Immersive 3D Therapy Effective for Voice Hallucinations?

Medscape

21-07-2025

TOPLINE:
An immersive virtual reality (VR)-assisted therapy known as Challenge-VRT was associated with a greater reduction in severity and frequency of auditory verbal hallucinations in patients with schizophrenia than enhanced treatment as usual, a new randomized study showed.
METHODOLOGY:
This randomized parallel-group trial was conducted between 2020 and 2023 across three Danish regions and included adult patients with schizophrenia spectrum disorders (mean age, 33 years; 61% women) who experienced auditory verbal hallucinations for 3 or more months. On average, the patients experienced these voices for 15 years.
Participants were randomly assigned to receive either seven weekly sessions plus two booster sessions of Challenge-VRT (n = 140) or matching enhanced treatment as usual (control group; n = 131). Challenge-VRT used a VR avatar of the patient's voice to guide them through phases of empowerment, self-worth development, and recovery while they wore a head-mounted display and engaged in a 3D environment.
The primary outcome was clinician-rated severity of auditory verbal hallucinations, as measured by the Psychotic Symptoms Rating Scales-Auditory Hallucinations (PSYRATS-AH) total score at 12 weeks.
Secondary outcomes included social functioning, the PSYRATS-AH-Frequency and Distress subscales, and the Voice Power Differential Scale.
TAKEAWAY:
Compared with the control group, the Challenge-VRT group had a significant reduction in severity of auditory verbal hallucinations (adjusted mean difference, -2.3; P = .03) at 12 weeks.
The VR group also showed a significant reduction in hallucination frequency at 12 (P = .02) and 24 (P = .03) weeks. Other secondary outcomes did not differ significantly between the groups.
Challenge-VRT was generally well-tolerated, with a 79% completion rate for all seven weekly sessions. Although 37% of participants reported increased hallucination symptoms after the first three sessions, the frequency decreased after the fourth session and continued declining until the end of the study.
Serious adverse events potentially related to the VR treatment included five cases of hospital admission due to exacerbation of auditory verbal hallucinations and one episode of self-harm. Additionally, women had higher rates of psychiatric admissions and higher simulation sickness scores than men.
IN PRACTICE:
'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,' the investigators wrote.
However, Mark Hayward, University of Sussex, Brighton, UK, noted several concerns in an accompanying editorial, including about how to effectively train clinicians to deliver this therapy and why the outcomes weren't sustainable. He also questioned whether a 3D immersive environment is superior to a 2D environment, such as watching something on a computer screen.
'The findings from the Challenge trial suggest that 3D does not add value to avatar therapy. If people with psychosis who are distressed by hearing voices are to build sustainable momentum for their recovery journeys, some of the remaining questions about avatar therapy need to be addressed,' Hayward wrote.
SOURCE:
The study was led by Lisa Charlotte Smith, PhD, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark. It was published online on July 2 in The Lancet Psychiatry.
LIMITATIONS:
The control group received counseling without a structured treatment manual or formal quality assessment, making direct comparison with Challenge-VRT challenging. Hospitalization data were incomplete, and frequent but undocumented technical problems with the VR system remained unassessed. Key outcome scales were also unreliable or inapplicable for subgroups. Additionally, the real-world sample underrepresented ethnic diversity, and the use of a therapist-controlled, immersive avatar raised ethical concerns about informed consent and off-session effects.
DISCLOSURES:
The study was funded by 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. Four of the 13 investigators reported having financial ties and research collaborations with Heka VR, who provided the software, and other sources. Full details are provided in the original article. The other investigators and the editorialist reported having no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.