send in the clowns…

Posted on Saturday 5 January 2013

    Isn’t it rich, aren’t we a pair
    Me here at last on the ground – and you in mid-air
    Send in the clowns

    Isn’t it bliss, don’t you approve
    One who keeps tearing around – and one who can’t move
    But where are the clowns – send in the clowns

    Just when I stopped opening doors
    Finally finding the one that I wanted – was yours
    Making my entrance again with my usual flair
    So sure of my lines – then nobody’s there

    Don’t you love a farce; my fault I fear
    I thought that you’d want what I want – sorry my dear
    But where are the clowns – there ought to be clowns
    Maybe next year

    Isn’t it rich, isn’t it queer
    Losing my timing this late in my career
    But where are the clowns – send in the clowns
    Don’t bother they’re here
I hardly intend to imply that the authors of this article are clowns. They are some of our best and brightest. The song’s author explains:
    The "clowns" in the title do not refer to circus clowns. Instead, they symbolize fools, as Sondheim explained in a 1990 interview. "I get a lot of letters over the years asking what the title means and what the song’s about; I never thought it would be in any way esoteric. I wanted to use theatrical imagery in the song, because she’s an actress, but it’s not supposed to be a circus… It’s a theater reference meaning ‘if the show isn’t going well, let’s send in the clowns’; in other words, ‘let’s do the jokes.’ I always want to know, when I’m writing a song, what the end is going to be, so ‘Send in the Clowns’ didn’t settle in until I got the notion, ‘Don’t bother, they’re here’, which means that ‘We are the fools’."
The Initial Field Trials of DSM-5: New Blooms and Old Thorns
by Robert Freedman, David A. Lewis, Robert Michels, Daniel S. Pine, Susan K. Schultz, Carol A. Tamminga, Glen O. Gabbard, Susan Shur-Fen Gau, Daniel C. Javitt, Maria A. Oquendo, Patrick E. Shrout, Eduard Vieta, and Joel Yager
American Journal of Psychiatry 2013 170:1-5.

“A rose is a rose is a rose”. For psychiatric diagnosis, we still interpret this line as Robins and Guze did for their Research Diagnostic Criteria — that reliability is the first test of validity for diagnosis. To develop an evidence-based psychiatry, the Robins and Guze strategy [i.e., empirically validated criteria for the recognizable signs and symptoms of illness] was adopted by DSM-III and DSM-IV. The initial reliability results from the DSM-5 Field Trials are now reported in three articles in this issue. As for all previous DSM editions, the methods used to assess reliability reflect current standards for psychiatric investigation. Independent interviews by two different clinicians trained in the diagnoses, each prompted by a computerized checklist, assessment of agreement across different academic centers, and a pre-established statistical plan are now employed for the first time in the DSM Field Trials. As for most new endeavors, the end results are mixed, with both positive and disappointing findings…

The questionable reliability of major depressive disorder, unchanged from DSM-IV, is obviously a problem. Major depressive disorder has always been problematic because its criteria encompass a wide range of illness, from gravely disabled melancholic patients to many individuals in the general population who do not seek treatment. Although symptom severity on the Hamilton Depression Rating Scale distinguishes those patients who respond more specifically to pharmacotherapy, the DSM-IV criteria do not capture that distinction. A second problem not resolved by the DSM-IV criteria is the common co-occurrence of anxiety, which markedly diminishes the effects of antidepressant treatment. The DSM-5 work group decided not to change the criteria for major depressive disorder from DSM-IV and instead created other diagnoses for the mixture between anxiety and depression. However, these efforts did not improve the poor reliability of DSM-IV depression; “mixed anxiety and depression” has a kappa of 0…
While I appreciate their acknowledging the point that the Major Depressive Disorder diagnosis "encompass[es] a wide range of illness," they go on to talk as if it’s a continuum [which it isn’t] based on severity [which isn’t true enough to count on] and imply that response to pharmacotherapy is the point of diagnosis [is it?]. But I digress [as a johnny one-note tends to do]. "As for most new endeavors, the end results are mixed, with both positive and disappointing findings." Sorry, but it doesn’t look so new to me – it’s over thirty years old. If they’re implying that the DSM-5 Task Force used a better method than the DSM-III and DSM-IV, they’re invalidating the past, not explaining the present [send that part back for a rewrite]:
“A rose is a rose is a rose is a rose” had deeper meaning for Gertrude Stein, to do not only with the classification of the flower but also with its enduring essence. Understanding the natural course of a disorder, its response to treatment, and its impact on the life of the individual are the reasons that we strive to make reliable diagnoses, but a single diagnostic interview, regardless of how reliable, does not capture the essence of what is happening to a patient. If there are lessons for clinicians and patients and families reading these field trials, perhaps the most important one is that accurate diagnosis must be part of the ongoing clinical dialogue with the patient.
Couldn’t have said it better. Note to self: Send that quote to the people who answer the phones at the Managed Care centers so they’ll start saying, "Doctor, are you sure you’ve thoroughly evaluated your patient? How about seeing them a few more times to be sure you’ve made a precise diagnosis."
The improvement of diagnosis is also ongoing. Future tests need to consider clinical utility in actual treatment situations and the reliability and practicality of applying the new criteria outside academic medical centers. Solo practitioners and mental health clinics may not have resources for the level of training that the field trials required. The patients were required to speak and read English, although some were bilingual. Reliability may not be the same for patients who have lower levels of education or for whom English is not their most fluent language. The findings of these field trials will be used to make further improvements, and hence the final criteria may change and require further testing after DSM-5 publication. Like its predecessors, DSM-5 does not accomplish all that it intended, but it marks continued progress for many patients for whom the benefits of diagnoses and treatment were previously unrealized.
The only reason this post is here is for this latter paragraph. It’s just more future-think. The Task Force talks of a living document to be added to, updated. The expert clowns were sent in to lighten up the discussion and talk about how the Field Trials will lead to yet some other future improvement. But they’re not mentioning that there were two Field Trials planned, but only one got done. And they’re talking about future improvements before the pages even have ink on them. This editorial reads like Sondheim’s line, "Maybe next year." And I’d add to "Don’t bother they’re here" that they can’t count on fools in the audience forever. This editorial is an apology, perhaps a Eulogy…

    January 5, 2013 | 5:07 PM

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