Jonathan Ipser | University of Cape Town (original) (raw)

Papers by Jonathan Ipser

Meta-analyses are seen as representing the pinnacle of a hierarchy of evidence used to inform cli... more Meta-analyses are seen as representing the pinnacle of a hierarchy of evidence used to inform clinical practice. Therefore, the potential importance of differences in the rigor with which they are conducted and reported warrants consideration. In this review, we use standardized instruments to describe the scientific and reporting quality of meta-analyses of randomized controlled trials of the treatment of anxiety disorders. We also use traditional and novel metrics of article impact to assess the influence of meta-analyses across a range of research fields in the anxiety disorders. Overall, although the meta-analyses that we examined had some flaws, their quality of reporting was generally acceptable. Neither the scientific nor reporting quality of the meta-analyses was predicted by any of the impact metrics. The finding that treatment meta-analyses were cited less frequently than quantitative reviews of studies in current "hot spots" of research (ie, genetics, imaging) points to the multifactorial nature of citation patterns. A list of the meta-analyses included in this review is available on an evidence-based website of anxiety and trauma-related disorders.

BACKGROUND: Anxiety disorders are a potentially disabling group of disorders which are prevalent ... more BACKGROUND: Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders. OBJECTIVES: To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies. SELECTION CRITERIA: All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders. DATA COLLECTION AND ANALYSIS: Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken. MAIN RESULTS: 22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%). AUTHORS' CONCLUSIONS: Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

BACKGROUND: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slig... more BACKGROUND: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Trials have investigated the use of serotonin reuptake inhibitors (SRIs) and cognitive behaviour therapy (CBT) for BDD. OBJECTIVES: To assess the efficacy of pharmacotherapy, psychotherapy or a combination of both treatment modalities for body dysmorphic disorder. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety and Neurosis Trial Register (December 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (January 1966 to December 2007), and PsycINFO (1967 to December 2007). Ongoing and unpublished trials were located through searching the metaRegister of Controlled Trials, the CRISP and WHO ICTRP search portals (databases searched in December 2007), and through contacting key researchers and pharmaceutical companies. Additional studies were located through study reference lists. SELECTION CRITERIA: Randomised controlled trials (RCTs) of patients meeting DSM or ICD diagnostic criteria for BDD, in which the trials compare pharmacotherapy, psychotherapy or multi-modal treatment groups with active or non-active control groups. Short or long-term trials were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary effect sizes for dichotomous and continuous outcomes were calculated using a random effects model and heterogeneity was assessed. MAIN RESULTS: Two pharmacotherapy and three psychotherapy trials were eligible for inclusion in the review, with data from four short-term RCTs (169 participants) available for analysis. Response data from a single placebo-controlled trial of fluoxetine suggested overall superiority of medication relative to placebo (relative risk (RR) 3.07, 95% CI 1.4 to 6.72, n = 67). Symptom severity was also significantly reduced in the RCTs of fluoxetine and clomipramine (relative to desipramine), as well as in the two CBT trials (WMD -44.96, 95% CI -54.43 to -35.49, n = 73). A low relapse rate (4/22) was demonstrated in one trial of CBT. AUTHORS' CONCLUSIONS: Results from the small number of available RCTs suggest that SRIs and CBT may be useful in treating patients with BDD. The findings of these studies need to be replicated. In addition, future controlled studies in other samples, such as adolescents, and using other selective SRIs, as well as a range of psychological therapy approaches and modalities (alone and in combination), are essential in supplementing the sparse data currently available.

