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Thursday, July 15, 2010
Carlat on NPR's "Fresh Air"
I found the host, Dave Davies (who was filling in for Terry Gross), extremely informed and I am perpetually impressed by the quality of programming on NPR. Today I was on another NPR show called Radio Boston, hosted by Meghna Chakrabarti (listen to it here) and again was amazed at the production quality and the intelligence of the questioning. Next time pledge week comes around for your local NPR affiliate, I urge you to pony up.
43 comments:
- moviedoc said...
You did good on NPR. My only dissent:
Who does, or ever did, one hour psychotherapy sessions?
How much of those so-called psychiatrist psychotherapy sessions are really devoted, not to psychotherapy, but to med management and administrative matters?
Both you and the moderator perpetuate the myth that all "therapy" is the same, and that every psychiatric patient should get it, which just ain't so.
But my blood boils every time I hear you talk about those psychopharm experts who have sold out to big pharma for $millions.
Keep up the good work. - July 15, 2010 at 7:37 PM
- pacificpsych said...
Good job! :)
I must admit to some irritation when I think: why didn't you see this before? Why doesn't everyone see this? How can anyone practice this way, not really talking with their patients? How can anyone do these 15 minute u-know-whats? How can anyone believe the Pharma propaganda?
But no matter. Let's move forward.
Now that you're reformed, maybe you could start a movement. Really change things. You could be the messiah. :) - July 15, 2010 at 9:56 PM
Years ago, I bought a used Triumph sports car. I did not have it long before a connecting rod broke. I saw a reputable mechanic who told me I needed the engine rebuilt. I asked him if he could just repair the cylinder with the broken rod so I could sell the car. He looked me in the eye and said, "I don't do patch jobs." He had too much integrity to practice his craft any other way.
That said, Liberty N. Justice really takes off at Dr. Carlat in a comment to the post below this one. The one embedded point he makes in his diatribe that appears to hold true is that Dr. Carlat has written a book denouncing psychiatric "patch jobs" but then rationalizes practicing essentially that way by maintaining a list of hundreds of patients.
I dunno. I don't walk in Dr. Carlat shoes or have any knowledge about how he practices psychiatry. However, while Liberty N. Justice's splenetic denunciation of Dr. Carlat is not a conviction, it unfortunately sort of rings true as an indictment.
I hope Dr. Carlat considers that as his professional sensibilities evolve. - July 16, 2010 at 9:12 AM
Dr. Carlat,
During the interview, you said:
""But on the other hand, what we don't know is we don't know how the medications actually work in the brain. So whereas it's not uncommon - and I still do this, actually, when patients ask me about these medications, I'll often say something like, well, the way Zoloft works is it increases the levels of serotonin in your brain, in your synapses, the neurons, and presumably the reason you're depressed or anxious is that you have some sort of a deficiency.
And I say that not because I really believe it, because I know that the evidence isn't really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we're doing when we're prescribing medications.""
And they certainly don't want to hear that a psychiatrist essentially has no idea how these medications work.
I mean no disrespect but that is the most insulting thing I have ever heard a medical professional say.
Patients want honesty, not lies.
Maybe you shouldn't be prescribing medications that you can't come up with a truthful answer for.
""DAVIES: But that's pretty close to the truth?
Dr. CARLAT: Unfortunately, it is close to the truth. We're in a paradoxical situation, I think, where, you know, we prescribe medications that do work, according to the trials, and yet as opposed to essentially all other branches of medicine, we don't understand the pathophysiology of what generates mental illness, and we don't understand exactly how our medications work.""
I have seen no evidence whatsoever that these meds work even short term. The study that is most cited as this evidence, the Star D study, is completely flawed and nowhere near the 67% success rate that is cited.
""DAVIES: And it can be reassuring if you're prescribing a medication to tell someone, well, there's really a biological origin of your difficulty here, and we can treat it with - by treating the biology.
Dr. CARLAT: Right, which is exactly why I still tell patients that at times. But I think, you know, one thing that has happened is that because there's been such a vacuum in our knowledge about mechanism, the drug companies have been happy to sort of fill that vacuum with their own version of knowledge so that usually, if you see a commercial for Zoloft on TV, you'll be hearing the line about serotonin deficiencies and chemical imbalances, even though we don't really have the data to back it up.
It becomes a very useful marketing line for drug companies, and then it becomes a reasonable thing for us to say to patients to give them more confidence in the treatment that they're getting from us. But it may not be true. ""
No, no, no. It isn't reasonable to lie to patients. Why you and alot of your colleagues think that is ok is mind boggling.
I do applaud you for being honest about this. At least you haven't tried to sugar coat things. But it is still disgraceful that you think it is ok to lie about the serotonin issue.
AA - July 16, 2010 at 1:04 PM
Dr. Carlat,
During the interview, you said:
""But on the other hand, what we don't know is we don't know how the medications actually work in the brain. So whereas it's not uncommon - and I still do this, actually, when patients ask me about these medications, I'll often say something like, well, the way Zoloft works is it increases the levels of serotonin in your brain, in your synapses, the neurons, and presumably the reason you're depressed or anxious is that you have some sort of a deficiency.
And I say that not because I really believe it, because I know that the evidence isn't really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we're doing when we're prescribing medications.""
And they certainly don't want to hear that a psychiatrist essentially has no idea how these medications work.
I mean no disrespect but that is the most insulting thing I have ever heard a medical professional say.
Patients want honesty, not lies.
Maybe you shouldn't be prescribing medications that you can't come up with a truthful answer for.
""DAVIES: But that's pretty close to the truth?
Dr. CARLAT: Unfortunately, it is close to the truth. We're in a paradoxical situation, I think, where, you know, we prescribe medications that do work, according to the trials, and yet as opposed to essentially all other branches of medicine, we don't understand the pathophysiology of what generates mental illness, and we don't understand exactly how our medications work.""
I have seen no evidence whatsoever that these meds work even short term. The study that is most cited as this evidence, the Star D study, is completely flawed and nowhere near the 67% success rate that is cited.
""DAVIES: And it can be reassuring if you're prescribing a medication to tell someone, well, there's really a biological origin of your difficulty here, and we can treat it with - by treating the biology.
