TOPLINE

Psychological and psychosocial interventions targeting auditory hallucinations in patients with schizophrenia spectrum disorders were associated with reduced severity and frequency of hallucinations and other symptoms, with avatar therapy showing the most consistent benefits, a new meta-analysis found.

METHODOLOGY

• A systematic review and meta-analysis of 23 randomized clinical trials published until August 18, 2025, examined psychological and psychosocial interventions specifically targeting auditory hallucinations in more than 2000 adults with schizophrenia spectrum disorders (mean age, 39 years; 53% men).
• Nearly 1100 participants were included in the intervention groups across five therapeutic approaches, namely, cognitive-behavioral therapy, avatar therapy, relating and dialogue therapy, digital approaches, and integrative interventions. The other participants were included in the control group (active control, treatment as usual, waitlist control, or a combination of these).
• The primary outcome was between-group change in severity in auditory hallucinations from baseline to post-treatment. Secondary outcomes included changes in auditory hallucination severity, frequency, distress, and beliefs and other clinical outcomes, such as total symptoms, positive symptoms, negative symptoms, delusions, depression, and anxiety.

TAKEAWAY

• Compared with control interventions, targeted interventions were linked to reduced auditory hallucination severity post-treatment (standardized mean difference [SMD], -0.18; P = .007; low evidence; number needed to treat = 16) and at a mean follow-up of 27 weeks (SMD, -0.15; P = .01).
• Targeted interventions were also associated with reductions in distress (SMD, -0.19; P = .01) and frequency (SMD, -0.28; P = .002) of the hallucinations, total symptoms (SMD, -0.29; P = .002), positive symptoms (SMD, -0.24; P < .001), delusions (SMD, -0.27; P < .001), depression (SMD, -0.19; P = .001), and anxiety (SMD, -0.28; P = .006) compared with control interventions post-treatment.
• In subgroup analysis, only avatar therapy was associated with reduced auditory hallucination severity, frequency, and distress (SMDs, -0.37, -0.34, and -0.29, respectively; P < .001 for all).

IN PRACTICE

“To the best of our knowledge, this is the first systematic review and meta-analysis of psychological and psychosocial interventions” specifically targeting auditory hallucinations in patients with schizophrenia, the investigators wrote.

Based on the results, they noted that clinicians should consider adding these interventions to pharmacologic treatments for this patient population, “with avatar therapy showing the most promise among the included approaches.”

SOURCE

The study was led by Laura Fässler, Charité – University Medicine Berlin, Berlin, Germany. It was published online on June 17 in JAMA Psychiatry.

LIMITATIONS 

Methods such as scaling of measures and therapeutic approaches varied across trials, limiting statistical power, and subgroups lacked head-to-head trials. Most studies were rated as having a high risk for bias or some concerns, and detailed descriptions were not available for all pharmacologic treatments. Secondary outcomes had heterogeneous measures, which may have contributed to statistical heterogeneity. Effect sizes were also aggregated only for the first follow-up, with substantial differences across trials. 

DISCLOSURES

The study was funded by the Elsa-Neumann scholarship of the federal state of Berlin. Disclosure information for the study investigators is available in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.