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Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: A randomized controlled trial


Mark van der Gaag, PhD, Prinsegracht 63, 2512 EX The Hague, The Netherlands (e-mail:


Objectives.  This study investigates whether depression can be ameliorated by weakening the associations between auditory verbal hallucinations and easily activated networks with negative self-evaluations, by strengthening the access to competing memories of positive self-esteem.

Design.  A randomized controlled clinical trial comparing competitive memory training (COMET) with treatment as usual (TAU) in schizophrenia patients with persistent auditory hallucinations.

Methods.  Patients with schizophrenia-spectrum disorders were randomized into COMET (n = 39) versus TAU (n = 38). COMET consisted of seven sessions with four stages: (1) identification of aspects of negative self-esteem reinforced by the voice; (2) retrieval and re-living of memories associated with positive self-esteem; (3) positive self-esteem is brought in to compete with the content of the voices to weaken the association between voice content and negative self-evaluation; and (4) learning to disengage from the voices and to accept the voices as psychic phenomena.

Results.  Compared to TAU the COMET group improved on depression but there were no significant effects on auditory hallucinations. The effect of COMET on depression was fully mediated by self-esteem and acceptance of voices, and partially mediated by social rank and attributed power to the voices.

Conclusions.  COMET can be helpful in reappraising the meaning and changing the emotional impact of auditory hallucinations. These findings are consistent with the results of comparable COMET protocols applied in other psychiatric diagnoses. The technique can be used within regular cognitive behavioural therapy.