Long‐term clinical and cost‐effectiveness of a therapist‐supported online remote behavioural intervention for tics in children and adolescents: extended 12‐ and 18‐month follow‐up of a single‐blind randomised controlled trial

Abstract

Background: Little is known about the long-term effectiveness of behavioural therapy for tics. We aimed to assess the long-term clinical and cost-effectiveness of online therapist-supported exposure and response prevention (ERP) therapy for tics 12 and 18 months after treatment initiation. Methods: ORBIT (online remote behavioural intervention for tics) was a two-arm (1:1 ratio), superiority, single-blind, multicentre randomised controlled trial comparing online ERP for tics with online psychoeducation. The trial was conducted across two Child and Adolescent Mental Health Services in England. Participants were recruited from these two sites, across other clinics in England, or by self-referral. This study was a naturalistic follow-up of participants at 12-and 18-month postrandomisation. Participants were permitted to use alternative treatments recommended by their clinician. The key outcome was the Yale Global Tic Severity Scale Total Tic Severity Score (YGTSS-TTSS). A full economic evaluation was conducted. Registrations are ISRCTN (ISRCTN70758207); ClinicalTrials.gov (NCT03483493). Results: Two hundred and twenty-four participants were enrolled: 112 to ERP and 112 to psychoeducation. The sample was predominately male (177; 79%) and of white ethnicity (195; 87%). The ERP intervention reduced baseline YGTSS-TTSS by 2.64 points (95% CI: À4.48 to À0.79) with an effect size of À0.36 (95% CI: À0.61 to À0.11) after 12 months and by 2.01 points (95% CI: À3.86 to À0.15) with an effect size of À0.27 (95% CI -0.52 to À0.02) after 18 months, compared with psychoeducation. Very few participants (<10%) started new tic treatment during follow-up. The cost difference in ERP compared with psychoeducation was £304.94 (À139.41 to 749.29). At 18 months, the cost per QALY gained was £16,708 for ERP compared with psychoeducation. Conclusions: Remotely delivered online ERP is a clinical and costeffective intervention with durable benefits extending for up to 18 months. This represents an efficient public mental health approach to increase access to behavioural therapy and improve outcomes for tics.

Internet-Delivered Exposure and Response Prevention for Pediatric Tourette Syndrome

“…The sister ORBIT trial presented data up to 18 months after randomization (equivalent to 15 months after treatment) and showed a similar tic severity improvement for the ERP group to that in the present study (6.9 raw points on the YGTSS-TTSS) but a slightly smaller improvement for psychoeducation (4.5 points). 13,14 A similar pattern was shown for the treatment response rates, with both studies classifying 55% of participants as treatment responders in the ERP group, while there was a difference for JAMA Network Open | Psychiatry psychoeducation (50% in the current study, 41% in ORBIT). The somewhat unexpected larger effect of the comparator in our study may be due to a range of reasons, such as a sample population with milder symptom severity and the use of more experienced therapists.…”

“…41 This ICER was comparable to the £16 708 (approximately US $20 800) cost per QALY gained reported at 18 months after randomization in the ORBIT trial. 14 In summary, the probability of ERP being cost-effective compared with psychoeducation at the 12-month follow-up varied for each increasingly wider costing perspective: 78% for the health care organization perspective, 100% (dominance) for the health care sector perspective, and 65% for the societal perspective. A 12-month time frame is typically considered short for a health economic evaluation, and an extended time horizon has, on average, been shown to lead to more favorable estimates.…”

“…13 These results were maintained long-term (about 15 months after treatment). 14 In a largely identical study involving 221 participants conducted in Sweden, 15 internet-delivered ERP was not superior to psychoeducation in reducing tic severity at the primary end point (3 months posttreatment), but the ORBIT trial results were replicated on a secondary measure of treatment response. 16 Overall, within-group results indicated clinically relevant improvements from both interventions, requiring minimal therapist time.…”

“…At the primary end point (posttreatment), internet-delivered ERP was superior to psychoeducation in reducing tic severity, requiring only minimal therapist resources . These results were maintained long-term (about 15 months after treatment) . In a largely identical study involving 221 participants conducted in Sweden, internet-delivered ERP was not superior to psychoeducation in reducing tic severity at the primary end point (3 months posttreatment), but the ORBIT trial results were replicated on a secondary measure of treatment response .…”

Editorial: It is time to modernize the concept of ADHD!

“…Such a mobile decision support system may support (a) the diagnostic process, for example, by complementing existing diagnostic tools (interviews and questionnaires) with information on real‐time and real‐world markers of functioning that allows clinicians to steer clear of existing stereotypical ADHD presentations and to better embrace the heterogeneity of ADHD, (b) monitoring and boosting of functioning by the user with ADHD, for example, by providing lifestyle advice when needed and taking value‐based, shared decisions about treatment needs, and such a DSS (c) can be used as a tool to deliver treatment online, that is, in a broadly accessible way not hampered by waiting lists. For the latter, the work by Hollis and colleagues presented elsewhere in this issue (Hollis et al., 2023) sets the stage: they show that a behavioral intervention – in their case for tics – can effectively and cost‐effectively be administered online, providing an efficient mental health approach that increases access to effective treatment. An important additional requirement for a successful transition into a new concept of ADHD is an increased focus on education and training about ADHD.…”