Social anxiety disorder (SAD) is a prevalent, disabling disorder. We aimed to assess the effects ... more Social anxiety disorder (SAD) is a prevalent, disabling disorder. We aimed to assess the effects of pharmacotherapy for SAD and to determine whether particular classes of medication are more effective and/or better tolerated than others. A systematic review and meta-analysis was conducted of all published and unpublished placebo-controlled randomized controlled trials (RCTs) undertaken between 1966 and 2007. A rigorous search, which included searching the Cochrane CCDANTR, MEDLINE and PsycINFO electronic databases, yielded a total of 51 RCTs (9914 participants) considered eligible for inclusion in the review. On average, over half of trial participants responded to medication, as assessed with the improvement item of the Clinical Global Impressions scale (55.2%), with approximately four participants having to be treated for an average of 12 weeks before an additional person responded to medication, relative to placebo (number needed to benefit = 4.19). There was substantial variation across medication classes in the number of dropouts due to adverse events, with an average number needed to harm of 14.4. Maintenance and relapse prevention studies confirm the value of longer-term medication in treatment responders. Medication was also effective in reducing SAD symptoms, comorbid depressive symptoms and associated disability. However, evidence for the efficacy of beta-blockers in treating performance anxiety was lacking. Taken together, trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors provide the largest evidence base for agents that are both effective and well tolerated. This review is an updated version of a Cochrane Review in The Cochrane Library, Issue 4, 2004. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.

A vast amount of information describing health interventions is available on the Internet. This p... more A vast amount of information describing health interventions is available on the Internet. This paper describes the systematic retrieval and quality assessment of websites containing information on the treatment of anxiety disorders. Separate searches were conducted for information on generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder, and specific phobia. The Google, Yahoo, and MSN search engines yielded 540 results, 110 of which were eligible for inclusion. Sixty-seven unique websites were identified. The DISCERN scale was used to evaluate quality of content. The authors also compared the websites in terms of popularity, readability, and a range of technical criteria. Websites were generally of poor to moderate quality. Higher-quality scores were obtained for websites whose authors attributed their sources and provided a clear statement of the purpose of the website. The paper closes by considering limitations of the review and possible future research avenues.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and disabling condition. Evidenc... more BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and disabling condition. Evidence that PTSD is characterized by specific psychobiological dysfunctions has contributed to a growing interest in use of medication in its treatment. OBJECTIVES: To assess the effects of medication in the treatment of PTSD. DESIGN: Systematic review of randomised controlled trials (RCTs) following the Cochrane Collaboration guidelines. A more detailed version of the review is published in the Cochrane Database of Systematic Reviews. METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register, the Cochrane Central Register of Controlled Trials (Cochrane Library issue 4, 2004), MEDLINE (January 1966 - December 2004), PsycINFO (1966 - 2004), the National PTSD Center Pilots database, and the meta register module of the Controlled Trials database. Reference lists of retrieved articles were searched for additional studies. Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin re-uptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were done. MAIN RESULTS: Thirty-five short-term (14 weeks or less) RCTs were included in the analysis (4 597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference (WMD) = -5.76, 95% confidence interval (CI)-8.16 - -3.36, N = 2 507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents compared with placebo (relative risk (RR) = 1.49, 95% CI: 1.28, 1.73, number needed to treat (NNT) = 4.85, N = 1 272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (N = 628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs. Medication was also effective in reducing the severity of the PTSD re-experiencing/intrusion, avoidance/numbing, and hyperarousal symptom clusters in 9 trials (N = 1 304). In addition, medication was superior to placebo in reducing comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of the 3 maintenance trials suggested that long-term medication may be required in treating PTSD. CONCLUSION: Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability, and should be considered as part of the treatment of this disorder. The findings of this review support the status of SSRIs as first-line agents in the pharmacotherapy of PTSD, as well as their value in longterm treatment. However, there remain important gaps in the evidence base, and there is a continued need for more effective agents in the management of PTSD.

