- Email: [email protected]
COMPUTER ASSISTED THERAPY FOR AUDITORY HALLUCINATIONS: THE AVATAR CLINICAL TRIAL
S74
Abstracts of the 4th Biennial Schizophrenia International Research Conference / Schizophrenia Research 153, Supplement 1 (2014) S1–S384
THE MRC COMMAND TRIAL: RESULTS OF A MULTI-CENTRE, RANDOMISED CONTROLLED TRIAL OF COGNITIVE THERAPY TO PREVENT HARMFUL COMPLIANCE WITH COMMAND HALLUCINATIONS Max Birchwood 1 , Maria Michail 2 , Alan Meaden 3 , Shon Lewis 4 , Linda Davies 5 , Graham Dunn 5 , Til Wykes 6 , Nick Tarrier 6 , Emmanuelle Peters 6 1 University of Warwick; 2 Institute of Mental Health,School of Nursing, Midwifery & Physiotherapy, Faculty of Medicine & Health Sciences, University of Nottingham; 3 School of Psychology, University of Birmingham, UK; 4 University of Birmingham, Birmingham, U.K; 5 Institute of Population Health, University of Manchester, Manchester, UK; 6 King’s College London, Institute of Psychiatry, Department of Psychology Background: Acting on command hallucinations in psychosis can have serious consequences for self and others and is a major source of clinical and public concern. There are no evidence-based treatment options to reduce this risk behaviour. Our new treatment uses cognitive therapy to challenge the perceived power of voices to inflict harm on the voice hearer if commands are not followed, thereby motivating compliance. Methods: COMMAND is a pragmatic, single blind, intention-to-treat, randomized controlled trial comparing Cognitive Therapy for Command Hallucinations (CTCH) + Treatment as Usual (TAU) with TAU alone. Eligible participants were from UK mental health services reporting command hallucinations for at least 6 months leading to major episodes of harm to self or others. The primary outcome was harmful compliance and secondary outcomes: beliefs about voices’ power and related distress; psychotic and depression symptoms. Outcome was assessed at 9 and 18 months. The trial was registered under controlled-trials.com (ISRCTN62304114). Findings: 197 participants were randomly assigned (98 to CTCH+TAU and 99 to TAU), representing 81.4% of eligible individuals. At 18 months, 46% of the TAU participants fully complied compared to 28% of those receiving CTCH+TAU (odds ratio = 0.45, 95% confidence interval 0.23 to 0.88, p=0.021). The estimate of the treatment effect common to both follow-up points was 0.57 (95% confidence interval 0.33 to 0.98, p=0.042). The total estimated treatment effect for voice power common to both time points was -1.819 (95% confidence interval, -3.457 to -0.181, p=0.03). Treatment effects for secondary outcomes were not significant. Interpretation: The trial demonstrated a large and significant reduction in harmful compliance, in parallel with the singular target of treatment, the perceived power of the voice. We believe this marks a significant breakthrough in this high risk group which consumes much clinical and public concern. Funding: Medical Research Council UK and the National Institute for Health Research.