Dr. CARLAT: Right, which is exactly why I still tell patients that at times. But I think, you know, one thing that has happened is that because there's been such a vacuum in our knowledge about mechanism, the drug companies have been happy to sort of fill that vacuum with their own version of knowledge so that usually, if you see a commercial for Zoloft on TV, you'll be hearing the line about serotonin deficiencies and chemical imbalances, even though we don't really have the data to back it up.
It becomes a very useful marketing line for drug companies, and then it becomes a reasonable thing for us to say to patients to give them more confidence in the treatment that they're getting from us. But it may not be true. ""
No, no, no. It isn't reasonable to lie to patients. Why you and alot of your colleagues think that is ok is mind boggling.
I do applaud you for being honest about this. At least you haven't tried to sugar coat things. But it is still disgraceful that you think it is ok to lie about the serotonin issue.
AA - July 16, 2010 at 1:05 PM
Dr. Carlat,
I tried to respond to various comments you made but I am sure it went though as it said my comment were too long to process.
To sum up what I said, it is disgraceful that you think it is ok to lie to patients about the Serotonin deficiency issue. If you can't come up with an honest reason to prescribe a medication, maybe you shouldn't be prescribing it.
Would you go to a surgeon who said he/she had no idea how this operation would turn out but the track record is excellent? I don't think so.
But for some reason, people with mental health labels are expected to accept care that would never fly in the rest of the medical arena. Somehow, with that label, we become less of a person and less deserving of respect.
That needs to stop.
I do applaud you for your honest and not sugar coating things. But lying to patients is not acceptable plain and simple.
AA - July 16, 2010 at 1:10 PM
Re: Anonymous It is still disgraceful that you think it is ok to lie about the serotonin issue.
I've thought the same thing. Psychiatrists are obviously trying to leverage the placebo effect by explicitly amplifying the supposed efficacy of a drug to a patient and downplaying side effects. Which on its face makes clinical sense.
However the practice is only ethical for prescriptions that are essentially benign like Omega-3 or St. John's Wort or even taking a walk around the block. With prescription psycho-pharmaceuticals though, the ethical boundaries are transgressed by what the physician does not tell the patient because of the potential nocebo effect.
Along with the placebo inducing nudge, should the physician also tell the patient that he could be trashed by a drug like Cymbalta or an antipsychotic, so that he can make a fully informed decision to take the medication?
I know the clinical instruction involves a complex therapeutic trade, but in the end, a physician who can't answer that question affirmatively probably shouldn't be in the business. - July 16, 2010 at 2:06 PM
I routinely tell my patients that we have no idea how these medications work. I point out to them that there are hundreds of known compounds that affect mood and brain function. I also point out that the research data is completely contradictory regarding effects of medications.
I find that my patients welcome this information. And they are also willing to try a medication and often benefit from the medication I prescribe. Why? I don't know, but I find that the patients I have who are willing to try medications do much better than those who are not willing, even if they do not stay on the medications.
Regarding the studies on medication effectiveness. It is impossible to to scientific research on human subjects in this field. Real scientific research requires rigorously controlled experiments. There is no way of running such an experiment with human beings in a natural setting. What researchers do is make attempts to control for a few variables, and then they assume (or pretend) that the rest of the variables do not matter. That is not science.
When working with a patient I am working with someone with a unique genetic makeup, one that has never existed before and will never exist again. Furthermore, that person has been shaped by unique environmental events and lives in a unique environment now. There is not and never will be a controlled study on that person.
All the research data can give me are some rough guidelines. So I make recommendations for medications, supplements, therapy, behaviors, etc based on what I think will do the least harm, and give the most benefit. (Even exercise can be harmful so there is no risk-free approach). I then make sure that I follow patients closely and listen to what they tell me so that I can adjust what I am doing if it is not working or causing problems.
If each patient is treated as unique, then the potential for harm is much less. It is not the medications that are the problem, it is that providers use a cookie-cutter approach based on data that is meaningless and contradictory. Note that this applies to therapy as well. I have seen patients who were traumatized by therapists insisting they were sexually abused as a child because the therapist had a cookie-cutter approach to therapy. - July 16, 2010 at 3:55 PM
Look forward to listening, did hear it publicized on NPR on many occasions before it aired. Thank you for moving forward the debate, which beyond fringes or some of us mental health Non-MD's, it seemed to not be brought up much. Biological reductionism and determinism has its appeal I suppose, one piece of the puzzle does not the puzzle make.
Some good comments here, SteveM rightly points out that Placebo effect may very well be a great thing for patience, but not when the drugs have many well known side effects some quite serious--particularly in the case of the Atypicals which in my practice I've seen turn many children into bloated lethargic kids with no real effect on their problems--perhaps because sedating children that AREN'T Manic-depressive/psychotics should be unethical. If you want a kid to sleep, give them sleeping pills.
Unfortunately like all the other scripts out there, Patients seem to want to walk away with pills, although I don't see this as often in the mental health field--its usually someone with power--schools/parents/group home's/social service that want the children to take the drugs.
I don't want most of the psychiatrists I've met to be doing psychotherapy, most have no real training in it, and exude a simplistic biological reductionism, especially behind closed doors that seems demeaning and irrational. Clearly the BioPyschoSocial theory integrates the various components to the complexity to brain development. After study after study about environmental factors needed to turn genes on and the like, I still see some treat neuroscience as if everything is predetermined and human's somehow don't actually LEARN both consciously and unconsciously through their lives.
Some psychotherapists as well I think go too far the other direction and discount or don't consider medical ailments from tumors, cancer, thyroidism, TBI's and the like. I had one particularly 'horrible' client that after being in the system finally got MRI's, they found massive lesions in his frontal cortex...perhaps this explained why both psychotherapy and 15 years of medications had only minimal effect.
Customized care should be the goal for psychotherapy and psychotropics. But many clients I have seen clearly have health issues that effect their mental health and functioning, and poor folks and those with horrible parents deserve a chance to grow up without automatically having their brain altered by years of drugs approved by TPTB.
The most telling thing for me was the study in 2005, that single best predictor of if someone was going to be on psychotropic drugs was not if both parents had severe mental illnesses, but rather if a child/adult was in the foster care system.
