Visuospatial imagery-competing task interventions for reducing intrusive memories following real-world trauma: a systematic review and meta-analysis.

BACKGROUND: Intrusive memories are a hallmark of PTSD and predict its course, making the early post-trauma period a critical window for prevention. Visuospatial imagery-competing task interventions (ICTI) - brief Tetris-like gameplay after a memory reactivation cue - are grounded in the working memory interference hypothesis and show strong laboratory effects. The only prior RCT synthesis in real-world trauma identified three eligible studies, all rated low certainty. No pre-registered review has synthesised RCT evidence for visuospatial ICTI exclusively in real-world trauma using intrusive memory frequency as the primary outcome. OBJECTIVES: To estimate the pooled effect of visuospatial ICTI on intrusive memory frequency in real-world trauma; examine whether an explicit memory reactivation cue moderates this effect; evaluate effects on PTSD severity, depression, anxiety, adverse events, and attrition; and identify gaps to inform future trial design. METHODS: Seven databases were searched from inception to March 2026 for RCTs of visuospatial ICTI in adults exposed to real-world DSM-5 Criterion A trauma. The primary outcome was intrusive memory frequency via prospective daily diary. Risk of bias was assessed with RoB 2 and ROBINS-I, certainty with GRADE. Random-effects meta-analysis pooled raw mean differences for parallel-group RCTs with compatible diary data. Registered on PROSPERO (CRD420261336501); reported per PRISMA 2020. RESULTS: Of 818 records identified, 13 studies (9 RCTs, 4 non-randomised) met eligibility criteria. Five parallel-group RCTs (n=359) were pooled for the primary outcome: ICTI reduced intrusive memories by 6.98 fewer episodes/week versus control (95% CI -9.84 to -4.13; I2 = 21.9%), moderate-certainty evidence (downgraded for risk of bias). PTSD severity also favoured ICTI (MD -2.42, 95% CI -4.40 to -0.44), low certainty due to inconsistency and indirectness. Depression and anxiety could not be meta-analysed due to measurement heterogeneity. No serious adverse events were attributed to ICTI; attrition was generally low. Non-pooled evidence was broadly consistent, though one VR-based trial and one crossover trial in chronic PTSD found no benefit. CONCLUSIONS: Visuospatial ICTI produces a clinically interpretable, moderate-certainty reduction in intrusive memory frequency after real-world trauma, with low-certainty but favourable effects on PTSD severity. The evidence base remains limited to five pooled RCTs. ICTI should be considered a promising targeted intervention rather than an established treatment, pending larger independent trials. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261336501, identifier CRD420261336501.