Around 70% of people diagnosed with schizophrenia-spectrum disorders experience distressing voices (or auditory verbal hallucinations) and these symptoms are associated with significant distress and impaired quality of life.
Despite medication, voices can frequently persist for decades. The recommended frontline psychological treatment, Cognitive Behavioural Therapy for psychosis (CBTp) has demonstrated small to moderate effects.
How are we meeting this challenge?
Over the last 10 to 15 years AVATAR therapy has moved from an exciting proof of concept to a digital therapy for distressing voices in psychosis with robust evidence of clinical efficacy and safety. The therapy consists of a ‘trialogue’ between therapist, patient, and a digital representation of the voice (the avatar) and aims to reduce distress and help people live life on their own terms.
The therapy involves one assessment session where the avatar is created followed by up to 12 therapy sessions, delivered across two phases: the first focuses on exposure and anxiety reduction, empowerment, and self-confidence whilst the second is more personalised with a broader range of therapeutic targets, such as trauma and social identity.
Our BRC has supported AVATAR in its transition from early stage research in 2014 to a multi-site randomised controlled trial that involved 8 NHS Trusts from 2020 – 2023, working with other NIHR infrastructure such as the NIHR King’s Clinical Research Facility and NIHR Manchester BRC.
This latest trial, funded by Wellcome has focused on optimising and personalising the therapy, alongside assessing the cost-effectiveness and scope for wider implementation. The trial found that the longer version of therapy delivered reductions in voice-related distress, voice frequency and a wide range of beneficial effects in wellbeing, empowerment and recovery. The published results of the trial were covered in national and international media.
Patient and public involvement (PPI) played a major role at all stages, including design, recruitment of staff and participants, analysis and dissemination through accessible plain English summaries. The PPI group included over 20 members from different backgrounds, with lived experience of mental health conditions and recovery, including carers. The profound impact of PPI on development of the therapy was discussed within a co-authored output published in BMC Psychiatry.
Through these published papers, the AVATAR website and events the team have shared their approach to PPI with others working in a similar field.
Collaboration and Achievement
AVATAR2 (the second trial) was supported by the NIHR King’s CRF which hosted therapy delivery, the NIHR Maudsley BRC and NIHR Manchester BRC.
Our BRC’s theme lead in Clinical trials, Genomics and Prediction Modelling was lead Statistician on the trial and was supported by a NIHR Research Professorship.
AVATAR has received a NICE-Early Evaluation Assessment (EVA) recommendation which is a scheme for promising health technologies that have the potential to address national unmet needs. The cohort has a focus on digital therapies for psychosis and the AVATAR team will be generating real world evidence on clinical and cost-effectiveness.
Looking to the future
In line with the NICE-EVA recommendation the next step is to test the clinical and cost-effectiveness of AVATAR therapy in routine care pathways, across diverse NHS settings. The team has an invited application for real-world NHS evidence generation currently under review. This will identify barriers and facilitators to sustainable implementation and provide generalisable knowledge for future innovators in digital mental health innovators.
The ongoing Wellcome-funded AVATAR3 project is testing the acceptability and feasibility of AVATAR therapy delivered across two Low- and Middle-Income countries (LMIC) – Ethiopia and .India. In parallel UK based work we are developing a version of the therapy where the avatars are voices using Artificial Intelligence (AI)- powered agents (“AVATAR-AI”). This represents a world first, and, potentially, the key to wider and more cost-effective implementation. By demonstrating that it is possible to train a widely available UK workforce to support AVATAR-AI, it can deliver a step-change in UK-based implementation of AVATAR therapy.
Impact
- Addressing an unmet need in the NHS through developing a novel digital therapy for management of distressing voices.
- Enabling the delivery of a clinical trial with 345 participants from 8 NHS Trusts and in collaboration with NIHR infrastructure.
- Creating an inclusive and impactul PPIE model that could be adapted for use in development of other digital therapies.
- Laying the foundations to explore the potential of AI support to augment the therapy and support scale up to make it accessible to more patients.
- Achieving NICE-EVA recommendation to evaluate clinical and cost-effectiveness in routine care pathways, across diverse NHS settings.
Further reading/watching