Looks like Big Pharma won over the Health Care Bill, Americans will continue to pay the most of drugs of all types, as the same companies sell them cheaper in foreign and competitive markets. I don't remember what year it was, but Prozac made 5 Billion one year alone in PROFIT, that drug must have been amazingly effective to sell like that eh? Maybe when R&D is the largest portion of monies spent, and Marketing is limited to Doctors rather than the public at large that knows more American Idol contenstants than Presidents, I'll give up on my pessimism.
-M - July 16, 2010 at 4:03 PM
"And I say that not because I really believe it, because I know that the evidence isn't really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we're doing when we're prescribing medications."
DR.C: So why don't you just tell your patients that the man in the moon caused their depression? Really, this crap about a chemical imbalance being THE CAUSE of depression is just plain absurd. There is NO research supporting this position. NONE. So why do you lie to your patients? - July 16, 2010 at 9:53 PM
- Amy B said...
I listened to you on NPR and I felt compelled to find your blog. I must tell you, not everyone in your profession is as greedy and unprincipled as you are. I see a Jungian analyst for hour long sessions once a week and he has only ever showed the highest degree of professionalism towards me. I can't imagine a reputable analyst not wanting to hear about a patient's personal life, in order to get to the next ten minute consultation. That is not practicing psychiatry, that's not practicing medicine, that's not even doing a decent job of being a human being. The banality of the way you talk about your work is shocking. It doesn't even sound like you have any more knowledge of how the mind works than the average guy on the street, yet you make a high income dispensing drugs to unwitting patients. I can't believe you still have professional credentials.
- July 17, 2010 at 10:55 AM
- David M. Allen M.D. said...
To those who think we have to know exactly how a drug works in order to take it: We still don't know exactly how aspirin works for headaches. Ever take one?
To say that no psychiatric drug works for any psychiatric condition is not consistent with reality. Just because a lot of them are used inappropriately on misdiagnosed patients without monitoring the patient for side effects, does not mean we have to throw the baby out with the bathwater.
Unfortunately, there is an epidemic of misuse by reductionistic psychiatrists of some potentially very toxic medications. I get referred patients damaged by this sort of thing all the time.
On the other hand, we don't need even more schizophrenics living on the street in cardboard boxes or languishing in jail instead of a hospital. - July 17, 2010 at 12:24 PM
Dr. Allen said,
""To those who think we have to know exactly how a drug works in order to take it: We still don't know exactly how aspirin works for headaches. Ever take one?""
Actually, I don't since it is ototoxic and I already have a hearing loss and tinnitus from taking psych meds. From what I have read, once you develop an ototoxic reaction from taking meds, you're more susceptible to developing the same type of reactions from any med that has similar properties.
Anyway, you're missing the point. Dr. Carlat was criticized by several of us for being dishonest about the Serotonin deficiency issue. If he had been honest about not knowing how these drugs work, that would have been perfectly acceptable. He wasn't as he stated that he felt patients expected doctors to know how these meds work.
However, I will add that comparing aspirin to a psych med is like comparing an apple to chocolate. Yes, many psych meds like aspirin have ototoxic properties.
But I think anyone would take the side effect profile of aspirin over a psych med any day. So if a doctor doesn't know how aspirin works, at least the risk isn't nearly as great as taking a psych med.
I just think if doctors don't understand how meds that have horrific side effects work, that doesn't make me feel confident about taking the med. I think Dr. Carlat realizes this and that is why he feels the need to use the Serotonin theory even though he knows it is false.
""To say that no psychiatric drug works for any psychiatric condition is not consistent with reality. Just because a lot of them are used inappropriately on misdiagnosed patients without monitoring the patient for side effects, does not mean we have to throw the baby out with the bathwater.""
Again, you misinterpreted what I said. I said they don't work for a majority of people which is a big difference from stating they don't work at all.
""On the other hand, we don't need even more schizophrenics living on the street in cardboard boxes or languishing in jail"
I hate to tell you Dr. Allen but there are people with schizophrenia living successful lives without being on meds. So this is not an either or situation.
Unfortunately, they will never be studied because many of your colleagues don't want to hear success stories about people who are succeeding without being on meds.
And even if someone goes off meds but needs to be on them doesn't mean those gloom and doom scenarios you report will occur.
You all are always talking about destigmatizing mental illness but giving gloom and doom scenarious like that is definitely stigmatizing people with schizophrenia.
AA - July 17, 2010 at 2:18 PM
- Supremacy Claus said...
Dr. Carlat: NPR allows you to promote your book. You are soliciting funds on its behalf. That seems like a quid pro quo (payback) for a favor.
Please, explain how that differs from a drug company's inviting frequent prescribers to a meeting at a golf resort. - July 17, 2010 at 2:22 PM
Re: Supremacy Clause - "quid pro quo (payback) for a favor.
That's quite a nano-nit you're picking with the guy.
An off hand comment made to a small cohort of eccentric readers like us to support a non-profit is analagous to wining and dining doctors who will only get re-wined and re-dined if they continue to aggressively prescribe specific drugs?
Moreover, Dr. Carlat is an academic who lives in Massachusetts for crying out loud! Of course he supports NPR. That's what academics in Massachusetts do!
And he probably recycles, reads the NY Times, eats Ben and Jerry's, shops at Whole Foods and grocery co-opts and uses sea salt when he cooks.
Dr. Carlat is being perfectly consistent with his station in life by promoting NPR. And he's doing a nice job of professional mortification by posting the comment bombs that are tossed at him about the stuff that really matters.
Given him a break on the NPR thing... - July 18, 2010 at 8:20 AM
- pacificpsych said...
He probably doesn't recycle and doesn't shop at a co-op. He drives 40 when the going is good, 80 in snowstorms. He drinks coffee at Dunkin' Donuts. But he does shop at Whole Foods. His proceeds from the book will buy him one shopping trip there.
- July 18, 2010 at 10:03 AM
- Supremacy Claus said...
Steve: Say his appearance helped to sell 100 books. Say his reminder has 10 people subscribe to NPR. The stated aim of the appearance is to inform the public. However, the real aim is to sell books and to increase subscriptions.
