Exploring treatment moderators in a randomized clinical trial of virtual reality-based vs. standard cognitive behavioral therapy for paranoia

BACKGROUND: Virtual reality-based cognitive behavioral therapy for psychosis (VR-CBTp) has demonstrated effectiveness in reducing paranoid ideation. This study examined moderators of treatment response in VR-CBTp compared to CBTp among individuals with paranoid ideation. METHODS: Eighty-one individuals with a psychotic disorder were included in these secondary analyses of the TOPIC-VR trial. Participants were randomized to maximally 16 sessions of CBTp or VR-CBTp. Moderator analyses examined clinical (baseline safety behaviors, paranoia, social anxiety) and sociodemographic factors (sex, age, employment status) influencing treatment effects on paranoid ideation (questionnaires and experience sampling method measured) at post-treatment. All moderation analyses were exploratory, without correction for multiple comparisons. RESULTS: Baseline momentary safety behaviors moderated treatment response for both paranoid ideation and momentary paranoia; higher safety behaviors predicted greater VR-CBTp benefit. Baseline paranoid ideation also moderated momentary paranoia, favoring VR-CBTp. No other moderation effects emerged. CONCLUSIONS: These exploratory findings suggest that VR-CBTp might be particularly effective for patients with elevated safety behaviors and severe paranoid ideation, providing preliminary support for personalized treatment allocation.