JMIR Publications

ABSTRACT

Background:

Auditory verbal hallucinations (AVH) are among the most disabling symptoms of schizophrenia and often persist despite treatment. Virtual reality-assisted therapies (VRT) are a new generation of relational interventions for AVH, but comparative evidence against gold-standard interventions is currently lacking.

Objective:

This study aimed to assess whether VRT (9 sessions) is superior to a short course of cognitive behavioral therapy (CBT; 9 sessions) in reducing AVH in individuals with treatment-resistant schizophrenia.

Methods:

In this assessor-blind, parallel-group randomized controlled trial conducted from 2019 to 2026 at an academic center in Montreal, 136 adults with schizophrenia or schizoaffective disorder and persistent AVH were randomized 1:1 to VRT or CBT, stratified by gender and clozapine status. Both nine-session therapies targeted maladaptive beliefs and relationships with voices. Outcomes were assessed at baseline, post-treatment, and 3‑month follow-up. The predetermined primary outcome was AVH severity measured with the auditory hallucination subscale of the Psychotic Symptoms Rating Scale. Secondary outcome notably included the general psychotic symptomatology measured using the Positive and Negative Syndrome Scale. Linear mixed‑effect models tested time‑by‑treatment interactions.

Results:

Participants had a mean age of 40.3 years, 63% were male, and 57% received clozapine. Intention‑to‑treat analyses showed a significant time‑by‑treatment interaction favoring VRT (p=0.012). VRT produced greater and more sustained reductions in AVH severity, with effect sizes increasing from post‑treatment (d=0.81) to follow‑up (d=1.17), indicating consolidation of therapeutic gains. CBT yielded a moderate post‑treatment reduction (d=0.58) that attenuated at follow‑up (d=0.39). Both interventions improved psychotic symptoms, emotional regulation, and voice acceptance, while VRT also reduced maladaptive beliefs about voices and improved self‑esteem.

Conclusions:

VRT outperformed a short course CBT in reducing persistent AVH in treatment‑resistant schizophrenia. Results on secondary outcomes, such as the general psychotic symptomatology, were similar for both interventions. Overall, these findings support VRT’s value as a personalized and clinically effective intervention. Clinical Trial: ClinicalTrials.gov [NCT04054778]; https://clinicaltrials.gov/.