Say, a doctor has 100 patients on a medication. He is called for a meeting at a nice resort. The stated aim is to give feedback to the company. The real aim is to comp prescriptions, comp as in a Vegas casino. Drop $10 million they will buy you a Rolls Royce, as a token of their gratitude. Drop $100, your drink is for free.
These transactions are all structured the same. They have a pretextual stated aim but a hidden financial agenda.
I am not just interested in having Dr. Carlat make a self-criticizing disclosure. I am more interested in his recognizing his unintentional hypocrisy.
In none of these cases is any harm done to others. So, people should be left alone. In the case of medication prescriptions, patients are benefited by modern brand name medications that the doctor would give to himself or a family member.
When patients do well, the doctor's life is heavenly. When patients do poorly, life is hell. No comp could induce a doctor to not do as best as he can for his patients. - July 18, 2010 at 10:39 AM
- Joanna Barker said...
Dr. Carlat, thank you. The fact that you question your practice and that of your colleagues suggests you have a level of medical curiosity not shared by many in your field. By talking about the flaws of your field you are helping clients everywhere to make informed choices, something that I believe is actively discouraged by mental health professionals.
Psychiatry is not the only branch of medicine that flat out lies to it's consumers, but it is the one that can get away with it most easily. A lot of people here are very angry and for good reason. But rather than attack Dr. Carlat for participating in practices which I will admit disturb me greatly (particularly the "don't ask, don't tell" bit), I think we should encourage his critical thinking, his pioneering spirit, and his interest in at least showing people what they're getting up front. Therefore, once again, thank you. I invite you to look at my blog, http://psychsystem.blogspot.com if you'd like to read a patient and nurse's perspective (albeit and angry and I may say bitter one). - July 18, 2010 at 10:11 PM
- David M. Allen M.D. said...
Dear AA,
I agree with you about one point: I never tell my patients that we know exactly what causes certain psychiatric disorders or exactly how the drugs work. All I can tell them is that the meds stand a good chance of helping for the particular symptoms they have, and that most of the time side effects are mild and can be managed.
All medicines have potentially toxic side effects for some people, dearie. Maybe you wouldn't take an aspirin quickly if you had a heart attack, and maybe you'd die because you did not.
Obviously if aspirin hurts your ears, under most circumstances you shouldn't take it. That doesn't change the fact that most of us have no problem with it at all, and we would rather take it than suffer with a tension headache.
It's always a matter of weighing risks versus benefits. If you think risks always outweigh benefits in psychiatric meds, you have absolutely no idea what you're talking about.
Not taking psych meds when they might be helpful can also be fatal.
Yes, there are mild schizophrenics who do ok without meds; people just consider them eccentric. They often don't even come to psychiatric attention. To compare them with more severe cases means that you are the one who is comparing apples to chocolate.
You've probably never even seen a severe melancholic depression, because nowadays hardly anyone gets to that point without being treated. To say that antidepressants "don't work" without asking for whom and for what is just plain ignorant. - July 18, 2010 at 11:47 PM
- Supremacy Claus said...
Joanne: I agree that you should try to avoid psychiatric inpatient hospitalization. You should also avoid going the cardiac intensive care unit where the torments are all day, physical, mental, and spiritual.
I have a suggestion. Try to adhere to your outpatient treatment so that you never return to the inpatient service. About half of adverse patient events come from non-adherence to treatment. Only a tiny minority of patients who commit suicide have any medication in them. Half are over the legal limit for blood alcohol level. Getting people to stop getting drunk and high would cut the psychiatry budget in half, as well as close most hospital psychiatric beds.
That being said, the strong medicalization of psychiatry was forced by the HMO's in the 1990's. That brought the specialty completely in line with all other chronic disease specialties. Its diagnoses are as reliable as those in cardiology. Its treatments are as effective as those in pulmonology and gastroenterology, with fewer risks and side effects.
Dr. Carlat wants a return to the atavistic practices of the 1970's, which were a type of cult fraud. When you add the pretextual attacks on drug companies, from all sides, here is the real agenda.
Insurance companies, not idealistic Boston left wingers, evil insurance companies want dark skinned people on medicaid to receive only generic drugs. They do not want them to get expensive brand name medications that Dr. Carlat would take himself, or give to a loved one. I would like Dr. Carlat to cite a single patient he ever harmed by taking drug company fees to speak or to go on trips. On the other hand, I want to come over to your and his houses to give your dogs Haldol 1 mg. Is that OK with you? If it is not OK, explain why it is OK to give to dark skinned folks.
Stop getting high, adhere to treatment, avoid the inpatient service. Stop the attacks on the sources of our future treatments, the drug companies. Stop bashing the superior treatments of biological psychiatry. - July 18, 2010 at 11:49 PM
Joanna makes a good point about Dr. Carlat's critical thinking. It is refreshing in a field that seems to be particularly weak in the area of self reflection. Nevertheless there was a lot in the NPR interview that was of dismay and concern. Here's a write-up that "nails" it on a blog that makes for some cautionary reading by anyone who thinks diagnoses and psych drugs can be used in a cavalier and offhand manner without proper disclosure of the dangers, including death and disability. http://bipolarblast.wordpress.com/2010/07/19/daniel-carlat-md-on-fresh-air-discussed-by-giovanna-pompele/
- July 19, 2010 at 9:47 AM
If you appreciate the perspective that Dr Carlat is taking with his book and this blog, he really is taking on a sizeable entrenched group in our profession, and he risks being ostracized and minimized by said cronies. Having been there, in much smaller size and scope, it ain't fun, but, if you are an advocate and ally to responsible and ethical health care interventions, you do what is right, not what is easy and convenient. I just find some of his censoring at this site to be a bit frustrating, especially since the Schwarberg incident last year.
Hey, if a reader makes a critical but reasonable criticism or rebuke of someone mentioned in the blog posting, that is on us, especially if we use our name that can be traced back! It is only the defenses of the narcissist and/or antisocial that claim you the blog author are guilty for others' comments.
Put a disclaimer in the blog or at the end of the comment. DVDs do it all the time! - July 19, 2010 at 11:37 AM
I can only echo what many here have said: lying--or rather grossly oversimplifying what we do and do not know about the mechanisms of action of psychotropic drugs--is flatly unethical. Or does Dr Carlat propose some kind of utilitarian defense of such behavior? I'd be curious.
