Avatar-mediated Therapy Versus Cognitive Behavioural Therapy for Persisting Experiences of Hearing Voices (AMETHYST)

Remotely Delivered Avatar-mediated Therapy Versus Cognitive Behavioural Therapy for Persisting Auditory Hallucinations: Randomised Controlled Superiority Trial

The aim of this study is to compare the effects of a new psychological therapy, Avatar Therapy, to the current standard therapy, Cognitive Behavioural Therapy (CBT), in improving outcomes in people living with psychotic disorders who have persisting experiences of hearing voices (auditory verbal hallucinations, AVHs).

Study Overview

• Status: Recruiting
• Conditions: Psychotic Disorders; Schizophrenia and Related Disorders; Auditory Hallucination
• Intervention / Treatment: Behavioral: Cognitive behavioural therapy (CBT); Behavioral: Avatar therapy

Detailed Description

Continually hearing critical, abusive or threatening voices (auditory verbal hallucinations, AVHs) is a major persisting and disabling symptom of psychotic disorders such as schizophrenia. Current treatments have universally had only modest impact. In preliminary trials, a brief digitally supported treatment, using avatars to recreate AVHs during therapy, has produced some of the largest reductions in AVH severity seen to date. To definitively test the superiority of this innovative treatment, AMETHYST is a randomised controlled trial comparing avatar therapy to current recommended best practice treatment, CBT, for medication-resistant AVHs.

• Study Type: Interventional
• Enrollment (Estimated): 212
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Neil Thomas; Phone Number: +61 3 92148742; Email: neilthomas@swin.edu.au
• Study Contact Backup: Name: Alexandra Gaillard; Phone Number: +61 3 9214 3601; Email: agaillard@swin.edu.au

Study Locations

• Australia
  • Victoria
    • Hawthorn, Victoria, Australia, 3122
      • Recruiting
      • Swinburne University of Technology
      • Contact: Alexandra Gaillard, PhD; Phone Number: +61 3 9214 3601; Email: amethyst@swin.edu.au

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Schizophrenia-related disorder or a mood disorder with psychotic symptoms diagnosis confirmed using the Structured Clinical Interview for DSM (SCID)
• Experiencing current auditory verbal hallucinations as measured by the Positive and Negative Syndrome Scale (PANSS) item P3 ≥ 4
• Auditory verbal hallucinations present for at least one year
• Auditory verbal hallucinations include significant negative content (PSYRATS item 6 ≥ 2)
• Current treatment with antipsychotic medication at therapeutic levels as per RANZCP guidelines
• Access to the internet and a computer or other device on which videoconferencing software can be used
• Sufficient fluency in English for meaningful participation
• Age 18 or over
• Ability to give informed consent

Exclusion Criteria:

