1 Boring Old Man

^{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}

^{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’."}
^{Stephen Sondheim}

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…}

^{“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.}

^{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.}