We reviewed the literature on the effects of land use changes on mediterranean river ecosystems (med-rivers) to provide a foundation and directions for future research on catchment management during times of rapid human population growth and climate change. Seasonal human demand for water in mediterranean climate regions (med-regions) is high, leading to intense competition for water with riverine communities often containing many endemic species. The responses of river communities to human alterations of land use, vegetation, hydrological, and hydrochemical conditions are similar in mediterranean and other climatic regions. High variation in hydrological regimes in med-regions, however, tends to exacerbate the magnitude of these responses. For example, land use changes promote longer dry season flows, concentrating contaminants, allowing the accumulation of detritus, algae, and plants, and fostering higher temperatures and lower dissolved oxygen levels, all of which may extirpate sensitive native species. Exotic species often thrive in med-rivers altered by human activity, further homogenizing river communities worldwide. We recommend that future research rigorously evaluate the effects of management and restoration practices on river ecosystems, delineate the cause-effect pathways leading from human perturbations to stream biological communities, and incorporate analyses of the effects of scale, land use heterogeneity, and high temporal hydrological variability on stream communities. © 2012 Springer Science+Business Media Dordrecht.