None of this is to say that we shouldn't be prescribing psychotropic drugs, but we, as physicians, should fully disclose what we know about their risks and benefits (and there are, obviously, quite significant risks) AND the risks and befits of non-pharmacological interventions, and allow and encourage patients to make a truly informed decision. The paternalistic attitude you display in the NPR interview ('I know better than my patients and therefore feel no qualms about misleading them for their own good') astounds me. Not that I haven't seen it before... (Perhaps the real shocker is that you're supposed to be the face of reform.) - July 20, 2010 at 8:50 AM
- Uma said...
this addresses questions many of us have, thank you!
- July 21, 2010 at 5:29 AM
- Uma said...
Supremacy Claus: Why do people resent the book Dr Carlat wrote? Are you saying that since the book isn't free, he's making as much money as he would, if he became a spokesman for a drug?
Go see the book page on Amazon. As a writer I know all too well how easy it is to buy book reviews. He's not a sleay marketer and never resorted to sensationalism (have you seen how Dr Perricone promotes his 'cure'?) THAT is marketing for money. Have you seen Dr. Mehmet Oz on Oprah? Does this guy seem to be doing anything remotely similar?
I have seen your other comments where you had less restraint. You're trying to sound reasonable because the other way didn't work.
Well nice try, but get a life will you? - July 21, 2010 at 6:23 AM
- Daniel Carlat said...
Thank you all for your comments. I continue to be amazed at how difficult it is to predict what statement will provoke the most withering criticism. My words on Fresh Air about how I sometimes repeat the myth of the chemical imbalance to patients was meant to point out that this is a popular, though unproven explanation for how our drugs work in the absence of any more compelling explanation.
I don't lie to any of my patients. Here is how I actually phrase it, when I bring up the subject at all: "We have no idea exactly how the drugs help to cure depression. One theory is that there is a chemical imbalance, and that Zoloft [if that is what I am prescribing] somehow increases the amount of a chemical called serotonin. But the actual mechanism may be something else entirely. Someday, we'll figure out what's actually happening with these drugs, but the key point is that they do work."
Some would argue that antidepressants don't work at all, but I disagree with that and have explained my thoughts in various places, such as this blog and in Unhinged.
As to issues of self-promotion and making money--yes, I do promote myself and I do make money. Neither of these activities is unethical, and neither relates to deceiving the public and other doctors by engaging in clearly unethical activities such as certifying industry-funded educational programs as "CME", ghostwriting for commmercial concerns without disclosure, and using one's MD as a platform for promoting a specific company's drug. - July 21, 2010 at 7:34 AM
Clearly, you didn't write your book or do this blog merely to make money--and its ridiculous that people would attempt to make such an argument. We live in a world where money is a requirement and the more you have the more freedom you have to say what you want--at least potentially.
Likely if economics weren't an issue more M.D.'s would come out of the woodwork as well in regards to the general theme of this blog.
The lack of integration within the 'mental health SYSTEM' is what has always been startling to me. I rarely get to talk with Psychiatrists even for the briefest consult, unless its in regards to forced hospitalization--which is an extreme rarity. I'm a firm believe in a holistic approach that doesn't really exist in practice. For many clients lifestyle changes are imperative for dramatic changes in their mental health, not only psychotherapy or medications.
I have found Anti-depressants to be one of the least effective class of drugs out there, particularly when its the only treatment. I again state that Psychiatry has become the cult of radical biological reductionism which i find to be demeaning to the complexity of the human/social condition. Telling a victim of abuse/trauma that they merely have 'chemical imbalances' is not even good dumbed down 'science'.
I hope that you make a lot of money, its how you use the money that is key--if you can leverage some wealth to advocate change and be a sorely needed voice in a system that harms as many people as it helps--mostly for the bottom line of Big Pharma, then by all means, make some money! As long as many M.D's feel the financial imperative to do what I have seen for years--15-20min consults asking questions about how they feel on their drugs and then titrating or giving them an additional drug and send them on their merry way--then there will be problems.
My experience shows that poor people get lousy treatment and are medicating with many more drugs, compared to wealthier clients I've seen that usually are only on 1-2 psychotropics. I've witnessed behavioral problem children routinely being given 4-5 medications, most clearly just to fatigue them. Amphetamines to make them alert during school, some Atypicals to tire them out, some anti-depressants to try and help them feel better about their abuse and lack of parents etc etc.
Perhaps its not SOMA that we need, but for the majority it remains the same thing that bothers the "non-mentally ill" money problems, relationship problems, trauma's and how various life experiences play out via their unique neural networks. I continue to advocate for children who have no real say, and whose livers and bodies are taking a beating by lifetime drug use--of the legal variety.
-M - July 21, 2010 at 8:25 AM
- Supremacy Claus said...
The duty to Google.
Every patient has it today. It can result in an analysis of a treatment, its pitfalls, and limits at the Nobel laureate level. The patient has the ability to read all scientific articles with abstracts by going to PubMed.
This duty to Google has eliminated all present and future litigation claims of lack of informed consent. Consent is a slow process of deepening knowledge and grasping of the effects of a treatment. Even a three hour discussion with slides and a sandwich provided by the drug company will not replace repeated research over weeks by the patient.
The chemical imbalance is a good lay simplification of otherwise complex and unknown drug effects. It carries a removal of responsibility from the patient for many of the symptoms. Diabetes (body is not making a hormone)is a better analogy than Parkinsons disease (imbalance between dopamine and choline). Almost all psychiatric disorders are disinhibited states. The mute, frozen depressed patient has good evidence of disinhibiition.
I have no criticism of promotion of a book, nor of a radio network. I am criticizing such promotion by folks who criticize such promotion by others, including drug companies. Promote away. But stop bashing others doing the exact same thing, especially based on race. - July 21, 2010 at 1:44 PM
Dr. Allen,
Please refrain from using the word dearie in your response to me. That comes across as condescending even if that wasn't your intention.
Ok, please post a link to an accessible study that shows the antidepressants work even in the short term. Ok, I know, the Star D study is your answer
Well, in reviewing the study and asking other people's opinions to make sure I wasn't missing something, it nowhere near the 67% remittance rate that is quoted. It is extremely low.
Any other fully accessible studies not financed by drug companies?
