Cost-effectiveness of virtual reality-based avatar therapy for patients with treatment-resistant schizophrenia

Auditory hallucinations are a severe and persistent symptom in schizophrenia spectrum disorders, affecting over one million people in Europe, with approximately 25–30% showing treatment resistance. Virtual reality-based Avatar (VR-Avatar) therapy has emerged as a promising, voice-focused intervention, but evidence on its economic value remains limited. This study aims to address this gap. A multicentre, trial-based economic evaluation of VR-Avatar was conducted alongside a waiting-list-controlled clinical study in Hungary, Poland and Spain. Eligible adults with schizophrenia spectrum disorder and treatment-resistant auditory hallucinations underwent a 12-week waiting-list period with treatment as usual (TAU), followed by a 12-week VR-Avatar intervention. The modified intention-to-treat (mITT) analysis included 62 participants with at least two consecutive assessments; complete-cases analyses were also performed. Outcomes included quality-adjusted life-years (QALY) and voice-related symptoms. The economic evaluation was conducted from healthcare system and societal perspectives. Clinical outcomes were analysed using change scores, with incremental effects estimated as the difference between mean changes during the VR-Avatar and TAU periods. Uncertainty was assessed using non-parametric bootstrapping. Clinical outcomes were largely unchanged during the waiting-list period, whereas VR-Avatar was associated with significant improvements in PSYRATS-AH total score (mean reduction − 6.4), distress (− 4.4), and frequency (− 1.5), alongside improvements in beliefs about voices (malevolence and omnipotence). The observed symptom reductions translated into an incremental QALY gain of 0.011 relative to TAU. Incremental costs were modest (€316 per patient from the healthcare system perspective and €267 from the societal perspective), with the lower societal incremental cost reflecting reduced productivity losses during the intervention period, consistent with the observed improvement in symptoms. The corresponding ICERs were €28,780/QALY and €24,270/QALY, respectively. Symptom-based analyses further supported favourable cost-effectiveness across key outcomes. This study provides early evidence that VR-Avatar may deliver clinically meaningful benefits at an acceptable additional cost. The findings support further evaluation in larger randomised trials and may inform future reimbursement decisions in European mental healthcare systems. ClinicalTrials.gov, TRN: NCT06505564, Registration date: 19 July 2024.