Immersive virtual reality-assisted therapy targeting persistent auditory verbal hallucinations in patients diagnosed with schizophrenia spectrum disorders in Denmark: the Challenge assessor-masked, randomised clinical trial

BACKGROUND: Auditory verbal hallucinations are among the most frequent and debilitating symptoms of schizophrenia spectrum disorders (henceforth termed schizophrenia), particularly in patients with treatment-resistant symptoms. Current treatment options have suboptimal response rates and innovative interventions are needed. This study aimed to evaluate the efficacy and safety of a novel immersive virtual reality-assisted therapy (Challenge-VRT) for auditory verbal hallucinations.

METHODS: In this randomised, assessor-masked, parallel-group superiority clinical trial, patients with schizophrenia were recruited from outpatient psychiatric services across three Danish regions. Key inclusion criteria were age 18 years or older, auditory verbal hallucinations for at least 3 months, and insufficient symptom response to antipsychotic medication. Exclusion criteria included being unable to identify a dominant voice, current substance dependence, and organic brain disorder. Participants were randomly assigned (1:1) via a secure web-based system using permuted blocks (block size 12), stratified by site and antipsychotic treatment. Allocation was concealed from outcome assessors. Participants were assigned to either Challenge-VRT (seven weekly immersive virtual reality sessions plus two booster sessions) or a control intervention of enhanced treatment-as-usual, matched in frequency and duration. Challenge-VRT was co-developed with individuals with lived experience of auditory verbal hallucinations. The primary outcome was clinician-rated auditory verbal hallucination severity measured by the Psychotic Symptoms Rating Scales-Auditory Hallucinations total score (PSYRATS-AH) at 12 weeks post baseline. Secondary outcomes were PSYRATS-AH frequency, PSYRATS-AH-Distress, The Voice Power Differential Scale, the Voices Acceptance and Action Scale, the Assertive Responding to Voices subscale from the Approve-Voices, and the Personal and Social Performance Scale, all at 12 weeks. Analyses followed the intention-to-treat principle and used linear mixed models. This study is registered with ClinicalTrials.gov, number NCT04661163, and is now completed.

FINDINGS: Between Nov 16, 2020, and June 14, 2023, 399 patients were referred for potential study inclusion, 62 patients were excluded (declined to participate or unable to be contacted), and 337 were assessed for eligibility. Of these, 66 did not meet the inclusion criteria. 271 participants were randomly assigned to Challenge-VRT (n=140) or enhanced treatment-as-usual (n=131). One participant was excluded post-randomisation, resulting in 270 included in the analysis of all outcomes. Participants had a mean age of 32·83 years (SD 11·9, range 18-72), 105 (39%) were male, and 165 (61%) were female. No data on ethnicity were collected. At 12 weeks, Challenge-VRT significantly reduced auditory verbal hallucination severity compared with enhanced treatment-as-usual on the PSYRATS-AH (adjusted mean difference -2·26 [95% CI -4·26 to -0·25]; p=0·027; Cohen's d, 0·27). Among secondary outcomes, a significant reduction in PSYRATS-AH frequency was observed in the Challenge-VRT group at both 12 weeks (adjusted mean difference -0·84 [95% CI -1·53 to -0·14]; p=0·018) and 24 weeks (adjusted mean difference -0·86 [95% CI -1·65 to -0·07]; p=0·034). No significant differences were found for other secondary outcomes. The intervention was generally well tolerated. Six serious adverse events occurred that might have been related to the Challenge-VRT intervention (five cases of hospital admission due to exacerbation of auditory verbal hallucinations and one episode of self-harm). No deaths occurred during the trial.

INTERPRETATION: Challenge-VRT showed short-term efficacy in reducing the severity of auditory verbal hallucinations in patients with schizophrenia, and the findings support further development and evaluation of immersive virtual reality-based therapies in this population.

FUNDING: The Innovation Fund Denmark, Independent Research Fund Denmark, Innovation Fund North Denmark Region, Psychiatry Research Fund North Denmark Region, and The M L Jørgensen and Gunnar Hansen Fund.

TRANSLATION: For the Danish translation of the abstract see Supplementary Materials section.