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THE INTERNATIONAL PSYCHOPHARMACOLOGY ALGORITHM PROJECT (IPAP)


IPAP


The 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.

Funding

In 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.

Algorithms

The 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.

sample algorithm

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.

I A. Strong Evidence from at least one systematic review of multiple well-designed randomized control trials.
I B. Multiple well designed randomized control trials.

II. Strong Evidence from at least one properly designed randomized controlled trial of appropriate size.

III. Evidence from well-designed trial without randomization, single group pre-post, cohort, time series or matched case-control studies.

IV. Evidence from well-designed non-experimental studies from more than one center or research group.

V. Opinions of respected authorities based on clinical evidence, descriptive studies or reports of expert committees.

Reference
Long, AF. (2002) 'Critically appraising research studies' in McSherry R, Simmons M and Abbott P (eds) Evidence-Informed Nursing: A Guide for Clinical Nurses. London: Routledge.

Ken Jobson


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.

Ken

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

History of IPAP

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 and Its Results

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.

Buffalo group

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.  IPAP Special Advisor David N. Osser MD had published an article entitled "The Role of Guidelines and Algorithms for Psychopharmacology in 2007" in the journal Psychiatry Times (April 01, 2007 Vol. 24 No. 4). Dr Osser was one of the leaders of the Psychopharmacology Algorithm Project at the Harvard South Shore Dept of Psychiatry (PAPHSSDP) and a long-time contributor to IPAP. He also currently maintains an algorithm project at Harvard.

 


The IPAP Advisory Group

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 IPAP Faculties

The Faculties consisted of the following distinguished members for the respective algorithms:

PTSD ALGORITHM – June 2005

Chair

Jonathan Davidson, Duke University Medical Center

Co-chairs

Ken Jobson MD, IPAP
Dan Stein, Universities of Stellenbosch and Cape Town
Kathryn Connor, Duke University Medical Center

Faculty

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

Consultants

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 PhD, CINP

Webmaster & Information Engineering

Paul Nordstrom August MBBS, Biomedical Informatician

SCHIZOPHRENIA ALGORITHM – March 2006

Chair

Herbert Y. Meltzer MD (Chair), Psychiatric Hospital at Vanderbilt

Co-chairs

Donald Goff MD (Co-Chair), Freedom Trail Clinic, Boston
David N. Osser MD (Co-Chair), Harvard Medical School at the Brockton Division

Faculty

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

Consultants

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

GAD ALGORITHM – November 2006

Chair

Jonathan Davidson, Duke University Medical Center

Co-chairs

Ken Jobson, IPAP
Dan Stein, Universities of Stellenbosch and Cape Town
Kathryn Connor, Duke University Medical Center
Wei Zhang, Duke University Medical Center

Faculty

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

Consultants

Dean S Hartley III, Hartley Consulting
David Osser, Harvard Medical School
David Penniman, University at Buffalo
Oakley Ray, CINP

Webmaster & Information Engineering

Paul Nordstrom August, Kenzen Systems

SUBSTANCE ABUSE ALGORITHM – 2008-10

Chair

Roger Weiss, MD, Harvard University

Co-chairs

Tom Kosten, MD, Baylor University
Ken Jobson, MD, IPAP

Faculty

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

Consultants

Dean S Hartley III, PhD, Hartley Consulting
David Osser, MD, Harvard Medical School
David Penniman, PhD, Nylink, State University of New York

Webmaster & Information Engineering

Paul Nordstrom August, MBBS, Kenzen Systems

 



Conclusion

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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