Objective To present a service evaluation of a new Habit-Reversal clinical pathway at a tertiary neurological care setting.

Method Guided by both a psychologist and a neuropsychiatrist, a clinical pathway within a neuropsychiatry department was established in April 2021. All patients with a diagnosis of Gilles de la Tourette Syndrome (GTS) or Tic Disorder (TD) assessed and offered Habit Reversal Training (HRT) between June 2021 and June 2023 were included in this evaluation. Patients were exempt if their symptoms were more consistent with Tourettic Obsessive-Compulsive Disorder (TOCD) or had contra-indications such as Functional Tics (FT). All treated patients received an individual course of HRT which began with a psychologist-led face-to-face assessment with the exception of one which for practical reasons took place virtually. All sessions thereafter lasted fifty minutes. To evaluate treatment effectiveness, patients completed pre-, post and at each session self-reported tic management ratings (Likert-type response continua) and a well-validated measure of psychological well-being (i.e., Clinical Outcomes in Routine Evaluation-10).

Results By the end of June 2023, 40 patients had been referred to the HRT clinical pathway. 7 patients completed twelve sessions and 22 patients completed six sessions. 11 patients were not suitable due to either HRT not being a suitable intervention, failure to engage, or other psychiatric co-morbidities impacting on engagement.

We report two main findings:

• First, in both cycles of HRT, self-reported tic management improvement scores were reported. The improvement between baseline and training end ranged from 90%–80% (12-weeks, n=5) and 90%–20% (6-weeks, n=15). Either no improvement or no scores being available was also reported (12-weeks: n=2/6 weeks: n=7). Deriving the improvement score entailed patients being asked the following question ‘by how much do you think your symptoms have improved since our first consultation in this clinic?’ Improvements gained in tic management during respective HRT cycles also facilitated improvements in modulating illness representation and enhancing quality of life. We are yet to identify any specific reason(s) as to why some patients benefit from HRT and others do not.

• Second, self-reported improvements in psychological wellbeing (i.e., symptoms related to depression and anxiety) carried over to patients who attended either cycle of HRT. Factors common with improvements in psychological well-being included treating clinician access to ongoing case-based supervision and video recording review of treatment process.

Conclusion Within specific limitations, this evaluation provides evidence that HRT delivered within a tertiary neurological care setting can lead to improvement in GTS and TD symptom management. Future research could: (i) explore the clinical profile of patients with GTS and TD to the point that decisions regarding suitability of HRT can be precisely made, (ii) consider the cost-effectiveness of delivering a HRT treatment pathway, and (iii) develop HRT to the point that it may be considered as a viable treatment option for other tic related conditions (i.e., TOCD and FT).