BACKGROUND: A large proportion of patients with anxiety disorders fail to respond to first-line m... more BACKGROUND: A large proportion of patients with anxiety disorders fail to respond to first-line medication interventions, despite evidence of the effectiveness of these agents. OBJECTIVES: To assess the effects of medication versus placebo augmentation in the treatment of patients with anxiety disorders who have failed to respond adequately to first-line drug therapies. SEARCH STRATEGY: The Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 3/8/2005, MEDLINE (January 1966 to July 2005) and PsycINFO (1966 to 2005, Part A). Unpublished trials were identified through the Controlled Trials database and the National Institute of Health's Computer Retrieval of Information on Scientific Projects (CRISP) service (1972 to 2005). Additional studies in any language were sought in reference lists of retrieved articles. SELECTION CRITERIA: All randomised controlled trials (RCTs) of the medication augmentation of pharmacotherapy for treatment resistant anxiety disorders. DATA COLLECTION AND ANALYSIS: Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by class of augmentation agent and anxiety disorder. Overall effect estimates were calculated using a random-effects model, heterogeneity was assessed and subgroup/sensitivity analyses were undertaken. MAIN RESULTS: Twenty eight short-term (average of seven weeks) randomised controlled trials (740 participants) were included in the review, 20 of which investigated augmentation of medication for treatment-resistant obsessive compulsive disorder (OCD). Summary statistics for responder status from nine trials demonstrate overall superiority of a variety of medication agents to placebo (relative risk of non-response (RR) 3.16, 95% CI 1.08 to 9.23). Similarly, symptom severity was significantly reduced in the medication groups, relative to placebo (number of trials (N) = 14, standardised mean difference (SMD) -0.87, 95% CI -1.37 to -0.36). There is no evidence of a difference between medication and placebo in total dropout rate, or in the number of dropouts due to adverse events. AUTHORS' CONCLUSIONS: Medication augmentation can be an effective and well-tolerated short-term treatment strategy for non-responders to first-line pharmacotherapy of anxiety disorders. However, any conclusions must be tentative in view of methodological and clinical heterogeneity, and the fact that much of the relevant database is based on antipsychotic augmentation trials in OCD patients resistant to serotonin reuptake inhibitors (SRIs). Additional data are needed to address several areas, including the efficacy of augmentation over the longer-term, and the value of medication augmentation in comparison to other strategies (e.g. switching medication, adding psychotherapy).

RATIONALE: Pharmacotherapy is frequently considered in the treatment of disruptive behavior disor... more RATIONALE: Pharmacotherapy is frequently considered in the treatment of disruptive behavior disorders (DBDs) in children and adolescents. There are, however, no systematic reviews of this literature. OBJECTIVES: The aim of this work is to determine whether medication is effective in treating pediatric disruptive behavior disorders and related problems of impulse control, as well as to examine differences in the treatment response and tolerability of different medication classes and agents. MATERIALS AND METHODS: Randomized controlled trials of the pharmacotherapy of DBDs in children and adolescents were reviewed, and a meta-analysis of 14 trials (823 participants) was conducted. RESULTS: There is some evidence of the effectiveness of medication in treating DBDs, with positive outcomes for lithium and risperidone in particular. Pharmacotherapy also demonstrated some efficacy in reducing symptoms of aggression. Medication was relatively well-tolerated, as indicated by equivalent dropout rates in medication and comparison groups. CONCLUSIONS: There are relatively few controlled trials of the pharmacotherapy of disruptive behavior disorders or other impulse control disorders, despite the importance of research in this area. Given the potential adverse effects of agents such as lithium and risperidone, a careful risk-benefit analysis is needed for each patient.

… Child Health: A …, Jan 1, 2010

Abstract This is a commentary on a Cochrane review, published in this issue of EBCH, first publis... more Abstract This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858. CD005170. pub2.

Current Psychiatry Reports

South African journal of psychology, Jan 1, 2004

Biological Psychiatry, Jan 1, 2008

No abstract is available. To read the body of this article, please view the Full Text online. ...... more No abstract is available. To read the body of this article, please view the Full Text online. ... © 2008 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved. ... Visit SciVerse ScienceDirect to see if you have access via your institution. ... Advertisements on this site do not constitute a guarantee or endorsement by the journal, Association, or publisher of the quality or value of such product or of the claims made for it by its manufacturer.

