IPAPThe International Psychopharmacology Algorithm Project (IPAP) was a not-for-profit corporation registered in Tennessee. IPAP was established with the purpose of bringing together experts in psychiatry, psychopharmacology, and algorithm design to enable, enhance, and propagate the use of algorithms for the systematic treatment of major Axis I psychiatric disorders. The approach was polythetic with a central psychiatric focus, utilizing other relevant fields including data modeling, information science (informatics) cognitive science and general medicine. IPAP was founded by Kenneth O. Jobson, MD, who served as chairman of the board of IPAP until his death in 2023. FundingIn the main, IPAP’s projects were made possible by
grants from the Dean Foundation, a not-for-profit entity registered in
Wisconsin. The Dean Foundation accepted funds designated for use by IPAP
from both pharmaceutical companies (including Astra Zeneca,
Bristol-Myers Squibb, Eli Lilly, Janssen, Johnson & Johnson, Novartis,
Pfizer and Wyeth-Ayerst) and private donors.
Any funds accepted for the use of IPAP must be undesignated,
co-mingled and for use only at the discretion of IPAP for its research
and education projects. AlgorithmsThe basic concept of an algorithm, as constructed
by IPAP, was that a given medical treatment works well for some patients
and doesn’t work well with all patients.
Therefore, physicians needed a rational sequence for trying
something else when the first treatment didn’t work well. The design of
the algorithms evolved as the group worked on the problem, yielding an
evidence-based approach to produce and easy to understand and follow
sequence of steps that would be as effective and safe as the current
understanding would allow.
Note: This means that
algorithms can be expected to be modified as more is learned.
That reason alone is sufficient to explain why no algorithms are
displayed here. The members of IPAP asserted that an algorithm
could not be regarded as a “cookbook” set of instructions; patients
differ and must be treated as individuals.
The figure illustrates the structure of an
algorithm. The first step is
the diagnosis of the illness.
This is followed by the consideration of a number of factors; the
identities of the factors depend on the diagnosis.
Following this step is a flowchart symbol for a decision – an
evaluation. Here, two
choices are possible, psychosocial treatment or medication.
The algorithm is drawn as a flow chart; however, the flowchart is
an aide-memoire; the numbered nodes each have written notes that give
details. Each note may be a
simple sentence, a paragraph, or a page in length, depending on the
needs of the algorithm. The
“consideration” of step 2 is a special case, which is implicitly
included in each decision node and each of the considerations has its
own lettered note. In some
cases, loops may be included in the algorithm to provide for
reevaluations. The medications that are indicated in the algorithm
are given by class, not by particular formulation.
For instance, “SSRI” stands for selective serotonin reuptake
inhibitor. The members of
IPAP determined that brand-name medications would not be listed, nor
would a particular formulation be advised.
The basic reason was that the level of evidence distinguishing
among the class members was absent or weak as compared to that
distinguishing the efficacy of the classes.
Additionally, some formulations were not approved for use in all
countries and each physician might have greater familiarity with the use
of some formulations as compared to others. "The Five
Strengths of Evidence"
Adapted from York St. John College, Website for The
Practical Use of Research Methods for Health Professionals, Extra Resources:
Models of Appraisal. Reference |
Ken JobsonDr. Kenneth O. Jobson was a successful psychiatrist; friends told me that he had treated their child where no one else had been successful. Ken was a successful businessman; he created and sold a psychopharmacology lab. Ken was a persuasive connector; he convinced pharmaceutical companies to pay for a novel endeavor and convinced prominent scientists around the world to create evidence-based psychiatric treatment algorithms. Ken was a life-long learner; he was always interested in learning something new. And Ken was a teacher; he helped write articles and a book about what was going on in the world and how to improve it.  Dr. Kenneth O. Jobson was a successful
psychiatrist; friends told me that he had treated their child
where no one else had been successful.
Ken was a successful businessman; he created and sold a
psychopharmacology lab.
Ken was a persuasive connector; he convinced
pharmaceutical companies to pay for a novel endeavor and
convinced prominent scientists around the world to create
evidence-based psychiatric treatment algorithms.
Ken was a life-long learner; he was always interested in
learning something new.
