Treatment effect modifiers of virtual reality-based versus standard cognitive behavioral therapy for paranoia in schizophrenia spectrum disorders: an exploratory moderator analysis of clinical and demographic characteristics in the FaceYourFears trial

Clinical Snapshot

Key Findings

• P Value: Largely nonsignificant interactions

• Effect Size: Modest treatment effects with largely nonsignificant findings

• Primary Outcome: End-of-treatment paranoia levels

• Nnt Or Sensitivity: Not calculable due to modest effects and lack of dichotomous outcomes

• Confidence Interval: Not reported

Clinical Application

VR-CBTp requires specialised equipment and training; standard CBTp more readily available Both interventions align with RANZCP clinical practice guidelines for psychosis; VR technology may have limited availability in rural/remote areas; Medicare rebates available for psychological therapy Adults with schizophrenia spectrum disorders experiencing paranoia in specialist mental health services

Abstract

BACKGROUND: This exploratory study examined baseline characteristics modifying treatment effects on paranoia in individuals diagnosed with schizophrenia spectrum disorders following a 10-session virtual reality-based cognitive behavioral therapy for psychosis (VR-CBTp) or standard CBTp. METHODS: All participants in the FaceYourFears trial were included (n=254; CBTp n=128; VR-CBTp n=126). General linear and logistic regression models examined baseline variables associated with end-of-treatment paranoia. In covariate analyses, regression coefficients quantified associations across treatments. In moderation analyses, interaction terms (randomization x moderator) were tested, with corresponding regression coefficients estimated and assessed at the 25th (low), 50th (medium), and 75th (high) percentiles of continuous variables. RESULTS: Across treatments, higher baseline avolition, safety behavior, delusion severity, and cognitive biases were associated with end-of-treatment paranoia. Moderation analyses revealed interactions for avolition, delusion severity, and negative other-beliefs. Although avolition and delusion severity were associated with poorer outcomes overall, individuals with high avolition and those with moderate-to-high delusion severity improved more in VR-CBTp than CBTp, whereas participants with lower delusion severity showed better outcomes in CBTp. No demographic (age, gender, education, and occupation) or other clinical characteristics (diagnosis, paranoia, social anxiety, depression, anhedonia, total negative symptoms, functioning, core beliefs, or interpersonal trauma) were significantly associated with outcome. CONCLUSIONS: This exploratory study generates hypotheses for future research, including VR-CBTp's potential to engage individuals with high avolition. Given the modest effects and largely nonsignificant findings, both CBTp and VR-CBTp appear suitable for a wide range of individuals with paranoia, highlighting the importance of considering patient preferences.