• Auditory verbal hallucinations attributable to a primary substance use disorder or organic disorder
• Estimated full scale IQ < 70 (using the Test of Premorbid Functioning, TOPF)
• Within the last month or planned at the time of intake: a change of antipsychotic medication,
• Current or within the past 3 months receipt of individual psychological therapy for hearing voices, or receipt of electro-convulsive therapy or other brain stimulation treatment;
• AVHs in a language not spoken by the therapists.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Cognitive Behavioural Therapy (CBT); The standard therapy arm will be based on a focused cognitive behavioural therapy (CBT) protocol for AVHs. Sessions will involve discussing the characteristics of participant's AVHs, before applying core CBT approaches, adapted to the AVH experience, to conduct a thorough cognitive behavioural assessment with a focus on coping strategy enhancement and cognitive restructuring.	Behavioral: Cognitive behavioural therapy (CBT); Seven 50-minute therapy sessions conducted by videoconferencing.
Experimental: Avatar Therapy; The experimental arm will use avatar therapy. Sessions will involve generating an audio-visual avatar as a virtual representation of the primary 'voice' that the participant hears. This will be used to recreate AVHs experientially and allow participants to practice alternative ways of responding to the 'voice'. This innovative approach will be combined with the use of broader CBT methods.	Behavioral: Avatar therapy; Seven 50-minute therapy sessions conducted by videoconferencing.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Auditory verbal hallucination severity, measured by total score on the Psychotic Symptom Rating Scale - Auditory Hallucinations Scale (PSYRATS-AHS)	Clinician-rated scale providing an index of overall severity based on 11 aspects of hallucinations (frequency, duration, intensity of distress, etc.), rated masked to treatment allocation. Each of the 11-items are scored on a 5-point scale (0 - 4), scores range from 0 to 44, with increased symptom expression indicated by higher scores.	Immediately post intervention (3 months), controlling for baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in auditory verbal hallucination severity, measured by total score on the Psychotic Symptom Rating Scale - Auditory Hallucinations Scale (PSYRATS-AHS) over follow-ups	Follow-up timepoints on the clinician rated scale that is used to measure the primary outcome. Includes 11-items that are scored on a 5-point scale (0 - 4), scores range from 0 to 44, with increased symptom expression indicated by higher scores.	Baseline, follow-ups (6 and 9 months)
Change in auditory verbal hallucination-related distress, measured by the Psychotic Symptom Rating Scale - Auditory Hallucinations Scale (PSYRATS-AHS) Distress Score	Subscale of the clinician-rated scale that is used to measure the primary outcome. This includes 1-item that is scored on a 5-point scale (0 - 4), score ranges from 0 to 4, with increased symptom expression indicated by a higher score.	Baseline, immediately post intervention (3 months), and follow-ups (6 and 9 months)
Remission of hallucinations, indexed by a score below 3 on the Hallucination scale of the Positive and Negative Syndrome Scales (PANSS)	Clinician-rated scale to assess presence and severity of hallucinations. This includes 1-item, scored from 1 to 7, with increased symptom expression indicated by higher scores.	Immediately post intervention (3 months), follow-ups (6 and 9 months)
Change in overall psychosis symptom severity, measured by Positive and Negative Syndrome Scales (PANSS) total and sub scale scores	Clinician-rated scale to assess overall psychotic symptom severity on total and sub scale scores (Positive, Negative and General Psychopathology). Includes a total of 30-items that are scored on a 7-point scale (1 - 7). Total score ranges from 30 to 210; Positive and Negative sub scale scores range from 7 to 49; General Psychopathology sub scale scores range from 16 to 112. Higher scores are indicative of increased symptom expression.	Baseline, immediately post intervention (3 months), follow-ups (6 and 9 months)
Change in depressive symptoms, measured by the Calgary Depression Scale for Schizophrenia (CDSS)	Clinician-rated scale to assess depressive symptoms in schizophrenia. Includes a total of 9-items that are scored on a 4-point scale (0 - 3). Total score ranges from 0 to 27, with higher scores indicative of increased symptom expression.	Baseline, immediately post intervention (3 months), follow-ups (6 and 9 months)
Change in anxiety symptoms, measured by the anxiety scale of the 21-item Depression Anxiety Stress Scale (DASS-21)	Self-report measure to assess depression, anxiety, and stress. Includes a total of 21-items that are scored on a 4-point scale (0 - 3). Scoring is made up of three sub scales that each include 7 items (Depression, Anxiety, and Stress). The scores for each of the three sub scales range from 0 to 42, with higher scores indicating increased symptom expression.	Baseline, immediately post intervention (3 months), follow-ups (6 and 9 months)
Personal recovery (consumer-defined recovery), measured by the Questionnaire for the Process of Recovery (QPR)	A self-report measure to assess consumer-defined recovery from psychosis. Includes 15-items that are rated on a 5-point scale, scores range (0-4), scores range from 0-60, with greater recovery indicated by higher scores.	Baseline, immediately post intervention (3 months), follow-ups (6 and 9 months)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Satisfaction with therapy, measured by the Client Satisfaction Questionnaire (CSQ-8)	The 8-item Client Satisfaction Questionnaire (CSQ-8) will be administered at the end of treatment to assess and compare participants satisfaction across the two therapies. In addition, a group of participants will be purposively sampled to be invited to take part in a detailed semi-structured qualitative interview (conducted by a non-blinded researcher) about their experiences of the intervention.	Immediatedly post-intervention (3 months)
Adverse effects of therapy	Negative psychological effects such as discomfort and anxiety that are relevant to tolerability will be measured using the Negative Effects Questionnaire (NEQ), a 32-item psychometrically validated questionnaire developed for monitoring adverse effects of psychological therapies. The NEQ items are scored on a 5-point Likert scale (0-4) and differentiates between negative effects attributed to treatment and those caused by other circumstances. Potential deterioration in AVHs will be reported for each group by the proportion of participants showing deterioration above a reliable change index for the PSYRATS. Serious adverse events (SAEs) will include participant death, hospital admissions, episodes of crisis, assessment team treatment, attempted suicide, and violent incidents leading to police involvement; these will be recorded systematically.	Immediately post-intervention (3 months)
Cost-effectiveness	Cost-effectiveness calculations will use the Assessment of Quality of Life - 8 Dimensions (AQoL-8D) to measure quality of life as an index of utility, expressed in quality-adjusted life years (QALYs). The AQoL-8D includes 35-items covering 8 dimensions: Independent Living, Pain, Senses, Mental Health, Happiness, Coping, Relationships, and Self-worth. To both measure treatment as usual (TAU) and determine broader treatment costs, a Resource Use Questionnaire (RUQ), adapted for use in this population, will be used. Consent for administrative data (e.g., Medicare and Pharmaceutical Benefits, MBS/PBS) will also be collected. Prescribed medication will be considered in terms of both cost and chlorpromazine -equivalent antipsychotic medication dose.	Immediately post intervention (3 months), follow-ups (6 and 9 months)
Change in the impact of AVHs, measured by the Voice Impact Scale (VIS)	Self-report measure of the degree of impact of hearing voices on domains of distress, interference with day-to-day functioning, and positive impacts. Includes 24-items. Each item is individually scored from 0 (disagree completely) to 10 (agree completely) with higher scores on individual items indicating higher agreement with the items listed experience. Not applicable is also available if the item is not relevant.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in AVH content, measured by the Voice Content Questionnaire (VCQ)	Self-report process measure of the degree of negative and positive content of auditory verbal hallucinations. Includes 20-items scored on a 5-point rating scale (0 - 4). Two subscales are created: Positive and Negative sub scales with scores for each ranging from 0 to 40. Higher scores indicate increasing symptom expression of either positive or negative content.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in attention paid to AVHs, measured by the Listening and Believing Assessment for Voices	Self-report process measure of the extent to which the person listens to and believes AVH content. Each of the 18-items are scored on a 4-point scale (0-3), with items divided between four subscales: Actively listening to nasty voices, passively listening to nasty voices, believing nasty voices, and disregarding nasty voices. Scores for the first three respective subscales range from 0-12 and scores range from 0-20 for the disregarding nasty voices sub scale. Higher scores are indicative of greater engagement in sub scale listening and believing activities.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in confidence in coping with AVHs - single item rating	Self-report process measure. One-item scored on a scale from 1 - 10, with increasing confidence indicated by higher scores.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in interpersonal appraisals of AVHs, measured by the Beliefs About Voices Scale (BAVQ-R)	Self-report process measures of interpersonal appraisals of AVHs (e.g., as malevolent or powerful). Includes 18-items that are scored on a 4-point scale (0-3), with scores ranging from 0-18 for each of the three sub scales: malevolence (6-items), benevolence (6-items), and omnipotence (6-items). Greater malevolent, benevolent or omnipotent beliefs about voices are indicated by higher scores on each of their respective sub scales.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in interpersonal appraisals of AVHs, measured by the Voice Power Differential Scale (VPDS)	Self-report process measures of interpersonal appraisals of AVHs (e.g., as malevolent or powerful). Includes 7-items measuring the power differential between the voice and voice hearer on dimensions including, power, strength, confidence, respect, ability to inflict harm, superiority and knowledge that are each scored on a 5-point scale (1-5), with scores ranging from 7 to 35. Higher scores indicate greater perceived power differential in favour of the voice.	[Time Frame: Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)]
Change in interpersonal responses to AVHs, measured by the APPROVE	Self-report process measure of assertive, aggressive and passive interpersonal responses to AVHs. Includes 15-items that are scored on an 11-point scale (0-10), scores range from 0-150, with items divided between three sub scales: one assertive responding sub scale (5-items) and two non-assertive responding sub scales (passive and aggressive; 5-items each). Higher scores on each sub scale are indicative of greater engagement in sub scale behaviours.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in flexibility in interpersonal reponse to AVHs, measured by the Circumplex Scales for Interpersonal Efficacy (CSIE)	Self-report process measure of self-efficacy to respond in a range of different ways in a relationship, adapted to rate responses to AVH. Includes a total of 32-items that are scored from 0 (not at all confident) to 10 (absolutely confident). Eight sub scales (Agnetic, Agnetic & Uncommunal, Uncommunal, Unagnetic & Uncommunal, Unagnetic, Unagnetic & Communal, Communal, Agnetic & Communal) each of which include 4-items are calculated. The score of each sub scale is the sum of the 4-items (ranging from 0 to 40) divided by 4. Higher scores indicate increasing confidence.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)
Change in positive and negative views of self and others, measured by the Brief Core Schema Scales (BCSS)	Self-report process measure. Includes 24-items that are scored on a 5-point scale (0 - 4), scores range from 0 to 96, with four sub scales: negative-self, positive-self, negative others, and positive-others. Each sub scale includes 6-items, scores range from 0-24, with stronger belief in schemas indicated by higher scores.	Baseline, immediately post-intervention (3 months), follow-ups (6 and 9 months)