And Ken was a teacher; he helped write articles and a
book about what was going on in the world and how to improve it. On a personal level, Ken was a friend.
He was genuinely interested in his friends’ problems and
willing to help if that was possible.
He was modest about his own accomplishments and immodest
in his praise of others.
He was proud of all of his children, both biologic and
acquired. We went on some great adventures together.
R.I.P. Dean Hartley |
As the resident-in-charge of the Psychopharmacology Clinic
at the University of North Carolina at Chapel Hill in 1978 and later as
co-founder of the National Psychopharmacology Laboratory, Dr Kenneth Jobson
became aware of the salience of clinical questions about the sequencing of
medications, especially those about treatment following failed or inadequate
response. Subsequently a family
member’s life was prolonged by a treatment from M D Anderson Cancer hospital
using a protocol for previously resistant illness. Using this model, Jobson made
a commitment to try to improve medication choice in psychiatry through what
became known as the International Psychopharmacology Algorithm Project.
In 1985, Jobson contacted a group of colleagues to share
algorithms. They used a Delphi method -- each participant’s treatment sequences
would be submitted, then all shared among the group, minimizing the influence of
“expert” opinions. This “project” was well-received and informative. Eventually
the group addressed, one by one, the major Axis I psychiatric illnesses in this
way. This group included faculty
from Duke, Emory, Harvard, Stanford and Yale Universities; National Institutes
of Mental Health and multiple international sites including the Universities of
Vienna and Stellenbosch (South Africa) and from Sendai, Japan.
In 1992, speaking with longtime friend and colleague Bill
Potter, then head of intramural research at NIMH, Jobson learned that there was
virtually no interest in funding research about medication choice sequencing
(algorithms). Jobson explained that clinicians make those decisions daily and
spoke about his informal algorithm project. They agreed that it would be
worthwhile to have a national conference to create awareness of the need for
psychopharmacology algorithms. So, the project was formalized as the
International Psychopharmacology Algorithm Project and the first educational
conference was held in 1993 at the National Institutes of Mental Health.
In 1997, IPAP experimented with a web-based conference to create two
algorithms, hoping to speed up the process. Although the overall
results were positive, analysis of the process yielded a number
of suggestions, which were reported in the literature (see 1998,
Publications - External Review).
Additionally, several improvements to algorithm presentation were
suggested (1999, Publications -
External Review). A version of these suggestions are on the
webpage, The Language of Algorithms.In
the following years, IPAP held conferences (conf), symposia (sym), produced
algorithms (algo), translated algorithms to other languages (trans), and
published articles (pub), as shown in the table.
|
Year |
Month |
Conf |
Sym |
Algo |
Trans |
Pub |
Title |
|
1993 |
x |
National Institutes of Mental Health (NIMH) |
|||||
|
1996 |
x |
Vienna |
|||||
|
1997 |
x |
Web Conference |
|||||
|
1998 |
x |
Japanese Psychopharmacology Project's Yokohama
Forum |
|||||
|
1999 |
x |
Meta-Conference |
|||||
|
2000 |
x |
CPAP/IPAP Beijing Conference |
|||||
|
2002 |
x |
CPAP/IPAP Beijing Conference |
|||||
|
2002 |
x |
Collegium Internationale
Neuro-Psychopharmacologicum in Montreal |
|||||
|
2002 |
x |
World Congress of Psychiatry in Yokohama |
|||||
|
2005 |
6 |
x |
PTSD Algorithm |
||||
|
2005 |
x |
ADD/ADHD Beijing Conference |
|||||
|
2005 |
6 |
x |
"Comments on implications of CATIE Phase I results for the IPAP Schizophrenia Algorithm," David Osser and Herbert Meltzer |
||||
|
2006 |
1 |
x |
"Estimates
of Effects of Drugs," Herbert Meltzer and David Osser |
||||
|
2006 |
3 |
x |
Schizophrenia Algorithm |
||||
|
2006 |
5 |
x |
IPAP-University of Buffalo Symposium |
||||
|
2006 |
8 |
x |
x |
PTSD Algorithm, Spanish and Thai |
|||
|
2006 |
11 |
x |
Symposium on Diffusion, Adoption, and
Maintenance of Psychiatric Treatment Algorithms White Paper: Blueprint
for Collaboration, Maureen Adamson |
||||
|
2006 |
11 |
x |
Generalized Anxiety Disorder (GAD) Algorithm |
||||
|
2007 |
2 |
x |
"Psychiatrist Prescribes O.R.," ORMS Today.
