Highlights
- The GAINS-02 trial demonstrated that a brief digital imagery-competing task intervention (ICTI) significantly lowered the frequency of intrusive memories in healthcare workers compared to both active control and treatment as usual.
- Participants using the ICTI reported a median of 0.5 intrusive memories at week 4, compared to 5.0 in the control groups, with a Bayes Factor (BF) of 114.1, indicating robust evidence of efficacy.
- The intervention, which utilizes visuospatial competition (Tetris gameplay with mental rotation) following memory retrieval, was found to be safe, scalable, and well-received by staff exposed to traumatic events during the COVID-19 pandemic.
- This study addresses a critical unmet need for evidence-based, low-intensity psychological interventions that can be deployed within demanding healthcare environments.
Background: The Unmet Need for Scalable Trauma Interventions
Psychological trauma is an inherent risk in clinical medicine, particularly during public health crises. Healthcare workers frequently witness untimely deaths, gruesome injuries, and profound human suffering—experiences that can trigger intrusive memories. These ‘flashbacks’ are hallmark symptoms of post-traumatic stress disorder (PTSD) and can significantly impair an individual’s mental health, cognitive functioning, and professional performance. Despite the high prevalence of trauma exposure, there remains a global shortage of scalable, evidence-based interventions that can be administered quickly and effectively without the need for intensive, long-term psychotherapy.
The COVID-19 pandemic exacerbated this issue, leaving a significant portion of the medical workforce with persistent psychological distress. Traditional interventions often require significant time commitments and specialized personnel, which are frequently unavailable to frontline staff. Therefore, the development of a ‘cognitive vaccine’ or a brief digital intervention that targets the consolidation or maintenance of traumatic memories is a high priority for occupational health and psychiatry.
Study Design: The GAINS-02 Trial
The GAINS-02 study was a decentralized, digital, parallel-group Bayesian adaptive randomized controlled trial. This innovative design allowed for the efficient evaluation of the intervention’s efficacy while maintaining rigorous statistical standards. The study recruited healthcare workers in the UK who had been exposed to at least one traumatic event and reported three or more intrusive memories in the week prior to screening.
Population and Randomization
A total of 99 participants were randomized into three groups: the digital imagery-competing task intervention (ICTI, n=40), an active control (n=39), and treatment as usual (TAU, n=20). The cohort had a mean age of 41.2 years and was predominantly female (86%) and White (90%), reflecting the demographic makeup of the participating healthcare facilities. Randomization was conducted via a web-based system using block randomization (2:2:1 ratio).
The Intervention: Cognitive Interference via Mental Rotation
The ICTI is based on the principle of ‘visuospatial interference.’ When a traumatic memory is retrieved, it enters a labile state where it can be modified before being reconsolidated. By engaging in a high-load visuospatial task—specifically, playing Tetris with a focus on mental rotation—immediately after a brief, guided retrieval of the traumatic image, the intervention competes for the same limited cognitive resources required to keep the sensory image of the memory intact. This process is theorized to ‘blur’ the intrusive visual component of the memory without erasing the factual narrative of the event. The active control involved a music-listening task, which provides a distraction but lacks the specific visuospatial competition required to disrupt memory reconsolidation.
Key Findings: Robust Reduction in Intrusive Memories
The primary outcome of the trial was the number of intrusive memories experienced during the fourth week following the intervention, adjusted for baseline frequency. The results provided compelling evidence for the efficacy of the ICTI.
Primary Outcome Analysis
Using Bayesian regression analyses, the researchers found that participants in the ICTI group reported significantly fewer intrusive memories at the 4-week mark. The median number of intrusive memories in the ICTI group was 0.5 (IQR 0.0–5.0), whereas both the active control and the treatment-as-usual groups reported a median of 5.0. The statistical strength of this finding was reflected in a Bayes Factor (BF) of 114.1 when compared to the active control, and 15.8 when compared to TAU. A BF over 100 is generally considered ‘decisive’ evidence in favor of the experimental hypothesis.
Secondary Outcomes and Safety Profile
Beyond the reduction in memory frequency, the study observed improvements in broader PTSD symptoms. Importantly, the intervention was found to be safe. No adverse events were specifically linked to the ICTI gameplay itself. The most common adverse event reported was COVID-19 infection (n=7), and two participants noted the burden of maintaining a daily diary. Serious adverse events (n=6) were all hospitalizations unrelated to the study procedures. The absence of ‘harm’—such as the potential for the intervention to worsen memories or cause distress during retrieval—is a critical finding for clinical implementation.
Expert Commentary: Mechanisms and Clinical Implications
The success of the ICTI in the GAINS-02 trial highlights a paradigm shift in how we approach trauma recovery. Traditionally, trauma interventions are reactive, occurring months or years after the event. The ICTI represents a proactive, ‘low-intensity’ approach that can be used shortly after exposure or once symptoms begin to manifest.
The Science of Memory Consolidation Interference
From a mechanistic perspective, the ICTI targets the sensory-perceptual (visual) aspect of traumatic memories. Neurobiological theories suggest that visuospatial tasks and visual memory imagery share the same limited-capacity slave system in the working memory (the visuospatial sketchpad). By taxing this system while the memory is active, the intervention reduces the vividness and subsequent ‘intrusiveness’ of the memory. This is distinct from simple distraction; the ‘mental rotation’ element of the Tetris gameplay is essential, as it requires active manipulation of visual information.
Strengths and Limitations
The trial’s strengths include its decentralized nature, which allowed healthcare workers to participate around their demanding schedules, and its use of a Bayesian adaptive design, which is highly suited for clinical trials where rapid insights are needed. However, the study population was somewhat homogeneous, being largely female and White, which may limit the generalizability of the findings to more diverse workforces. Furthermore, while the 4-week results are impressive, longer-term follow-up is necessary to determine the durability of these effects over months or years.
Conclusion: A New Paradigm for Early Intervention
The GAINS-02 trial provides robust evidence that a brief, digital imagery-competing task intervention can effectively reduce the burden of intrusive memories in healthcare staff. Given the scalability of digital tools, this intervention has the potential to be integrated into standard occupational health protocols for medical personnel, emergency responders, and other high-risk professions. By providing a ‘psychological first-aid’ tool that is both evidence-based and easy to use, we can better protect the mental health of those who dedicate their lives to caring for others.
Funding and ClinicalTrials.gov
This research was supported by the Wellcome Trust, the Swedish Research Council, the UK Medical Research Council, and the National Institute for Health and Care Research. The trial is registered at clinicaltrials.gov under the identifier NCT05616676.
References
Beckenstrom AC, Bonsall MB, Markham A, et al. A digital imagery-competing task intervention for stopping intrusive memories in trauma-exposed health-care staff during the COVID-19 pandemic in the UK: a Bayesian adaptive randomised clinical trial. Lancet Psychiatry. 2026;13(3):233-247. doi:10.1016/S2215-0366(25)00397-9.