COMPUTER ASSISTED THERAPY FOR AUDITORY HALLUCINATIONS: THE AVATAR CLINICAL TRIAL Tom Craig 1 , Philippa Garety 2 , Thomas Ward 2 , Mar Rus-Calafell 3 , Geoffrey Williams 4 , Mark Huckvale 4 , Julian Leff 5 1 Institute of Psychiatry, King’s College London; 2 King’s College London, Institute of Psychiatry Department of Psychology; 3 King’s College London, Institute of Psychiatry, Health Services and Population Research; 4 University College London, Speech, Hearing and Phonetic Sciences; 5 University College London Background: About 25% of people with schizophrenia continue to suffer with persecutory auditory hallucinations (AH) despite adequate treatment. Existing psychological therapies such as cognitive behaviour therapy are lengthy and costly. An adaptation of “voices dialogue” therapy in which patients are encouraged to enter into a dialogue with their voices appears to be helpful (Romme et al 2009) and informed the development of AVATAR therapy. Methods: Patients create a representation of the entity they imagine as the source of their AH using computerised face animation software. Using a further programme, they then select and modify a speech sample (actually the voice of the therapist) tweaking this until they are satisfied that it matches the quality of the AH that they experience. Therapy proceeds with patient and therapist at linked computers in separate rooms. The therapist is able to speak either as the avatar (which the patient perceives as appropriately lip and facially synced), or in his/her own voice when giving advice and coping instructions. Therapy is provided over 7 weekly sessions
each of which lasts half an hour. The character of the “avatar” becomes gradually more supportive and less threatening as therapy proceeds. Each session is recorded and given to the patient on a portable MP3 player with instructions to listen to the recording between sessions to reinforce progress. The system was evaluated in a pilot study comparing AVATAR therapy with treatment as usual (Leff et al 2013). We are now moving on to a larger randomised controlled trial comparing 7 sessions of AVATAR therapy with a supportive counselling control condition for 142 patients with treatment-resistant auditory hallucinations. Results: In the pilot study that included 26 patients, 14 were randomised to AVATAR. Compared to the 12 who received TAU, patients who received AVATAR therapy reported statistically and clinically significant reductions in total PSYRATS score (average reduction of -8.75 points, p<0.002) and total BAVQ-R (average reduction −5.9 points, p<0.004). Three patients stopped hearing voices entirely. The 12 patients who were in the control arm were subsequently offered AVATAR therapy and 8 accepted the offer. A secondary analysis looking at within-group change across all patients who received AVATAR therapy confirmed the results of the first analysis. The larger replication RCT is just underway. We will present some basic descriptive data, illustrative cases and demonstrate the revised AVATAR system which is more sophisticated in the graphics and voice synchronisation. Discussion: Results of the first pilot study were striking but the sample was small, proved difficult to recruit and had a substantial drop-out. It was delivered by a single highly experienced therapist. The new study will be delivered by several therapists and will attempt to provide a control for therapist time and attention. Outcome data will be collected by independent research team so that we can test for the adequacy of masking of the assessments. References: [1] Romme et al. 2009. Living with voices: 50 stories of recovery. PCCS Books. [2] Leff et al. 2013. Computer assisted therapy for medication-resistant auditoyr hallucinations: proof of concept study. British J Psychiatry 202, 428–33.
THE RESULTS OF EYE MOVEMENT DESENSITISATION AND REPROCESSING AND PROLONGED EXPOSURE IN PATIENTS WITH POSTTRAUMATIC STRESS DISORDER AND CHRONIC PSYCHOTIC DISORDER Mark van der Gaag 1,2 , Berber van der Vleugel 3 , Paul de Bont 4 , David van den Berg 5 , Ad de Jongh 6 , Agnes van Minnen 7 1 Parnassia/VU University; 2 VU University, Amsterdam, The Netherlands; 3 Noord-Holland Noord, Alkmaar, The Netherlands; 4 Mental Health Organization (MHO) GGZ Oost Brabant Land van Cuijk en Noord Limburg & Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands; 5 Parnassia Psychiatric Institute, Den Haag, The Netherlands; 6 Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam & Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), VU University Amsterdam, The Netherlands; 7 Behavioural Science Institute, NijCare, Radboud University, Nijmegen & MHO ’Pro Persona’, Centre for Anxiety Disorders Overwaal, Lent, The Netherlands Background: Many patients with schizophrenia also suffer from posttraumatic stress disorder (PTSD). This condition is underdiagnosed and undertreated. Hardly any evidence is available on the efficacy and safety of trauma treatment in psychotic patients. Methods: 155 patients with a chronic psychotic dirorder and PTSD were randomised into three arms: Eye Movement Desensitisation