Review question
Is Avatar Therapy an effective add-on treatment for people with schizophrenia and schizoaffective disorder?
Background
Auditory hallucination is perceiving voices when there is no external stimulus. Around 70% of people with schizophrenia experience these. Medication may help cause these to decrease or disappear. However, some people do not want to take medication and, in a proportion of people, it has little meaningful effect. Avatar Therapy is an experimental technology that uses a visualised avatar face, voice and other sensory input to create an interactive computerised environment. We investigated the effects of Avatar Therapy for improving auditory hallucinations for people with schizophrenia.
Searches
Cochrane Schizophrenia's Information Specialist searched through the Cochrane Schizophrenia Group's database for randomised trials (clinical studies where people are randomly put into one of two or more treatment groups) of people with schizophrenia receiving either Avatar Therapy or treatment as usual. We found 14 reports from four studies.
The evidence is current to April 2020.
Trials
Four studies met our inclusion criteria, three of which provided useable data and one is still underway. The reliability of the evidence for the three included studies was very low to low. All data were limited to six weeks' treatment and one week' follow-up and, in some cases, data were not usable (we contacted the authors). All the reported data are just for the short-term period of trials and it is apparent that we need more studies with medium- to long-term periods to be able to estimate the rate of Avatar Therapy's effectiveness.
Conclusions
Three short-term studies with 195 participants were included in this review. Avatar Therapy was compared with treatment as usual and supportive counselling. Evidence from the trials was not high quality. Although there were some suggestions of positive effects, because of the unclear meaning for front-line care, and the considerable risk of bias of each of the results, we cannot be certain of these effects. There is just as great a risk of Avatar Therapy causing problems to people. More trials are needed, and those undertaking them should collaborate, work with all involved to choose outcomes that mean something in daily life, and design studies that will provide clear information across months to years for anyone who is interested.
Our analyses of available data shows few, if any, consistent effects of Avatar Therapy for people living with schizophrenia who experience auditory hallucinations. Where there are effects, or suggestions of effects, we are uncertain because of their risk of bias and their unclear clinical meaning. The theory behind Avatar Therapy is compelling but the practice needs testing in large, long, well-designed, well-reported randomised trials undertaken with help from – but not under the direction of – Avatar Therapy pioneers.
Many people with schizophrenia do not achieve satisfactory improvements in their mental state, particularly the symptom of hearing voices (hallucinations), with medical treatment.
To examine the effects of Avatar Therapy for people with schizophrenia or related disorders.
In December 2016, November 2018 and April 2019, the Cochrane Schizophrenia Group's Study-Based Register of Trials (including registries of clinical trials) was searched, review authors checked references of all identified relevant reports to identify more studies and contacted authors of trials for additional information.
All randomised clinical trials focusing on Avatar Therapy for people with schizophrenia or related disorders.
We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and 95% confidence intervals (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and 95% CIs. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. Our main outcomes of interest were clinically important change in; mental state, insight, global state, quality of life and functioning as well as adverse effects and leaving the study early.
We found 14 potentially relevant references for three studies (participants = 195) comparing Avatar Therapy with two other interventions; treatment as usual or supportive counselling. Both Avatar Therapy and supportive counselling were given in addition (add-on) to the participants' normal care. All of the studies had high risk of bias across one or more domains for methodology and, for other risks of bias, authors from one of the studies were involved in the development of the avatar systems on trial and in another trial, authors had patents on the avatar system pending.
1. Avatar Therapy compared with treatment as usual
When Avatar Therapy was compared with treatment as usual average endpoint Positive and Negative Syndrome Scale – Positive (PANSS-P) scores were not different between treatment groups (MD –1.93, 95% CI –5.10 to 1.24; studies = 1, participants = 19; very low-certainty evidence). A measure of insight (Revised Beliefs about Voices Questionnaire; BAVQ-R) showed an effect in favour of Avatar Therapy (MD –5.97, 95% CI –10.98 to –0.96; studies = 1, participants = 19; very low-certainty evidence). No one was rehospitalised in either group in the short term (risk difference (RD) 0.00, 95% CI –0.20 to 0.20; studies = 1, participants = 19; low-certainty evidence). Numbers leaving the study early from each group were not clearly different – although more did leave from the Avatar Therapy group (6/14 versus 0/12; RR 11.27, 95% CI 0.70 to 181.41; studies = 1, participants = 26; low-certainty evidence). There was no clear difference in anxiety between treatment groups (RR 5.54, 95% CI 0.34 to 89.80; studies = 1, participants = 19; low-certainty evidence). For quality of life, average Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (QLESQ-SF) scores favoured Avatar Therapy (MD 9.99, 95% CI 3.89 to 16.09; studies = 1, participants = 19; very low-certainty evidence). No study reported data for functioning.
2. Avatar Therapy compared with supportive counselling
When Avatar Therapy was compared with supportive counselling (all short-term), general mental state (Psychotic Symptom Rating Scale (PSYRATS)) scores favoured the Avatar Therapy group (MD –4.74, 95% CI –8.01 to –1.47; studies = 1, participants = 124; low-certainty evidence). For insight (BAVQ-R), there was a small effect in favour of Avatar Therapy (MD –8.39, 95% CI –14.31 to –2.47; studies = 1, participants = 124; low-certainty evidence). Around 20% of each group left the study early (risk ratio (RR) 1.06, 95% CI 0.59 to 1.89; studies = 1, participants = 150; moderate-certainty evidence). Analysis of quality of life scores (Manchester Short Assessment of Quality of Life (MANSA)) showed no clear difference between groups (MD 2.69, 95% CI –1.48 to 6.86; studies = 1, participants = 120; low-certainty evidence). No data were available for rehospitalisation rates, adverse events or functioning.