Hsu, Tien-Wei ORCID: https://orcid.org/0000-0003-4136-1251, Liang, Chih-Sung ORCID: https://orcid.org/0000-0003-1138-5586, Changchien, Te-Chang ORCID: https://orcid.org/0009-0009-3120-7569, Tseng, Ping-Tao, Carvalho, Andre F., Stubbs, Brendon, Thompson, Trevor ORCID: https://orcid.org/0000-0001-9880-782X, Böge, Kerem, Hsu, Chih-Wei, Yang, Fu-Chi, Tu, Yu-Kang and Lin, Yu-Hsuan ORCID: https://orcid.org/0000-0001-9393-3886 (2026) AVATAR versus cognitive-behavioral therapy for medication-resistant auditory hallucination: a systematic review and network meta-analysis. Psychological Medicine, 56:e107. ISSN 0033-2917 (Print), 1469-8978 (Online) (doi:10.1017/s0033291726104127)

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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.

Item Type:	Article
Uncontrolled Keywords:	auditory hallucinations, AVATAR, CBT, psychosis, schizophrenia spectrum disorder, treatment resistance, network meta-analysis
Subjects:	B Philosophy. Psychology. Religion > BF Psychology R Medicine > R Medicine (General) R Medicine > RC Internal medicine > RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry
Faculty / School / Research Centre / Research Group:	Faculty of Education, Health & Human Sciences Faculty of Education, Health & Human Sciences > Institute for Lifecourse Development Faculty of Education, Health & Human Sciences > Institute for Lifecourse Development > Centre for Chronic Illness and Ageing Faculty of Law, Arts and Social Sciences Faculty of Law, Arts and Social Sciences > School of Humanities and Social Sciences
Last Modified:	16 Apr 2026 15:40
URI:	https://gala.gre.ac.uk/id/eprint/52846

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