Meta-analyses are seen as representing the pinnacle of a hierarchy of evidence used to inform cli... more Meta-analyses are seen as representing the pinnacle of a hierarchy of evidence used to inform clinical practice. Therefore, the potential importance of differences in the rigor with which they are conducted and reported warrants consideration. In this review, we use standardized instruments to describe the scientific and reporting quality of meta-analyses of randomized controlled trials of the treatment of anxiety disorders. We also use traditional and novel metrics of article impact to assess the influence of meta-analyses across a range of research fields in the anxiety disorders. Overall, although the meta-analyses that we examined had some flaws, their quality of reporting was generally acceptable. Neither the scientific nor reporting quality of the meta-analyses was predicted by any of the impact metrics. The finding that treatment meta-analyses were cited less frequently than quantitative reviews of studies in current "hot spots" of research (ie, genetics, imaging) points to the multifactorial nature of citation patterns. A list of the meta-analyses included in this review is available on an evidence-based website of anxiety and trauma-related disorders.

BACKGROUND: Anxiety disorders are a potentially disabling group of disorders which are prevalent ... more BACKGROUND: Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders. OBJECTIVES: To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies. SELECTION CRITERIA: All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders. DATA COLLECTION AND ANALYSIS: Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken. MAIN RESULTS: 22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%). AUTHORS' CONCLUSIONS: Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.

BACKGROUND: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slig... more BACKGROUND: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Trials have investigated the use of serotonin reuptake inhibitors (SRIs) and cognitive behaviour therapy (CBT) for BDD. OBJECTIVES: To assess the efficacy of pharmacotherapy, psychotherapy or a combination of both treatment modalities for body dysmorphic disorder. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety and Neurosis Trial Register (December 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (January 1966 to December 2007), and PsycINFO (1967 to December 2007). Ongoing and unpublished trials were located through searching the metaRegister of Controlled Trials, the CRISP and WHO ICTRP search portals (databases searched in December 2007), and through contacting key researchers and pharmaceutical companies. Additional studies were located through study reference lists. SELECTION CRITERIA: Randomised controlled trials (RCTs) of patients meeting DSM or ICD diagnostic criteria for BDD, in which the trials compare pharmacotherapy, psychotherapy or multi-modal treatment groups with active or non-active control groups. Short or long-term trials were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary effect sizes for dichotomous and continuous outcomes were calculated using a random effects model and heterogeneity was assessed. MAIN RESULTS: Two pharmacotherapy and three psychotherapy trials were eligible for inclusion in the review, with data from four short-term RCTs (169 participants) available for analysis. Response data from a single placebo-controlled trial of fluoxetine suggested overall superiority of medication relative to placebo (relative risk (RR) 3.07, 95% CI 1.4 to 6.72, n = 67). Symptom severity was also significantly reduced in the RCTs of fluoxetine and clomipramine (relative to desipramine), as well as in the two CBT trials (WMD -44.96, 95% CI -54.43 to -35.49, n = 73). A low relapse rate (4/22) was demonstrated in one trial of CBT. AUTHORS' CONCLUSIONS: Results from the small number of available RCTs suggest that SRIs and CBT may be useful in treating patients with BDD. The findings of these studies need to be replicated. In addition, future controlled studies in other samples, such as adolescents, and using other selective SRIs, as well as a range of psychological therapy approaches and modalities (alone and in combination), are essential in supplementing the sparse data currently available.

