- Design
- Systematic review and meta-analysis of 23 randomised trials
- Population
- 2,016 adults with schizophrenia-spectrum disorders and auditory hallucinations
- Primary outcome
- Severity of auditory hallucinations after treatment
- Effect
- SMD -0.18 (95% CI -0.31 to -0.05), NNT 16; avatar therapy SMD -0.37 (-0.51 to -0.22)
A systematic review and meta-analysis in JAMA Psychiatry (published 1 October) pooled 23 randomised trials of psychological or psychosocial interventions aimed specifically at auditory hallucinations, in 2,016 adults with schizophrenia-spectrum disorders, across five therapeutic approaches.
After treatment, targeted interventions reduced hallucination severity compared with control (SMD -0.18, 95% CI -0.31 to -0.05; number needed to treat 16), with GRADE rating the evidence as low certainty. Benefits extended to how often voices occurred and how distressing they were, and to delusions, depression and anxiety. Avatar therapy, in which the patient converses with a computer-generated representation of the voice, showed the largest effect (SMD -0.37, -0.51 to -0.22). Dropout and adverse events suggested the treatments were well tolerated.
Persistent voices despite adequate antipsychotic treatment are common, and the usual response is another medication change. This review supports adding a voice-focused psychological intervention alongside medication, rather than treating psychotherapy as a general add-on. Avatar therapy is not widely available, especially in India, but CBT for psychosis with a voice-focused component can be delivered by trained staff now.
- For persistent distressing voices on adequate antipsychotic treatment, consider referral for a voice-focused psychological intervention.
- Ask specifically about the frequency, content and distress of voices, not only whether they are present.
- Look for services offering CBT for psychosis or avatar therapy, and record what is available locally.
- Continue antipsychotic treatment alongside psychological therapy; these trials added therapy, not replaced medication.
- Expect a modest average benefit; about one in 16 patients improves because of the therapy.
Why it matters
It gives clinicians an evidence-based next step for residual voices that is not another drug change.
Don't overread it
The overall effect is small and low-certainty; the avatar therapy result is a subgroup comparison from fewer trials.
The statistics, in plain English
A standardised mean difference of -0.18 is a small effect; -0.37 for avatar therapy is small-to-moderate. An NNT of 16 means 16 people need treating for one extra person to improve beyond control. Subgroup results across different therapies are less reliable than the pooled estimate, because they rest on fewer trials and were not randomised against each other.
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