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

August 16, 2022

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Source/Disclosures


Disclosure: Andren does not report relevant financial information. Pringsheim reports on research grants from Alberta Health and the Alberta Children’s Hospital Research Institute, as well as employment as a consultant on evidence-based medicine methods for the American Academy of Neurology. Piacentini reports support from NIMH, the Patient-Centered Outcomes Research Institute, the TLC Foundation for Body-Focused Repetitive Behaviors, and the Nicholas Endowment, receives consultant fees from Spinnaker Health, publishing fees from Guilford Press, Oxford University Press, and Elsevier, and travel/speaker honoraria from the Tourette Association of America, the International OCD Foundation, and the TLC Foundation for BFRBs. The relevant financial information of all other authors can be found in the study.


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Therapist-assisted internet-based exposure and response therapy resulted in higher response rates and was cost-effective for young people with Tourette syndrome or chronic tic disorder compared to internet-assisted tic education.

“Clinical guidelines recommend behavioral therapy as first-line treatment for Tourette syndrome and chronic tic disorder, but its availability is very limited.” Per Andren, PhD from the Center for Psychiatry Research, Karolinska Institute in Stockholm, Sweden, and colleagues wrote JAMA network open.




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Andren and other researchers developed an Internet-delivered form of exposure and response prevention therapy (ERP) for children and adolescents with Tourette syndrome (TS) or chronic tic disorder (CTD) and attempted to study its feasibility and effectiveness.

The study was a single-masked, randomized, parallel-group clinical study with nationwide recruitment, conducted at a research clinic in Stockholm. From an initial pool of 615 eligible individuals, 221 participants aged 9 to 17 years met diagnostic criteria. Participants were randomly assigned on a 1:1 basis to receive either 10 weeks of therapist-assisted internet-assisted ERP therapy for tics (n=111) or therapist-assisted internet-assisted education for tics (n=110). The primary endpoint was the change in tic severity from baseline to 3 months follow-up as measured by the Yale Global Tic Severity Scale Total Tic Severity Score (YGTSS-TTSS). Response to treatment was operationalized as a rating of 1 (“much improved”) or 2 (“much improved”) on the Clinical Global Impression-Improvement Scale. Registration started 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 required primary endpoint 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 ERP therapy group (mean [SD] at the beginning, 22.25 [5.6]; at 3-month follow-up, 16.17 [6.82]) and 5.29 in the comparator (mean [SD] at the beginning, 23.01 [5.92]; at 3 month follow-up, 17.72 [7.11]).

Intention-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 therapy responders in the ERP therapy group (51 of 108) than in the comparator group (31 of 108) at 3 months follow-up (OR=2.22; 95% CI, 1.27-3 ,9). ERP therapy resulted in more patients responding to treatment at little additional cost compared to structured education. The incremental cost per quality-adjusted life-year gained was below the Swedish willingness-to-pay threshold, at which there was a 66% to 76% probability that ERP therapy was cost-effective.

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

In a related editorial Tamara Pringsheim, MD, the Department of Clinical Neuroscience, 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 effectiveness of behavioral treatments for tic disorders…this is by no means to say that medications are useful in the treatment of.” TS no longer matter.”

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