and Reprocessing (EMDR; Shapiro protocol); Prolonged Exposure (PE; Foa protocol); or treatment as usual (TAU). Randomisation was performed stratified by research site by an independent randomisation agency. Both treatment conditions consisted of maximum eight 90-minute sessions. Therapists were trained in both interventions and supervised during the trial and treated patients in both treatment conditions. All sessions were recorded on video and treatment fidelity was checked. Assessments were performed by blind research assistents. Results: Both treatments were effective and hard large effect-sizes (EMDR: d=0.76 and PE d=0.83) on total Clinician-Administered PTSD Scale scores (CAPS) at the end of treatment. Also 66% of the treated patients no longer fulfilled the criteria for a PTSD diagnose (DSM-IV) at the end of treatment. The Number Needed to Treat for EMDR was 2.4 and for PE the NNT was 3.4. Most adverse events took place in the TAU condition. Discussion: Both PTSD and PE are effective in reducing trauma symptoms on the CAPS and bring patients into remission of no longer fulfilling the
Abstracts of the 4th Biennial Schizophrenia International Research Conference / Schizophrenia Research 153, Supplement 1 (2014) S1–S384
THE MRC COMMAND TRIAL: RESULTS OF A MULTI-CENTRE, RANDOMISED CONTROLLED TRIAL OF COGNITIVE THERAPY TO PREVENT HARMFUL COMPLIANCE WITH COMMAND HALLUCINATIONS Max Birchwood 1 , Maria Michail 2 , Alan Meaden 3 , Shon Lewis 4 , Linda Davies 5 , Graham Dunn 5 , Til Wykes 6 , Nick Tarrier 6 , Emmanuelle Peters 6 1 University of Warwick; 2 Institute of Mental Health,School of Nursing, Midwifery & Physiotherapy, Faculty of Medicine & Health Sciences, University of Nottingham; 3 School of Psychology, University of Birmingham, UK; 4 University of Birmingham, Birmingham, U.K; 5 Institute of Population Health, University of Manchester, Manchester, UK; 6 King’s College London, Institute of Psychiatry, Department of Psychology Background: Acting on command hallucinations in psychosis can have serious consequences for self and others and is a major source of clinical and public concern. There are no evidence-based treatment options to reduce this risk behaviour. Our new treatment uses cognitive therapy to challenge the perceived power of voices to inflict harm on the voice hearer if commands are not followed, thereby motivating compliance. Methods: COMMAND is a pragmatic, single blind, intention-to-treat, randomized controlled trial comparing Cognitive Therapy for Command Hallucinations (CTCH) + Treatment as Usual (TAU) with TAU alone. Eligible participants were from UK mental health services reporting command hallucinations for at least 6 months leading to major episodes of harm to self or others. The primary outcome was harmful compliance and secondary outcomes: beliefs about voices’ power and related distress; psychotic and depression symptoms. Outcome was assessed at 9 and 18 months. The trial was registered under controlled-trials.com (ISRCTN62304114). Findings: 197 participants were randomly assigned (98 to CTCH+TAU and 99 to TAU), representing 81.4% of eligible individuals. At 18 months, 46% of the TAU participants fully complied compared to 28% of those receiving CTCH+TAU (odds ratio = 0.45, 95% confidence interval 0.23 to 0.88, p=0.021). The estimate of the treatment effect common to both follow-up points was 0.57 (95% confidence interval 0.33 to 0.98, p=0.042). The total estimated treatment effect for voice power common to both time points was -1.819 (95% confidence interval, -3.457 to -0.181, p=0.03). Treatment effects for secondary outcomes were not significant. Interpretation: The trial demonstrated a large and significant reduction in harmful compliance, in parallel with the singular target of treatment, the perceived power of the voice. We believe this marks a significant breakthrough in this high risk group which consumes much clinical and public concern. Funding: Medical Research Council UK and the National Institute for Health Research.
COMPUTER ASSISTED THERAPY FOR AUDITORY HALLUCINATIONS: THE AVATAR CLINICAL TRIAL Tom Craig 1 , Philippa Garety 2 , Thomas Ward 2 , Mar Rus-Calafell 3 , Geoffrey Williams 4 , Mark Huckvale 4 , Julian Leff 5 1 Institute of Psychiatry, King’s College London; 2 King’s College London, Institute of Psychiatry Department of Psychology; 3 King’s College London, Institute of Psychiatry, Health Services and Population Research; 4 University College London, Speech, Hearing and Phonetic Sciences; 5 University College London Background: About 25% of people with schizophrenia continue to suffer with persecutory auditory hallucinations (AH) despite adequate treatment. Existing psychological therapies such as cognitive behaviour therapy are lengthy and costly. An adaptation of “voices dialogue” therapy in which patients are encouraged to enter into a dialogue with their voices appears to be helpful (Romme et al 2009) and informed the development of AVATAR therapy. Methods: Patients create a representation of the entity they imagine as the source of their AH using computerised face animation software. Using a further programme, they then select and modify a speech sample (actually the voice of the therapist) tweaking this until they are satisfied that it matches the quality of the AH that they experience. Therapy proceeds with patient and therapist at linked computers in separate rooms. The therapist is able to speak either as the avatar (which the patient perceives as appropriately lip and facially synced), or in his/her own voice when giving advice and coping instructions. Therapy is provided over 7 weekly sessions
