some of them improved using avatar-based therapy was a good sign.

However, although this study was well-designed and showed promising results, it has a number of limitations:

• It involved a mix of people with different diagnoses and probably a different pattern of previous treatments. This makes it difficult to interpret who would benefit most from the treatment.
• The trial took place at a single site. The AVATAR system has only been used by this one set of clinicians. We would need to know that it could be adapted and used effectively by clinicians at other sites.
• The two treatments were delivered by different staff with different levels of experience. A fairer comparison may have involved the same staff delivering treatment to both groups.
• There were some differences between the two groups. For example, there were more people in the supportive counselling group who didn't turn up to any sessions at all than there were in the avatar therapy group. There was also a higher proportion of women in the supportive counselling group than in the avatar therapy group. Differences like these may affect the results.
• The score difference was only about 4 points at 12 weeks, and by 24 weeks there was no difference between the two groups. It's difficult to know whether the scale of improvement would make a meaningful difference to the person's daily life.
• The group receiving counselling showed improvement between 12 and 24 weeks whereas the scores of the group receiving avatar-treatment didn't change between 12 and 24 weeks. It could be that counselling had greater effect over time.

Larger studies at multiple sites are needed to see whether this could have potential as a new treatment for schizophrenia or related types of psychosis.