AA - July 21, 2010 at 5:46 PM
- David M. Allen M.D. said...
Sorry for the condescension. My apologies.
I haven't done a literature search lately, but with true major depression, rest assured that there are many unbiased studies which show that antidepressants are extremely effective.
The Pharma studies actually understate the effectiveness of antidepressants. I don't have room here to totally explain why. (I discussed it on a website called Healthy Skepticism but you have to pay to join the organization in order to see it).
Mostly it's because research organizations overdiagnose major depression because they get paid per subject enrolled. There is a different type of depression called dysthymia which generally does NOT respond to antidepressants.
It is in Pharma's interest to blur the distinction so doctors will overprescribe. They only have to beat placebo by a little, and there are enough patients with true major depression in their studies to do that, so they don't mind including dysthymics. There is much overlap in symptoms but the two conditions are different.
Widespread clinical experience (which is not synonymous with "anecdote") by doctors who actually apply the diagnostic criteria and make good clinical judgments rather than relying on "symptom checklists" trumps any studies in my mind. I can tell you from thirty years of my own experience prescribing them, watching residents prescribe them, and working in a wide variety of clinical settings in two states, there is no question that the drugs work for the right patients - but not for misdiagnosed ones who really need psychotherapy.
If you are interested in a balanced viewpoint about what works and what doesn't work in psychiatry and psychology, I invite you to check out my blog at http://davidmallenmd.blogspot.com/ - July 21, 2010 at 7:34 PM
Those of you who really buy into the effectiveness of a/ds -- and I wonder what distinctions you make between short term effectiveness and long term disability -- should read Irving Kirsch's recent book The Emperor's New Drugs. I'd be interested in hearing how his argument fits in with your faith in the objective wonders of a/ds.
I really think that those of you who say that a/ds work miraculously for one particular kind of depression but don't for others and also that they "unmask" "bipolar disorder" instead of actually cause it by inducing mania are living in a dream world.
I also think you should be much more suspicious of clinical trial results because they are so manipulated in the case of psychiatric drugs and outcomes are measured in terms of weeks when real clinical practice keeps treatment going for months and often years. Half the people who are "on placebo" in trials are actually in withdrawal from prior treatment because clinicians are so cavalier and ignorant about withdrawal. This skews results in favor of the psych drugs. The people with the good results are really having their withdrawal treated, not their depression. This goes on in clinical practice too. - July 21, 2010 at 9:25 PM
Well if I were you, I wouldn't say that antidepressants "work" until I know for sure they "work" for that patient. My blood still boils every time I remember my psychiatrist telling me yhat the treatments for bipolar were "good" when I spent the entire time in treatment completely fucking miserable... And come to find out, not even an honest review of the literature indicates treatments for bipolar are "good"
Let's be honest with ourselves and begin at the beginning. Please prove that these conditions are medical problems at all in the first place. In fact, every page in the DSM specifies that the "symptoms" must not be due to a medical condition, so what does that tell you? -kimbriel - July 22, 2010 at 12:12 AM
- Uma said...
I'm glad that while you create awareness about the problem, you don't claim to have the solution. all the quacks do that and lots of people get taken for a ride
- July 22, 2010 at 7:54 AM
- David M. Allen M.D. said...
I didn't say they always work, or that they work for every patient. Apparently I have to spell everything out for some people.
Many people who are diagnosed with bipolar disorder nowadays do not have it; the doctors ignore the established criteria, or in the case of pediatric bipolar, just make up their own.
Some DSM disorders are more clearly brain disorders while others are behavioral disorders. There are arguments in the field about which are which. The "proof" you request, which you would probably find fault with no matter what it was, is simply not possible considering out current knowledge base about neural networks. As someone said, if the brain were simple to understand, we would be too simple to understand it.
The medical exclusion requirement in the DSM refers to internal medicine conditions affecting other organ systems, not psychiatric conditions
In the meantime we have to settle for indirect evidence, which in certain disorders is quite massive and for other disorders almost non existant. - July 22, 2010 at 12:44 PM
Until you have an actual objective, scientific lab test for the purposes of diagnosis, there is no way to talk about over diagnosis or under diagnosis of any psychiatric condition. It's all just guess work. -kimbriel
- July 22, 2010 at 2:20 PM
- David M. Allen M.D. said...
Kimbriel -
To a degree, psych diagnosis does involve educated guesswork. Of course, you are totally discounting a couple hundred years of clinical observations, epidemiology, and thousands of journal articles published every year(admittedly of varying quality, but there are good ways to judge quality).
When I say overdiagnosis or underdiagnosis, I am referring specifically to whether a patient actually meets the DSM criteria for a disorder. We can dispute many of the criteria and some of the disorders, and believe me I often do, but the DSM got a lot of it right. And the distinctions are often not very subtle at all.
Major depression and dysthymia have been recognized as distinct in clinical presentation, time course, treatment response, and a bunch of other factors for a century or so. It used to be called depressive neurosis.
Typical cases of each look about as much alike as a cat and a dog. Those animals both have four legs, fur, a tail, two eyes and a nose. Still, we are somehow able to recognize the difference with a high degree of accuracy, and without running lab tests.
Maybe depressed people should see scientologists instead of psychiatrists and psychologists, so they can rid themselves of the space aliens and volcano gods that are the source of their trouble. - July 22, 2010 at 8:58 PM
- Doug Bremner said...
Dr Carlat was being honest. People took offense at how he used bs descriptions about serotonin to make people feel more comfortible about taking mind altering drugs. The people have spoken-- they don't want bs descriptions. So he wont do it any more. They dont want a psychiatrist who just does med checks-- he is going to try and move his practice more toward therapy. He said on his blog that he qualified his statements about neurobiology, but he didnt actually say that on the npr interview.
- July 22, 2010 at 10:52 PM
If a client is clearly depressed to a clinically significant level--they are suffering, plain and simple. If it's primarily biologically driven, or primarily environmental--usually this can be determined as well to some degree. We are biological beings who function socially in a complex world with unique neural networks derived from experience and our repetitive thoughts/beliefs about those experiences in addition to basic health considerations, and NT variances--that sometimes may be due to trauma/abuse even from the womb, and other time's due to perseverations/behaviors.
