Background
Auditory hallucinations (AH), the perception of hearing sounds or voices in the absence of external stimuli, are among the most common and debilitating psychotic symptoms of schizophrenia spectrum disorders (SSD).1–3 Approximately 60-80% of the 23 million individuals diagnosed with an SSD experience AH.4,5 The voices heard by individuals with AH are often described as threatening or derogatory,6 and are linked to an elevated risk of suicide, violence, disability, depression, and impaired functioning.6–10 Unfortunately, existing pharmacological11 and psychological12 treatments for AH show only modest benefits in symptom reduction.13,14 Hence, alternative, effective interventions are required to treat AH.
Virtual reality (VR) therapies have shown promise in the treatment of AH in SSDs.15–19 In VR therapy, individuals interact with controlled computer-generated environments that mirror real-world settings in which, some form of psychotherapy is typically guided by a therapist.20 VR was initially introduced as a treatment for anxiety and trauma-related disorders,21 and has repeatedly been found to be more effective than certain other treatments, including cognitive behavioural therapy (CBT), mindfulness therapy, and usual care,22–24 due to its ability to create a strong sense of presence in augmented environments (i.e., the subjective experience of being physically and psychologically present within the virtual environment, such that it feels real), reducing distress.25 This paper adopts a broad definition of VR, encompassing both immersive or 3D and non-immersive or 2D modalities. Immersive VR involves head-mounted displays or motion-tracking and stereoscopic display technology, while non-immersive VR involves interaction with 2D environments on a standard screen.26 Both forms of VR have demonstrated efficacy in the treatment of psychiatric disorders, including SSD.27
The aim of the present systematic review and meta-analysis was to assess the efficacy of immersive and non-immersive VR therapies for treating AH in SSDs.
Methods
This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.28
Data sources and search Strategy
A comprehensive literature search was conducted on Embase, APA PsychInfo, and MEDLINE via the Ovid Database to identify studies prior to August 2025.
Eligibility criteria
The eligibility criteria for study inclusion were as follows:
- Population: individuals ≥ 18 years of age, experiencing AH, diagnosed with SSD using the Diagnostic and Statistical Manual of Mental Disorders29 or International Classification of Diseases.30
- Interventions: studies that use immersive and non-immersive forms of VR.
- Comparators: only randomized controlled trials (RCTs) or randomized partial cross-over trials were included. Active controls, such as a VR control, CBT and supportive counselling, as well as treatment-as-usual (TAU) controls, were considered acceptable.
- Outcome measures: Eligible studies were required to report a quantitative measure of change in auditory hallucinations (AH), either as a primary or secondary outcome. The primary outcome for this review was AH severity, defined as the intensity of hallucinations and their impact on the individual.
Statistical analysis
Meta-analysis
R Studio (2024.09.1+394)31 was used to conduct the meta-analyses in instances where at least 2 studies had the required data available. The primary analyses examined the efficacy of the VR intervention versus control group on AH severity post-intervention and at follow-up. Standardized mean differences (SMDs) were calculated for both treatment and control groups using the mean difference (MD) from baseline to the endpoint and the standard deviation (SD) of the mean differences.32 Hedges’ g was interpreted using conventional thresholds for effect size: small (0.2), medium (0.5), and large (0.8).33
Results
Search results
Nine studies (n = 1,019) met the eligibility criteria for the systematic review and eight (n = 1,004) met the criteria for the meta-analyses. All studies measured AH outcomes using the PSYRATS-AH subscale.34 PSYRATS-AH measures AH severity through 11 questions, with each question being scored on a range from 0 to 4, with higher scores meaning worse AH severity.34 AH severity scores range from 0-44.34
Meta-analysis
Immediate post-intervention effects of VR on AH severity
VR was significantly more effective in reducing AH severity (Figure 1), with a small to medium effect size (Hedges’ g = −0.41, 95% CI [−0.62, −0.20], p < 0.01). This translates to a between-group estimated mean difference of 2.5 (6.0) points on the PSYRATS-AH subscale.
Figure 1. Forest plot of the meta-analysis comparing immediate post-intervention changes in auditory hallucination (AH) severity between VR and control conditions. Standardized mean difference (SMD): Negative values indicate greater VR effectiveness, while positive values indicate greater control group effectiveness.
Sustained effects of VR on AH severity
VR was significantly more effective than the control condition in reducing AH severity (Figure 2), with a small to moderate effect size: Hedges’ g = −0.28, 95% CI [−0.40, −0.17], p < 0.001. This translates to a between-group estimated mean difference of 1.7 (6.0) points on the PSYRATS-AH subscale.
Figure 2. Forest plot of the meta-analysis comparing sustained changes in auditory hallucination (AH) severity scores from baseline to follow-up between virtual reality (VR) and control conditions. Standardized mean difference (SMD): Negative values indicate greater VR effectiveness, while positive values indicate greater control group effectiveness.
Discussion
AH are debilitating, frequently persistent symptoms of SSD,1–3 often attributable to poor treatment engagement35,36 and limited efficacy of established treatments.37,12–14 VR therapies yielded small-to-moderate pooled effects in reducing AH severity immediately post-intervention and at follow-up extending up to 52 weeks.
The results seemed to be driven primarily by a therapy known as Avatar Therapy (AT), a VR therapy that can be both immersive and non-immersive.38–47 In AT, patients create an avatar that resembles the perceived voice and face of their AH and directly engage with it in simulated dialogue, with a therapist animating the avatar and simultaneously guiding the participants’ conversations with the persecutory avatar.48 Several theoretical mechanisms may account for the efficacy of AT in reducing AH. AT incorporates key psychotherapeutic components such as therapist-interaction, cognitive restructuring, and behavioural modification which may have led to the observed reduction in AH.38 Another theory proposes that the advantage of AT may stem from a controlled virtual environment that enables individuals to directly communicate with their voices, which is proposed to create a positive relationship with them, reduce feeling of helplessness, and ultimately reduce AH.38,40,42,49–52 The VR environment may also enhance the subjective sense of being present in the virtual environment (i.e., sense of presence), which can strengthen emotional engagement with the intervention and support the therapeutic process. Studies on VR have found that a higher sense of presence is associated with greater reductions in AH severity, supporting its role in VR’s effectiveness.53–55
Limitations
The small number of eligible studies reflects the current early stage of research in this domain and may impact the reliability of findings. Due to the small sample size, methodological differences across studies such as variations in intervention length and follow-up periods, may have introduced heterogeneity.
Future Directions
Given this study’s limitations, future research should focus on conducting larger, well-powered RCTs on the effectiveness of VR interventions for AH in SSD with differing lengths of treatments and follow-up periods. Once VR’s effectiveness has been established, its feasibility and cost-effectiveness in broader clinical settings should be evaluated. This includes implementation in primary care environments and community mental health centers, as an adjunctive treatment alongside antipsychotic medication.
Conclusion
This systematic review and meta-analysis provide preliminary evidence that AT delivered through VR may be an effective intervention for reducing AH severity in individuals with SSD. Across both immediate and long-term follow-up timepoints, VR-based AT demonstrated significant reductions in AH severity in several comparisons with established treatments (i.e., antipsychotic medications, CBT, and supportive counselling/psychotherapy). The limited number of studies on this topic suggests that more research is needed to reliably assess the efficacy of VR-delivered therapies for AH reduction in SSDs and to justify VR as a scalable addition to conventional treatments (i.e., antipsychotic medication) for individuals diagnosed with SSDs.
The full paper can be found here: https://doi.org/10.1093/schbul/sbag052
Edited by: Kealyn McDowell
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