Collaborators and Investigators

• Sponsor: Swinburne University of Technology
• Collaborators: University of Copenhagen; Monash University; University of Toronto; University of Manchester; University of Melbourne; University of the Sunshine Coast; Perth Voices Clinic
• Investigators: Principal Investigator: Neil Thomas, Swinburne University of Technology

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2023
• Primary Completion (Estimated): December 1, 2025
• Study Completion (Estimated): December 1, 2025

Study Registration Dates

• First Submitted: July 20, 2023
• First Submitted That Met QC Criteria: August 4, 2023
• First Posted (Actual): August 8, 2023

Study Record Updates

• Last Update Posted (Estimated): November 9, 2023
• Last Update Submitted That Met QC Criteria: November 8, 2023
• Last Verified: August 1, 2023

More Information

Terms related to this study

• Keywords: Schizophrenia; Psychosis; Telehealth; Cognitive behavior therapy; Virtual reality; Auditory verbal hallucinations; Psychological therapy; Avatar therapy
• Additional Relevant MeSH Terms: Mental Disorders; Nervous System Diseases; Neurologic Manifestations; Neurobehavioral Manifestations; Schizophrenia Spectrum and Other Psychotic Disorders; Perceptual Disorders; Schizophrenia; Psychotic Disorders; Hallucinations
• Other Study ID Numbers: GNT2015133

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No