Asking more of Psychiatrists, going back to Psychosocial histories and Physicals, or at least reviewing this information from Primary Care Physicians would be key in gaining a clearer perspective on the individual patient. This is not really the system we have, and this is not the system the HMO's want either. They want the quick fix, and Big Pharma wants permanent lifetime customers.
Pediatric disorders and off label drugging has risen dramatically and as some noted, they likely don't actually fit the albeit lousy DSM criteria, but many stakeholders from some parents who romance the pathology, from schools, to Group home's, hospitals push these diagnoses on children. It's estimated that the average adult brain has a quadrillion synapses--so yes neuroscience research almost always overstates things. Hell, they found another--what 50 neurotransmitters since the 1990's, yet the conversation remains focused on Serotonin half the time.
-M - July 23, 2010 at 6:03 PM
Dear Supremacy Claus,
You said said...
"The duty to Google. Every patient has it today... The patient has the ability to read all scientific articles with abstracts by going to PubMed... This duty to Google has eliminated all present and future litigation claims of lack of informed consent."
Wow. You really need to do some CME credits on the issue of health (il)literacy. - July 24, 2010 at 2:45 PM
- Supremacy Claus said...
Anonymouses: Doctors treat the distress of patients. They do not treat abnormal lab values.
Give a three hour presentation with a 100 page handout on a treatment. Three hours later give the patient a brief quiz. They know almost nothing of what was presented to them. Was that lecture informed consent, when the patient knows nearly nothing about a treatment, a short time later?
So informed consent is a process of learning and retaining by repetition increasing amounts of information about a treatment. That can only be achieved by self-study over a long period.
Everyone in the USA has access to the internet, if only by going to a local library.
In case law, there is a beginning of a realization of the duty to Google. A client sued a lawyer for malpractice for failing to find and collect from a defendant after a trial award. The lawyer said, the defendant was impossible to find. The judge Googled the defendant on his laptop from the bench, and found a couple of listings and locations of the defendant. Case closed, that was legal malpractice, failure to Google in a collection action. - July 24, 2010 at 7:01 PM
- moviedoc said...
Maybe you could say Dr. C lies to patients if he really pretends to know meds work by increasing serotonin levels. I certainly tell my patients I don't have a clue, but I would classify his as a harmless white lie. What I find more interesting is that some of his patients probably read this blog and bring to visits a gamut of reactions or challenges, raising the question of whether he does the right thing by putting his name out here vs. my practice of anonymity. I believe each of us should have the right to choose.
Put up or shut up: If you really believe Dr. C lies to his patients, why not complain to the American Psychiatric Association, or his state medical board (MA?)? Sure, some will say they're all in this together, but you can't lose. If they let him off, you can criticize the APA or the licensing board for failing to act. - July 25, 2010 at 10:33 AM
- Novalis said...
For more on the analogy between psychiatry and pain management, and a defense of the beleaguered Dr. Carlat, see my post at:
http://arspsychiatrica.blogspot.com - July 25, 2010 at 11:58 AM
Movie Doc,
As one of those folks you told to put up or shut up, I am curious as to how you define a harmless white lie.
I will give you example of one I read about that I feel is harmless and actually was the right thing to.
A doctor came upon an accident and said to a dying mother's question about her children being ok, that they were in good hands. One child tragically died.
The anger you are seeing from people like me is it seems that many patients and doctors have a different view as to what constitutes a harmless white lie in many situations. Instead of telling me to report Dr. Carlat, which you know is a bunch of BS, I think it would be more productive to try and understand where the other person is coming from.
AA - July 30, 2010 at 6:24 AM


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McCandless Township Pre-Marital Agreements
A premarital agreement serves as a security of marriage against relevant issues in the event of divorce and other unlikely situations. Typically, premarital agreements involve protecting financial assets and ownership of the spouses.
Approximately 50% of marriages in the United States end up in divorce proceedings. A premarital legal agreement prior to marriage establishes the financial and property rights of each party. Practically, it is wise to consider having it before engaging in matrimony. Also, it protects family businesses and serves other functions in a union.
The legal documents will mainly be used to 1) keep a spouse from taking on the debts of the other; 2) secure the property of one spouse; 3) determine how the assets of a spouse will be passed on to another after death; 4) simplify the asset division during the process of divorce, and 5) clarify the financial obligations of each spouse.
Call Best Divorce Lawyers PA West LLC at (412) 693-6655 to get a free consultation with a law expert.
Legal Definition of Premarital Agreement
A premarital agreement, also known as premarital contract, prenuptial agreement, or prenup, is an arrangement made by two single individuals as they anticipate some events in their future marriage. It is a formal written contract signed by both future spouses.
Pennsylvania Statutes differentiate a unilateral release from a premarital agreement. A unilateral release is the waive of rights to pursue claims. It is effective upon signing. On the other hand, a premarital agreement involves mutual promises made by future spouses as well as the relinquishing of rights effective in the event of divorce or death. It only becomes an effective agreement if two individuals marry one another.
Issues Covered by Premarital Agreement in McCandless Township
A premarital agreement addresses various issues involved in a marriage. It can settle financial liabilities during the marriage, asset, property, and debt division upon divorce or death, and alimony upon divorce.
Married couples have different needs and problems encountered during the marriage. A premarital agreement is not a size that fits all. The good news is, couples can tailor it according to their personal preferences. Marital concerns covered by a prenuptial agreement in McCandless Township, PA include but are not limited to the following:
- The right of a spouse to own the property of the other spouse
- The right of a spouse to use, buy, sell, and spend resources of the other during the marriage
- The right of each spouse to the inheritance or possessions of the other
- The asset and debts division should the married couple divorce or if a spouse dies
- The entitlement of a spouse to alimony and spousal support
- The entitlement of a spouse to death benefits of the other's insurance policy
- The operation of a family business
- All concerns agreed upon by the couple
Prenups can deal with a wide scope of marital problems except for the following issues:
- Child custody and support
- The upbringing of children in a religious way
- The provisional alimony provided while the divorce proceeding is ongoing
Why a Prenup May be Right for You
Making a prenuptial agreement with your future spouse offers benefits both for you and your imminent marriage. Consider the following explanations in answering why a prenup may be right for you.
