Reducing Intrusive Memories in Refugees and Asylum Seekers With PTSD

Reducing Intrusive Memories of Trauma Using a Visuospatial Interference Intervention With Refugees With Posttraumatic Stress Disorder (PTSD): A Test of Replication to a New Population

This research study is designed to investigate the use of a simple cognitive task for decreasing the number of intrusive memories of traumatic events experienced by refugees and asylum seekers with a diagnosis of Post-traumatic Stress Disorder (PTSD) currently living in the UK. The intervention includes a memory reminder cue, a 10-minute time gap and then around 20 minutes playing the mobile phone game Tetris, using mental rotation instructions. The study will have a multiple baseline case-series design (AB), with a randomised duration of baseline length up to three weeks. Thus, participants will complete a no-intervention phase of up to three weeks, followed by an intervention phase. Please see the intervention section for more details about the intervention sessions. Follow ups are conducted after each week to monitor the frequency of intrusive memories of trauma in a pen-and-paper diary. It is predicted that participants will report fewer intrusive memories after receiving the intervention than in the preceding baseline phase.

Study Overview

• Status: Terminated
• Conditions: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Trauma and Stressor Related Disorders; Post Traumatic Stress Disorder; Mental Disorder; Trauma, Psychological
• Intervention / Treatment: Behavioral: Brief cognitive intervention

Detailed Description

The study is being conducted at a specialist National Health Service (NHS) mental health service for refugees, asylum seekers and forced migrants suffering from Post-Traumatic Stress Disorder (PTSD). We aim to recruit up to 13 participants from this service to take part in the study, which is an extension of a pilot study previously conducted. Due to the Covid-19 pandemic, guidance from the trust R&D and NHS service manager states that face-to-face appointments should not currently take place at the NHS clinical recruitment site. Therefore, until this guidance changes, the research will take place remotely via video calls.

The study will have a multiple baseline case-series design (AB), with a randomised duration of baseline length up to three weeks. At the start of the baseline phase, participants will create, with the help of the researcher, a list of their most frequent and distressing intrusive memories of trauma. Each intrusive memory will be given a label (for example; a letter, colour or symbol) so that the frequency of each intrusive memory can be monitored in a pen and paper diary. The frequency of specific intrusive memories the person experiences after they have received the intervention will be compared with the frequency of specific intrusive memories they had during the baseline phase. For each specific intrusion the period prior to that intrusion being targeted in an intervention session will be the baseline phase (A); therefore, the baseline phase will include the minimum baseline duration (lasting up to three weeks) plus the additional weeks in which the specific intrusion remained untargeted by the intervention. The post intervention phase (B) will be the time after the specific intrusion was targeted. Some intrusive memories on the list may not be targeted by the intervention but will be monitored (through the intrusion diary) throughout the duration of the study for comparison.

This study is a follow-up to a study conducted in Sweden with refugees. ClinicalTrials.gov Identifier: NCT03760601

Our study is extending previous research to refugees and asylum seekers with a diagnosis of PTSD, accessing a secondary care mental health service and living in the United Kingdom (UK).

• Study Type: Interventional
• Enrollment (Actual): 6
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United Kingdom
  • London, United Kingdom, W9 2NW
    • Woodfield Trauma service

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• are on the wait list for treatment (trauma focused therapy) at Woodfield Trauma Service
• aged 18-65
• have experienced intrusive memories in the past two weeks, as assessed by scoring 1 or above on question 1 of the PCL-5
• are able to communicate with the researcher, with or without an interpreter
• have a fixed abode. This is operationalised as having a current address (including B&B or open access hostel) and evidence indicating that the person is likely to have a reliable address throughout the study. This is necessary to avoid sample attrition.
• can commit to attending regular appointments and keeping an intrusion diary throughout the duration of the study.
• if recruited remotely, have access to the internet and a device such as a mobile phone, I-pad or laptop, to engage in video calls and to play Tetris on.
• if recruited remotely, are able to find a quiet space for 1 hour a week to have an appointment e.g. without distraction from other family members.