Social anxiety disorder (SAD) is a prevalent, disabling disorder. We aimed to assess the effects ... more Social anxiety disorder (SAD) is a prevalent, disabling disorder. We aimed to assess the effects of pharmacotherapy for SAD and to determine whether particular classes of medication are more effective and/or better tolerated than others. A systematic review and meta-analysis was conducted of all published and unpublished placebo-controlled randomized controlled trials (RCTs) undertaken between 1966 and 2007. A rigorous search, which included searching the Cochrane CCDANTR, MEDLINE and PsycINFO electronic databases, yielded a total of 51 RCTs (9914 participants) considered eligible for inclusion in the review. On average, over half of trial participants responded to medication, as assessed with the improvement item of the Clinical Global Impressions scale (55.2%), with approximately four participants having to be treated for an average of 12 weeks before an additional person responded to medication, relative to placebo (number needed to benefit = 4.19). There was substantial variation across medication classes in the number of dropouts due to adverse events, with an average number needed to harm of 14.4. Maintenance and relapse prevention studies confirm the value of longer-term medication in treatment responders. Medication was also effective in reducing SAD symptoms, comorbid depressive symptoms and associated disability. However, evidence for the efficacy of beta-blockers in treating performance anxiety was lacking. Taken together, trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors provide the largest evidence base for agents that are both effective and well tolerated. This review is an updated version of a Cochrane Review in The Cochrane Library, Issue 4, 2004. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.

A vast amount of information describing health interventions is available on the Internet. This p... more A vast amount of information describing health interventions is available on the Internet. This paper describes the systematic retrieval and quality assessment of websites containing information on the treatment of anxiety disorders. Separate searches were conducted for information on generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder, and specific phobia. The Google, Yahoo, and MSN search engines yielded 540 results, 110 of which were eligible for inclusion. Sixty-seven unique websites were identified. The DISCERN scale was used to evaluate quality of content. The authors also compared the websites in terms of popularity, readability, and a range of technical criteria. Websites were generally of poor to moderate quality. Higher-quality scores were obtained for websites whose authors attributed their sources and provided a clear statement of the purpose of the website. The paper closes by considering limitations of the review and possible future research avenues.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and disabling condition. Evidenc... more BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent and disabling condition. Evidence that PTSD is characterized by specific psychobiological dysfunctions has contributed to a growing interest in use of medication in its treatment. OBJECTIVES: To assess the effects of medication in the treatment of PTSD. DESIGN: Systematic review of randomised controlled trials (RCTs) following the Cochrane Collaboration guidelines. A more detailed version of the review is published in the Cochrane Database of Systematic Reviews. METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register, the Cochrane Central Register of Controlled Trials (Cochrane Library issue 4, 2004), MEDLINE (January 1966 - December 2004), PsycINFO (1966 - 2004), the National PTSD Center Pilots database, and the meta register module of the Controlled Trials database. Reference lists of retrieved articles were searched for additional studies. Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin re-uptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were done. MAIN RESULTS: Thirty-five short-term (14 weeks or less) RCTs were included in the analysis (4 597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference (WMD) = -5.76, 95% confidence interval (CI)-8.16 - -3.36, N = 2 507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents compared with placebo (relative risk (RR) = 1.49, 95% CI: 1.28, 1.73, number needed to treat (NNT) = 4.85, N = 1 272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (N = 628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs. Medication was also effective in reducing the severity of the PTSD re-experiencing/intrusion, avoidance/numbing, and hyperarousal symptom clusters in 9 trials (N = 1 304). In addition, medication was superior to placebo in reducing comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of the 3 maintenance trials suggested that long-term medication may be required in treating PTSD. CONCLUSION: Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability, and should be considered as part of the treatment of this disorder. The findings of this review support the status of SSRIs as first-line agents in the pharmacotherapy of PTSD, as well as their value in longterm treatment. However, there remain important gaps in the evidence base, and there is a continued need for more effective agents in the management of PTSD.

