Digital AVATAR therapy for distressing voices in psychosis: the phase 2/3 AVATAR2 trial.
Level 2 - randomized trial
Individual phase 2/3 randomized controlled trial
PubMed 39468363 · doi:10.1038/s41591-024-03252-8
What was done
A phase 2/3 randomized controlled trial (AVATAR2) evaluated the efficacy of two digital dialogue interventions—AVATAR-Brief (AV-BRF) and AVATAR-Extended (AV-EXT)—both combined with treatment as usual (TAU) compared to TAU alone in 345 participants with psychosis. The primary outcome was voice-related distress evaluated via intention-to-treat analysis at 16 weeks (n = 300) and 28 weeks (n = 298). Secondary outcomes included voice severity and voice frequency.
What was found
At 16 weeks, voice-related distress improved significantly compared with TAU in both arms: AV-BRF effect was -1.05 points (96.5% CI: -2.110 to 0, P = 0.035, Cohen's d = 0.38) and AV-EXT effect was -1.60 points (96.5% CI: -3.133 to -0.058, P = 0.029, Cohen's d = 0.58). By 28 weeks, improvements in voice-related distress were no longer statistically significant: AV-BRF effect was -0.62 points (96.5% CI: -1.912 to 0.679, P = 0.316, Cohen's d = 0.22) and AV-EXT effect was -1.06 points (96.5% CI: -2.700 to 0.586, P = 0.175, Cohen's d = 0.38). Voice severity similarly improved at 16 weeks but not at 28 weeks in both groups. Voice frequency was significantly reduced in AV-EXT at both time points, but not in AV-BRF. No related serious adverse events occurred.
Why it matters
AVATAR therapy provides a digital psychotherapeutic option that delivers short-term reductions in voice-related distress for people with psychosis, with the extended protocol achieving clinically meaningful initial effect sizes.
Limits
Improvements in primary distress outcomes and voice severity were not sustained at 28 weeks. The comparison arm was treatment as usual rather than an active control, and the abstract does not report long-term follow-up beyond 28 weeks or blinding details.
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