Internet-based ERP therapy improved response in Tourette’s syndrome

August 16, 2022

2 minute read

Disclosures: Andren does not report any relevant financial information. Pringsheim reports research funding from Alberta Health and the Alberta Children’s Hospital Research Institute, and employment as an evidence-based medicine methodology consultant for the American Academy of Neurology. Piacentini reports support from NIMH, Patient-Centered Outcomes Research Institute, TLC Foundation for Body-Focused Repetitive Behaviors, and Nicholas Endowment, receiving consultancy fees from Spinnaker Health, publishing royalties from Guilford Press, Oxford University Press and Elsevier, and travel/speaker fees from the Tourette Association of America, the OCD International Foundation, and the TLC Foundation for BFRBs. Please see the study for relevant financial information from all other authors.

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Therapist-supported Internet-based exposure and response therapy resulted in higher response rates and was cost-effective for youth with Tourette syndrome or chronic tics compared to Internet-delivered tic education.

“Clinical guidelines recommend behavioral therapy as first-line treatment for Tourette’s syndrome and chronic tic, but its availability is very limited,” By Andrew, Ph.D. from the Center for Psychiatry Research at the Karolinska Institute in Stockholm, Sweden, and his colleagues wrote in Open JAMA Network.

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Andren and his fellow researchers have developed a form of exposure and response prevention (ERP) therapy for children and adolescents with Tourette syndrome (TS) or chronic tics (CTD) and sought to examine its feasibility and effectiveness.

The study was a randomized, parallel-group, single-blind, randomized superiority clinical trial with national recruitment and conducted at a research clinic in Stockholm. From an initial pool of 615 eligible people, 221 participants aged 9 to 17 met the diagnostic criteria. Participants were randomly assigned on a 1:1 basis to receive either 10 weeks of ERP therapy delivered over the Internet with the therapist for tics (n = 111) or education delivered over the Internet with the therapist for tics (n = 110). The primary outcome was the change in tic severity between baseline and 3-month follow-up, as measured by the Yale Global Tic Severity Scale Total Tic Severity Score (YGTSS-TTSS). Treatment response was operationalized as a score of 1 (“Very much improved”) or 2 (“Much improved”) on the Clinical Global Impression Improvement Scale. Registration began in April 2019 and ended in April 2021, with data analyzed between October 2021 and March 2022.

Results showed that 216 of 221 participants (97.7%) provided the necessary primary outcome data. Among randomly assigned participants (152 boys; mean age, 12.1 years), tic severity improved significantly, with a mean reduction of 6.08 points on the YGTSS-TTSS in the therapy group ERP (average [SD] at the start, 22.25 [5.6]; at 3 month follow-up, 16.17 [6.82]) and 5.29 in the comparator (average [SD] at the start, 23.01 [5.92]; at 3 month follow-up, 17.72 [7.11]).

Intent-to-treat analyzes showed that both cohorts improved similarly over time (interaction effect, 0.53; 95% CI, 1.28 to 0.22). Significantly more participants were classified as treatment responders in the ERP therapy group (51 of 108) than in the comparison group (31 of 108) at 3 months follow-up (OR = 2.22; 95% CI, 1.27-3.9). ERP therapy resulted in more responders to treatment by little extra charge compared to structured teaching. The additional cost per quality-adjusted life-year gained was below the Swedish willingness-to-pay threshold, at which ERP therapy had a 66% to 76% probability of being cost-effective.

“Implementing digital ERP intervention in mainstream healthcare would increase treatment availability for young people with TS or CTD,” Andren and colleagues wrote.

In a related editorial, Tamara Pringsheim, MD, from the Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences at the University of Calgary, and John Piacentini, PhD, from the Semel Institute for Neuroscience and Human Behavior at UCLA, wrote, “From a broader perspective, the results of this study provide further support for the acceptability and efficacy of treatments behavioral for tic disorders… this is in no way to say that drugs no longer play a role in the treatment of TS.

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