AVATAR versus cognitive-behavioral therapy for medication-resistant auditory hallucination: a systematic review and network meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported but CI suggests p > 0.05 for primary outcome

• Effect Size: SMD = -0.23 (95% CI: -0.55 to 0.10) favoring AVATAR but not statistically significant

• Primary Outcome: No significant difference in auditory hallucination severity reduction between AVATAR and CBT

• Nnt Or Sensitivity: Superior sustained improvement at 3 months: SMD = -0.37 (95% CI: -0.69 to -0.05)

• Confidence Interval: 95% CI crosses null, indicating non-significant primary outcome

Clinical Application

AVATAR therapy requires specialized digital technology and training, potentially limiting accessibility compared to traditional CBT Relevant to Australian mental health services; CBT already PBS-subsidized through Better Access scheme; AVATAR therapy would require TGA evaluation and PBS consideration for broader implementation Adults with treatment-resistant schizophrenia experiencing persistent auditory hallucinations despite adequate antipsychotic therapy

Abstract

Auditory hallucinations (AH) frequently persist in schizophrenia spectrum disorder despite antipsychotic treatment. Cognitive behavioral therapy (CBT) remains an established psychological intervention, whereas AVATAR (Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations) therapy has recently been introduced as a novel approach integrating interactive digital avatars. This meta-analysis compared the efficacy of AVATAR therapy with CBT for medication-resistant AH. A systematic search of five major databases up to June 1, 2025 identified randomized controlled trials (RCTs) that evaluated either therapy. The primary outcome was AH severity, and secondary outcomes included psychotic symptoms, mood measures, and all-cause discontinuation. Twenty-six RCTs (n = 2273; 65.0% male; mean age 39.3 [SD 4.1] years) met inclusion criteria. Compared with CBT, AVATAR therapy showed no significantly greater reduction in AH severity (standardized mean difference [SMD] = -0.23, 95% confidence interval [CI] = -0.55 to 0.10). However, it demonstrated superior sustained improvement three months post-treatment (SMD = -0.37, 95% CI = -0.69 to -0.05) and greater reduction in overall psychotic symptoms (SMD = -0.41, 95% CI = -0.75 to -0.06). No significant differences were observed in positive, negative, depressive, anxiety, or quality-of-life outcomes, and discontinuation rates were comparable. Interpretation should be cautious given evidence of small-study effects (Egger's tests p < 0.01 for AH severity) and predominantly moderate-to-high risk of bias across included trials. AVATAR therapy therefore shows lasting efficacy, comparable or slightly superior to CBT, and may serve as an alternative for patients with medication-resistant AH.

References

1. 1.Hsu, T. W., Liang, C. S., Changchien, T. C., Tseng, P. T., Carvalho, A. F., Stubbs, B., Thompson, T., Böge, K., Hsu, C. W., Yang, F. C., Tu, Y. K., & Lin, Y. H. (2026). AVATAR versus cognitive-behavioral therapy for medication-resistant auditory hallucination: a systematic review and network meta-analysis. Psychological Medicine. https://doi.org/10.1017/S0033291726104127