Exclusion Criteria:

• a current diagnosis of schizophrenia or bipolar disorder type 1
• Intelligence Quotient (IQ) < 80
• acute suicide risk
• substance dependence
• have been unable to complete the routine questionnaires given to new patients in the service at assessment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Baseline phase, followed by intervention phase; Within the baseline phase, measurements of the primary outcome measure (frequency of intrusive memories of trauma) will be collected in a pen-and-paper diary for up to three weeks (dependent on baseline length). Individual baseline phases will be used as control periods. In the intervention phase the participant will be offered around five intervention sessions with a researcher. Each session the participant will choose which intrusive memory they would like to focus on and the cognitive task will be completed. The intervention includes a memory reminder cue, a 10-minute time gap and then around 20 minutes playing the mobile phone game Tetris, using mental rotation instructions. Participants will be given instructions to continue to use the technique self-guided in the subsequent week. Measurements of the primary outcome measure (frequency of intrusive memories of trauma) will be collected in a pen-and-paper diary.

Behavioral: Brief cognitive intervention; See the information provided in the experimental arm description.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Frequency of intrusive memories	Number of intrusive memories of traumatic events recorded by participants in a daily pen and and paper diary.	Baseline weeks 1-3, throughout the duration of the intervention phase (approximately 5 weeks), post-intervention weeks 1-2 and for 1 week 2 months post-intervention. Change is assessed from baseline to post-intervention.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Concentration	A brief bespoke measure of concentration adapted from that used previously with refugees (Holmes et al., 2017). It has three questions about disruption to concentration from intrusive memories. A higher score on each question means a worse outcome.	Baseline, 2-weeks post-intervention and 2-months post-intervention
Social and Occupational Activity Tally (SOAT)	Developed by Woodfield Trauma Service. The measure asks how many hours the person has spent doing various activities in the past two weeks (for example, domestic chores, exercise, cultural activities). A higher score means a better outcome.	Baseline, 2-weeks post-intervention and 2-months post-intervention
Dissociation	Four items from the Dissociative Experiences Scale II - items two, three, 14 and 20 (DES II; Carlson, & Putnam, 1993). Each item asks how often (from 0% to 100% of the time) the dissociative experience described happens to the individual. A higher score on each question means a worse outcome.	Baseline, 2-weeks post-intervention and 2-months post-intervention
Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (PCL-5)	The PCL-5 (Weathers, Litz, Keane, Palmieri, Marx, & Schnurr, 2013) is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. Total scores can range from 0 to 80, with higher scores meaning a worse outcome.	Baseline and 2-weeks post-intervention
Patient Health Questionnaire (PHQ-9)	The PHQ-9 (Kroenke, Spitzer & Williams, 2001) is a nine-item self-report measure that assesses the nine DSM-IV symptoms of depression. Total scores can range from 0 to 27, with higher scores meaning a worse outcome.	Baseline and 2-weeks post-intervention
World Health Organisation Disability Assessment Schedule 2.0 (WHO DAS 2.0) 12 item version	The WHO DAS 2.0 (World Health Organisation, 2010) is a measure of health and disability. Total scores can range from 0 to 48, with higher scores meaning a worse outcome.	Baseline and 2-weeks post-intervention

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Self-Guided Intervention Adherence Questionnaire	A bespoke measure to assess adherence to self-guided practice of the intervention. It includes four questions to assess how often, and for how long, the person played Tetris after experiencing intrusive memories during the previous week.	Time Frame: Intervention sessions 2-5, 1 week post-intervention, 2 weeks post-intervention and 2 months post-intervention.
Feedback Questionnaire	A bespoke questionnaire to gain feedback on the intervention. It includes 16 questions to assess acceptability and usefulness of the intervention with a variety of response options including yes/no, visual analogue scales and open responses.	1-week post-intervention.

Collaborators and Investigators

• Sponsor: University of Surrey
• Collaborators: Uppsala University; Central and North West London NHS Foundation Trust
• Investigators: Principal Investigator: Emily Greenfield, University of Surrey

Study record dates

Study Major Dates

• Study Start (Actual): July 7, 2020
• Primary Completion (Actual): April 6, 2021
• Study Completion (Actual): April 6, 2021

Study Registration Dates

• First Submitted: May 14, 2020
• First Submitted That Met QC Criteria: May 14, 2020
• First Posted (Actual): May 19, 2020

Study Record Updates

• Last Update Posted (Actual): November 4, 2022
• Last Update Submitted That Met QC Criteria: November 1, 2022
• Last Verified: October 1, 2022

More Information

Terms related to this study

• Keywords: Post-Traumatic Stress Disorder; Intrusive Memories; Cognitive Task Interference
• Additional Relevant MeSH Terms: Pathologic Processes; Disease; Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic; Wounds and Injuries; Mental Disorders; Psychological Trauma; Trauma and Stressor Related Disorders
• Other Study ID Numbers: SPON 2019 032 FHMS (B)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No