Vol 34, No1, Dean Hartley and Ken Jobson |
||||
|
2007 |
4 |
x |
"The Role of Guidelines and Algorithms for
Psychopharmacology in 2007" in the journal Psychiatry Times (Vol.
24 No. 4), David Osser |
||||
|
2007 |
4 |
x |
x |
PTSD and GAD Algorithms, Chinese |
|||
|
2007 |
6 |
x |
x |
Generalized Anxiety Disorder (GAD) Algorithm,
Spanish |
|||
|
2007 |
12 |
x |
x |
Post-Traumatic Stress Disorder (PTSD) Algorithm,
Bahasa Indonesia |
|||
|
2008 |
10 |
x |
Substance Abuse (Alcohol, Cocaine, Nicotine, and
Opioid) Algorithms |
||||
|
2012 |
8 |
x |
Substance Abuse (Alcohol, Cocaine, Nicotine, and
Opioid) Algorithm Updates |
The Buffalo Symposium (May 5-6, 2006) provides a good
example of the IPAP conferences and symposia. A group of physicians,
educators, and informaticians gathered in Buffalo this weekend to explore ways
to develop and facilitate use of treatment guidelines to dramatically improve
patient care at the Invitational Symposium on Diffusion, Adoption, and
Maintenance of Psychiatric Treatment Algorithms. According to The First
National Report Card on Quality of Health Care in America (Rand Corporation,
2006), only 50% of patient care in general medicine is optimal. The Symposium,
co-sponsored by the International Psychopharmacology Algorithm Project
(IPAP) and the School of Informatics, University at Buffalo SUNY, focused
on opportunities to improve these outcomes through easy access to high quality
treatment guidelines available at the point-of-care.
The IPAP white paper Symposium on
Diffusion, Adoption, and Maintenance of Psychiatric Treatment Algorithms,
prepared by Maureen Adamson is available as a
PDF download (2.1 Mb) from this web site.
The White Paper, subtitled Blueprint for Collaboration represents
analysis and recommendations following the Symposium.
The last Advisory Group consisted of the following members:
·
Kenneth O. Jobson, MD, Psychiatry and
Psychopharmacology Services, Tennessee
·
Dean S. Hartley III, PhD, Principal, Hartley
Consulting
·
David Penniman, PhD, Consultant to Management in
Libraries and Information Services
·
Paul Nordstrom August, MBBS, Biomedical
Informatician, Kenzen Systems Pte Ltd
The Faculties consisted of the following distinguished members for the
respective algorithms:
Jonathan Davidson, Duke University Medical Center
Ken Jobson MD, IPAP
Dan Stein,
Universities of Stellenbosch and Cape Town
Kathryn Connor, Duke
University Medical Center
Marcio Bernik, Brazil
Matthew Friedman,
Dartmouth
Yoshiharu Kim, Japan
Yves Lecrubier MD (Counsellor), ECNP 98 Paris, Hopital de la Salpitriere
Hong Mah, China
Frank Njenga, Kenya
Joseph Zohar,
Israel
Dean S Hartley III PhD, Hartley Consulting
David Osser MD, Harvard Medical
School at the Brockton Division
David Penniman PhD, School of Informatics, Univ at Buffalo
Oakley Ray
Paul Nordstrom August
Herbert Y. Meltzer MD (Chair), Psychiatric Hospital
at Vanderbilt
Donald Goff MD (Co-Chair), Freedom Trail Clinic,
Boston
David N. Osser MD (Co-Chair), Harvard Medical School at the
Brockton Division
Donald Addington MD, MBBS, MRCPsych, FRCPC
(Counsellor), University of Calgary
David Copolov PhD (Counsellor),
Helio Elkis MD, PhD (Counsellor), University of Sao Paulo, Instituto
de Psyquiatria-Hospital das Clinicas
Wolfgang Fleischhacker MD
(Counsellor), Innsbruck University Clinics
Dan Haupt MD (Counsellor),
Dept of Psychiatry, Washington University School of Medicine
Masaki
Hayashida MD, PhD (Counsellor), Health Administration Center, Nagasaki
University
Dilip Jeste MD (Counsellor),
Yves Lecrubier MD
(Counsellor), ECNP 98 Paris, Hopital de la Salpitriere
Jeffery Lieberman
MD (Counsellor), University of North Carolina School of Medicine
Dieter
Naber Professor Dr. (Counsellor), Psychiatric University Hospital
Hamburg-Eppendorf
John Newcomer MD (Counsellor), Washington University
School of Medicine
Oakley Ray PhD (Counsellor), CINP
Liang Shu
MD (Counsellor), Institute of Mental Health, Peking University
Stephen M.
