AVATAR and SloMo digital therapies for psychosis recommended for use in NHS

The National Institute for Health and Care Excellence (NICE) has recommended two digital health technologies for psychosis developed at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London.

SloMo (previously SlowMo) can be used for managing distressing thoughts or paranoia. AVATAR therapy, developed in partnership with University College London, can be used to reduce the distress caused by voice-hearing in psychosis.

The digital technologies are supported by the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre (BRC) and Wellcome. They represent two of three digital technologies recommended by NICE which can now be used as an option in the NHS for adults and young people with psychosis.

The new recommendations are part of NICE’s Early Value Assessment (EVA) for medtech initiative which allows rapid assessment of digital products, devices and diagnostics with the aim of enabling the NHS and patients to benefit from promising technologies sooner. 

Professor Philippa Garety, Professor of Clinical Psychology at King’s IoPPN who has worked on both digital technologies, said:

“We welcome the NICE EVA recommendations and are particularly proud that two of the three technologies arise from work at King’s. We are strongly motivated at King’s to make a positive difference to the lives of people with psychosis and are delighted that we are now in a leading position to take the crucial next steps in translating our novel therapies into real world settings.” 

Professor Tom Craig, Emeritus Professor of Social Psychiatry at King’s IoPPN who led the first fully powered clinical trial of AVATAR therapy, said:

“The NICE EVA recommendations are an important and hugely welcome step towards our main goal as clinicians to provide effective treatments for our patients. It is encouraging that we have been able to develop expertise in using digital technology to deliver a new approach that could not have been provided without these tools.”

SloMo

SloMo is an inclusive, digitally supported therapy for managing distressing thoughts or paranoia. It is the first evidence based, UK Conformity Assessed (UKCA) marked digital therapeutic for treating paranoia.

Developed in close collaboration with people with lived experience of psychosis, the SloMo software is designed to accompany patients and therapists during in-person therapy sessions and extend into day-to-day life. It helps people manage worries by visualising their thoughts as fast spinning, grey bubbles, supporting the recognition of unhelpful, fast thinking patterns. Slow spinning, coloured bubbles are used to shrink fears and help people feel safer and live well.

The first version of SloMo was successfully tested in the largest randomised controlled trial of its kind, led by Professor Philippa Garety. The trial found robust evidence that SloMo reduced worries and improved self-concept and quality of life, with effects sustained over six months. Crucially, the trial also found that SloMo overcame the ‘digital divide’, with strong user experience and outcomes for marginalised groups who are commonly technologically excluded.

The team are currently further optimising SloMo to improve outcomes, alongside developing an automated training programme and evaluating its effectiveness in routine care. The new version of SloMo will be implemented in South London and Maudsley NHS Foundation Trust, Sussex Partnership NHS Foundation Trust and Cumbria, Northumberland Tyne and Wear NHS Foundation Trust.

Dr Amy Hardy, Senior Lecturer at King’s IoPPN, said:

“We are grateful for the NICE EVA recommendation which will support our mission to scale up and spread SloMo in the NHS within the next five years. Our transdisciplinary team have used inclusive, human-centred design to improve SloMo, working in close collaboration with people with lived experience and the psychological practitioner workforce. We look forward to sharing SloMo with our partner NHS trusts, and hope it can contribute to addressing the significant need for accessible, engaging, and effective psychological therapies for psychosis that reduce health inequities for marginalised groups.”

AVATAR therapy

AVATAR therapy is a digitally supported therapy which aims to reduce the distress related to voice-hearing in psychosis. Developed by researchers at the IoPPN, UCL and Avatar Therapy Ltd, the therapy uses computerised avatars to represent the internal voices experienced by people with psychosis to help them take back control in their relationship with the distressing voice.

During AVATAR therapy, patients are involved in a three-way dialogue between the patient, avatar and therapist. The first phase of the therapy focusses on reducing anxiety and supporting the person to stand up to the avatar. The second phase considers the specific character and nature of the voice in more detail, during dialogues in which the avatar concedes power and control to the person.

In a previous clinical trial, hosted at South London and Maudsley NHS Foundation Trust, IoPPN researchers found that AVATAR therapy resulted in a rapid and substantial fall in the frequency and associated distress of voices. The therapy was found to be superior to a supportive counselling control condition at 12 weeks.

Both phases of AVATAR therapy have been refined in line with the results from the first AVATAR trial. The team are now investigating the effectiveness of AVATAR2 therapy across eight clinical settings in four centres linked to the Universities of Glasgow of Manchester, UCL and King’s.

Professor Mark Huckvale, Emeritus Professor of Speech Science at UCL and CEO of Avatar Therapy Ltd, said:

“The positive assessment by NICE is a significant step in bringing AVATAR therapy to voice hearers within the NHS. Avatar Therapy Ltd is working with King’s College London and several NHS Trusts to further develop the AVATAR therapy software and to create pilot services which will test its efficacy and acceptability in clinical practice.”

Delivering and evaluating digital therapies

Access to psychological interventions for psychosis, such as cognitive behavioural therapy for psychosis (CBTp) varies and is very limited for some people. Digital health technologies for managing symptoms of psychosis offer another option for those who may otherwise not have access to psychological interventions. This could particularly benefit people having treatment in early intervention in psychosis (EIP) services.

Dr Thomas Ward, Clinical Lead for the AVATAR and SloMo therapy teams at King’s IoPPN, said:

“Both AVATAR and SloMo therapy use cutting-edge digital technology to augment what we know to be important in psychological therapy, namely offering a safe context in which people can find new ways of understanding and managing distressing experiences.

“[Following this NICE EVA recommendation] the next step is to establish whether the powerful impact observed in clinical trials can translate to diverse NHS settings. We hope that by meeting the complex challenges of implementation at scale, effective digital therapies like SloMo and AVATAR therapy can fulfil their promise to deliver real-world impact.”

The digital therapies will be all be delivered by a mental health professional trained in the technology.

They will be evaluated for effectiveness and cost-effectiveness in reducing voice-related distress and paranoia, and promoting wellbeing and the attainment of personalised goals more broadly. Through real-world implementation among diverse service-users and in routine NHS settings, researchers will better understand who benefits most from using the technologies, as well as assessing training costs, frequency of use, and patient completion rates.

When the evidence has been generated (three years or sooner), it will be submitted to NICE which will assess if the technologies can be routinely adopted in the NHS.