Early value assessment consultation document for HTE10056 Digital therapy for chronic tic disorders and Tourette syndrome

The scope for this early value assessment included a targeted population of people with a diagnosed primary tic disorder who have had psychoeducation, but their tics continue to be bothersome. There is no comprehensive clinical guideline for the diagnosis and management of tic disorders in children and young people in the UK. NICE's guideline on suspected neurological conditions: recognition and referral contains some information on tic disorders. It recommends that children and young people with tic disorders that have a significant impact on their quality of life, should be considered for referral to specialist mental health services, neurodevelopmental teams or for neurological assessment. Adults with tic disorders should be considered for neurological assessment if their symptoms are severe and the disorder continues to cause distress.

In the UK, people with chronic tic disorders and Tourette syndrome attend an initial appointment with a GP in primary care. When a tic disorder has a significant impact on a person's quality of life, they are usually referred to appropriate secondary or tertiary care services (depending on the presentation, comorbidities, and local specialist clinics). Children and young people may be referred to mental health services (including to the Children and Young People's Mental Health Services), neurodevelopmental teams, paediatric teams or paediatric neurology teams, depending on local services and pathways. Adults are usually referred to neurology services or to neuropsychiatry clinics. Because tics may improve with time, NICE's guideline on suspected neurological conditions: recognition and referral recommends a watch-and-wait approach for people presenting in primary care, especially if they do not have functional impairment. Current practice varies by location across the UK and by the availability of local services but, in general, treatment options for chronic tic disorders include:

• psychoeducation

• behavioural therapy

• pharmacological therapy

• deep brain stimulation and

• Botox.

Accepted evidence-based treatment options for diagnosed tic disorders are psychoeducation as a first line option and behavioural therapies for people who still have difficulties with their tics. For some people, behavioural approaches may not be as effective, feasible or accessible and other possible treatments (with or without behavioural therapies) will be discussed. Digital therapy for chronic tic disorders and Tourette syndrome would be offered after clinical assessment and diagnosis. These interventions should only be considered if the person (and parent or carer where appropriate) has had access to a form of psychoeducation. If the tic disorder continues to cause difficulties, a healthcare professional may consider referring people for these interventions.

The comparator is standard care for managing chronic tic disorders and Tourette syndrome, including psychoeducation and behavioural therapy. Standard care varies significantly across clinical practice. Digital therapy would be used in addition to standard care.

There was no evidence comparing any of the interventions with current standard care. The online psychoeducation may be a more active comparator than face-to-face psychoeducation in current UK clinical practice. In the economic modelling, the comparator for ORBIT is online psychoeducation in children and young people. The comparator for Neupulse is a waitlist control (that is, no stimulation) in children and young people 12 years and over, and in adults.