Stahl MD, PhD (Counsellor), Neuroscience Education Institute, Carlsbad
Peter J. Weiden MD (Counsellor), SUNY Downstate Medical Center
Kenneth O. Jobson MD (Technology Chair), IPAP
Paul Nordstrom August MBBS (Technology Consultant), Biomedical Informatician
Dean S. Hartley PhD (Technology Consultant), Hartley Consulting
W.
David Penniman PhD (Technology Consultant), School of Informatics, Univ at
Buffalo
Jonathan Davidson, Duke University Medical Center
Ken Jobson, IPAP
Dan Stein, Universities
of Stellenbosch and Cape Town
Kathryn Connor, Duke University Medical
Center
Wei Zhang, Duke University Medical Center
Yves Lecrubier, French National Institute of Health
and Medical Research (INSERM)
David Nutt, University of Bristol
Marcio Versiani, Federal University of Rio de Janeiro
Alexander
Cowell McFarlane, University of Adelaide
Ji Jianlin, Shanghai
Medical School
Osamu Tajima, School of Health Sciences, Kyorin
University
Dean S Hartley III, Hartley Consulting
David
Osser, Harvard Medical School
David Penniman, University at
Buffalo
Oakley Ray, CINP
Paul Nordstrom August, Kenzen Systems
Roger Weiss, MD, Harvard University
Tom Kosten, MD, Baylor University
Ken Jobson,
MD, IPAP
Marc Auriacombe, MD, University of Victor Segalen,
France
Kathy Brady, MD, University of South Carolina
Jonathan
Chick, MD, Royal Edinburgh Hospital, Scotland
Hilary Connery, MD PhD,
Harvard University
Colon Drummond, MD, King's College, London,
England
Gabriele Fischer, MD, Medical University of Vienna, Austria
JC Garbutt, MD, University of North Carolina
Ali Saffet Gonul,
MD, Ege University, Izmir, Turkey.
Susumu Higuchi, MD PhD,
National Hospital, Kirihama, Japan
John Hughes, MD, University of
Vermont
Masomi Iyo, MD PhD, Chiba University, Japan
Kyle
Kampman, MD, University of Pennsylvania
Falk Kiefer, MD,
University of Heidelberg, Germany
Jianhua Li, MD, Yunnan Institute,
China
Jeff Newport, MD, Emory University
David Nutt, MD,
University of Bristol, England
Marcelo Santos Cruz, MD PhD, Federal
University, Rio de Janeiro, Brazil
Zack Stowe, MD, Emory University
Eric Strain, MD, Johns Hopkins University
Lize Weich, MD,
Skitland Hospital, Stellenbosch University, South Africa
Robert West, MD,
University College of London, England
Donald Wilson, MD, Groote
Schuur Hospital, South Africa
Dean S Hartley III, PhD, Hartley Consulting
David Osser, MD, Harvard Medical School
David Penniman, PhD,
Nylink, State University of New York
Paul Nordstrom August, MBBS, Kenzen Systems
IPAP showed that psychopharmacology algorithms could be produced. It also inspired the creation of algorithm projects in Japan and China. With the death of Dr. Ken Jobson, IPAP has become history. However, in the US, David Osser at Harvard is maintaining a vigorous, evidence-based algorithm project. So, the work continues.
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