BACKGROUND: A large proportion of patients with anxiety disorders fail to respond to first-line m... more BACKGROUND: A large proportion of patients with anxiety disorders fail to respond to first-line medication interventions, despite evidence of the effectiveness of these agents. OBJECTIVES: To assess the effects of medication versus placebo augmentation in the treatment of patients with anxiety disorders who have failed to respond adequately to first-line drug therapies. SEARCH STRATEGY: The Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 3/8/2005, MEDLINE (January 1966 to July 2005) and PsycINFO (1966 to 2005, Part A). Unpublished trials were identified through the Controlled Trials database and the National Institute of Health's Computer Retrieval of Information on Scientific Projects (CRISP) service (1972 to 2005). Additional studies in any language were sought in reference lists of retrieved articles. SELECTION CRITERIA: All randomised controlled trials (RCTs) of the medication augmentation of pharmacotherapy for treatment resistant anxiety disorders. DATA COLLECTION AND ANALYSIS: Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by class of augmentation agent and anxiety disorder. Overall effect estimates were calculated using a random-effects model, heterogeneity was assessed and subgroup/sensitivity analyses were undertaken. MAIN RESULTS: Twenty eight short-term (average of seven weeks) randomised controlled trials (740 participants) were included in the review, 20 of which investigated augmentation of medication for treatment-resistant obsessive compulsive disorder (OCD). Summary statistics for responder status from nine trials demonstrate overall superiority of a variety of medication agents to placebo (relative risk of non-response (RR) 3.16, 95% CI 1.08 to 9.23). Similarly, symptom severity was significantly reduced in the medication groups, relative to placebo (number of trials (N) = 14, standardised mean difference (SMD) -0.87, 95% CI -1.37 to -0.36). There is no evidence of a difference between medication and placebo in total dropout rate, or in the number of dropouts due to adverse events. AUTHORS' CONCLUSIONS: Medication augmentation can be an effective and well-tolerated short-term treatment strategy for non-responders to first-line pharmacotherapy of anxiety disorders. However, any conclusions must be tentative in view of methodological and clinical heterogeneity, and the fact that much of the relevant database is based on antipsychotic augmentation trials in OCD patients resistant to serotonin reuptake inhibitors (SRIs). Additional data are needed to address several areas, including the efficacy of augmentation over the longer-term, and the value of medication augmentation in comparison to other strategies (e.g. switching medication, adding psychotherapy).

RATIONALE: Pharmacotherapy is frequently considered in the treatment of disruptive behavior disor... more RATIONALE: Pharmacotherapy is frequently considered in the treatment of disruptive behavior disorders (DBDs) in children and adolescents. There are, however, no systematic reviews of this literature. OBJECTIVES: The aim of this work is to determine whether medication is effective in treating pediatric disruptive behavior disorders and related problems of impulse control, as well as to examine differences in the treatment response and tolerability of different medication classes and agents. MATERIALS AND METHODS: Randomized controlled trials of the pharmacotherapy of DBDs in children and adolescents were reviewed, and a meta-analysis of 14 trials (823 participants) was conducted. RESULTS: There is some evidence of the effectiveness of medication in treating DBDs, with positive outcomes for lithium and risperidone in particular. Pharmacotherapy also demonstrated some efficacy in reducing symptoms of aggression. Medication was relatively well-tolerated, as indicated by equivalent dropout rates in medication and comparison groups. CONCLUSIONS: There are relatively few controlled trials of the pharmacotherapy of disruptive behavior disorders or other impulse control disorders, despite the importance of research in this area. Given the potential adverse effects of agents such as lithium and risperidone, a careful risk-benefit analysis is needed for each patient.

… Child Health: A …, Jan 1, 2010

Abstract This is a commentary on a Cochrane review, published in this issue of EBCH, first publis... more Abstract This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858. CD005170. pub2.

Current Psychiatry Reports

South African journal of psychology, Jan 1, 2004

Biological Psychiatry, Jan 1, 2008

No abstract is available. To read the body of this article, please view the Full Text online. ...... more No abstract is available. To read the body of this article, please view the Full Text online. ... © 2008 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved. ... Visit SciVerse ScienceDirect to see if you have access via your institution. ... Advertisements on this site do not constitute a guarantee or endorsement by the journal, Association, or publisher of the quality or value of such product or of the claims made for it by its manufacturer.