each of which lasts half an hour. The character of the “avatar” becomes gradually more supportive and less threatening as therapy proceeds. Each session is recorded and given to the patient on a portable MP3 player with instructions to listen to the recording between sessions to reinforce progress. The system was evaluated in a pilot study comparing AVATAR therapy with treatment as usual (Leff et al 2013). We are now moving on to a larger randomised controlled trial comparing 7 sessions of AVATAR therapy with a supportive counselling control condition for 142 patients with treatment-resistant auditory hallucinations. Results: In the pilot study that included 26 patients, 14 were randomised to AVATAR. Compared to the 12 who received TAU, patients who received AVATAR therapy reported statistically and clinically significant reductions in total PSYRATS score (average reduction of -8.75 points, p<0.002) and total BAVQ-R (average reduction −5.9 points, p<0.004). Three patients stopped hearing voices entirely. The 12 patients who were in the control arm were subsequently offered AVATAR therapy and 8 accepted the offer. A secondary analysis looking at within-group change across all patients who received AVATAR therapy confirmed the results of the first analysis. The larger replication RCT is just underway. We will present some basic descriptive data, illustrative cases and demonstrate the revised AVATAR system which is more sophisticated in the graphics and voice synchronisation. Discussion: Results of the first pilot study were striking but the sample was small, proved difficult to recruit and had a substantial drop-out. It was delivered by a single highly experienced therapist. The new study will be delivered by several therapists and will attempt to provide a control for therapist time and attention. Outcome data will be collected by independent research team so that we can test for the adequacy of masking of the assessments. References: [1] Romme et al. 2009. Living with voices: 50 stories of recovery. PCCS Books. [2] Leff et al. 2013. Computer assisted therapy for medication-resistant auditoyr hallucinations: proof of concept study. British J Psychiatry 202, 428–33.
THE RESULTS OF EYE MOVEMENT DESENSITISATION AND REPROCESSING AND PROLONGED EXPOSURE IN PATIENTS WITH POSTTRAUMATIC STRESS DISORDER AND CHRONIC PSYCHOTIC DISORDER Mark van der Gaag 1,2 , Berber van der Vleugel 3 , Paul de Bont 4 , David van den Berg 5 , Ad de Jongh 6 , Agnes van Minnen 7 1 Parnassia/VU University; 2 VU University, Amsterdam, The Netherlands; 3 Noord-Holland Noord, Alkmaar, The Netherlands; 4 Mental Health Organization (MHO) GGZ Oost Brabant Land van Cuijk en Noord Limburg & Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands; 5 Parnassia Psychiatric Institute, Den Haag, The Netherlands; 6 Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam & Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), VU University Amsterdam, The Netherlands; 7 Behavioural Science Institute, NijCare, Radboud University, Nijmegen & MHO ’Pro Persona’, Centre for Anxiety Disorders Overwaal, Lent, The Netherlands Background: Many patients with schizophrenia also suffer from posttraumatic stress disorder (PTSD). This condition is underdiagnosed and undertreated. Hardly any evidence is available on the efficacy and safety of trauma treatment in psychotic patients. Methods: 155 patients with a chronic psychotic dirorder and PTSD were randomised into three arms: Eye Movement Desensitisation and Reprocessing (EMDR; Shapiro protocol); Prolonged Exposure (PE; Foa protocol); or treatment as usual (TAU). Randomisation was performed stratified by research site by an independent randomisation agency. Both treatment conditions consisted of maximum eight 90-minute sessions. Therapists were trained in both interventions and supervised during the trial and treated patients in both treatment conditions. All sessions were recorded on video and treatment fidelity was checked. Assessments were performed by blind research assistents. Results: Both treatments were effective and hard large effect-sizes (EMDR: d=0.76 and PE d=0.83) on total Clinician-Administered PTSD Scale scores (CAPS) at the end of treatment. Also 66% of the treated patients no longer fulfilled the criteria for a PTSD diagnose (DSM-IV) at the end of treatment. The Number Needed to Treat for EMDR was 2.4 and for PE the NNT was 3.4. Most adverse events took place in the TAU condition. Discussion: Both PTSD and PE are effective in reducing trauma symptoms on the CAPS and bring patients into remission of no longer fulfilling the