You will be able to protect your personal belongings by documenting one another's separate assets. You will be able to support your estate plan as well. If you don't want the involvement of the court in terms of asset division, you can make that happen. Also, you can have a distinction between marital and community property.
You will be allowed to make a document and provide details regarding the special arrangements that you have with your future spouse. Once both of you have already signed the prenup agreement, you will be able to avoid long court hearings. It also reduces conflicts in the process of divorce. You will be prepared should problems arise in the future due to pre-established rules and procedures for varying issues.
Finally, you will not be liable for debts and purchases that your partner made. Medical fees, estate loans, educational expenses, and mortgages will be assigned to the spouse responsible for all this.
Hire a Premarital Agreement Attorney Now
Sometimes, couples think they don't need to make premarital agreements because they trust that their relationship will not encounter serious marital issues that would make them want to get a divorce. Yet, others have said the same thing prior to the wedding. And here they are, set up for something worse than a disaster because of marital dispute; hence, filing for a divorce.
Making this agreement does not mean you are pessimistic about your future marriage with your partner, but it secures both of the lives that are ahead of you. Make the right choice today! Premarital agreement attorneys from Best Divorce Lawyers PA West LLC will conduct the procedures positively. They will use their expertise to make things work in your favor.
Call Best Divorce Lawyers PA West LLC at (412) 693-6655 and book a free consultation with us today!


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Step 1 Complete a prequalification |
Work with your Mortgage Brokers Ottawa Agent to complete a prequalification. Obtaining a prequalification will allow you to be the most prepared for your home buying experience. |
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Once you receive your pre-approved mortgage amount, work with a Real Estate Agent to find the best home for you within your price range. |
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When you find the home you are interested in, your Real Estate Agent will provide you with the expertise and information you need to make the right offer and protect you from any potential risks or concerns through this process. Together with your Real Estate Agent you will determine the best conditions to include in the offer; we highly recommend that this includes a financing condition; your Real Estate Agent will likely recommend additional conditions such as a home inspection and other items depending on the property itself. At this point you will likely be asked to provide a deposit with your accepted offer. |
Step 4 Get approved for your mortgage |
Once you and the vendor have come to a conditional agreement, you will likely have a certain number of days to waive a financing condition. For an approval we will require a copy of the accepted offer as well as the MLS listing of the property. While you are already pre-approved, it is important that you get a committed approval from a lender to ensure that both YOU and the PROPERTY are approved for financing. This process may require an appraisal to be completed on the property, your Mortgage Agent will inform you of this based on the approval. |
Step 5 Waive your conditions to make the offer a "firm offer" |
After you have satisfied all of your conditions including the financing condition, you will work with your Real Estate Agent to determine if you are going to waive your conditions and finalize the sale. |
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Depending on the length of time of your financing condition, you may sign the mortgage documents before or after you waive your conditions. This is something you will discuss with your Mortgage Brokers Ottawa Agent during the approval process. |
Step 7 Wait |
This is the hardest part! After a flurry of activity in finding the right home, the waiting period from the time you confirm your purchase until the time you move in can seem like a long time. For the mortgage, your work is usually complete at this point. Your Mortgage Brokers Ottawa Agent may be following up with you on documentation required to complete the file with the lender. |
Step 8 Arrange your home insurance |
The mortgage lender will require that you have home insurance on your property, and your lawyer will need to show proof of that to the lender as part of the requirements. |
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Your lawyer will usually arrange for you to come to his or her office 2 or 3 days before the close date of your home purchase. Your lawyer will provide you with the amount of the cheque that you will need to bring which will be payable to your lawyer in trust. Please see the upfront costs table in this guide for more on the costs you should expect at time of closing. |


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How Much Am I Worth?
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The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in color. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or cancerous growth:
- Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth.
- A sore that fails to heal and bleeds easily.
- A lump or thickening on the skin lining the inside of the mouth.
- Chronic sore throat or hoarseness.
- Difficulty in chewing or swallowing.
These changes can be detected on the lips, cheeks, palate, and gum tissue around the teeth, tongue, face and/or neck. Pain does not always occur with pathology, and curiously, is not often associated with oral cancer. However, any The Villages, FL patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer.
We would recommend performing an oral cancer self-examination monthly and remember that your mouth is one of your body's most important warning systems. Do not ignore suspicious lumps or sores.
Browse through our video learning center and find more information about oral pathology or contact our office in The Villages, FL for any questions. Call us at (352) 391-5550.


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Ground Floor, 147 Praed Street, Westminster, London, W2 1RL (Show me directions) Show Map
Home Delivery
020 740...Landline Landline 020 722...Landline Landline
Monday to Wednesday: 08:00 to 02:00 , Thursday to Saturday: 08:00 to 03:00 , Sunday: 09:00 to 02:00
Your local Subway® Store, located at 147 Praed Street. And it's one of the only places on the planet that can offer over 38 million different sub, salad or wrap possibilities (we're pretty proud of that as you can tell). We let you choose from our freshly baked breads made with British flour, and fill it with whatever your mouth, stomach and heart desires. Take your pick of our range of tasty cheeses (including vegan of course), our protein-packed meat selection and freshly cut veggies, as you bring your sub, salad or wrap to life. Toast it if you like and packed it full of protein and veggie goodness, you can top it off with your choice of our delicious signature sauces - from spicy, to creamy, to vegan, and everything in between.
You can go meaty, go plant-based, go crunchy, go spicy, go saucy, or just go ALL OUT.
All Subway® stores are independently owned with talented Sandwich Artists™ ready to take your order in-store, for collection via our Subcard® app, or delivered straight to your home via our partnerships with Just Eat, Uber Eats or Deliveroo.
We're the. UK's Sub specialists, with over 38 million possible combinations for you to #MakeItWhatYouWant


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by PPC | Mar 30, 2020
WELCOME to our Creation Justice blog managed by the Creation Justice Team of Pittsboro Presbyterian Church. We're a small group with a BIG concern about the fate of all God's creatures, great and small, in this new era of human domination of our common home, planet Earth.
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Real Madrid Third Kids Replica Football Kit 2023/24
£44.90 Original price was: £44.90.£22.49Current price is: £22.49.
Why Choose Real Madrid Third Kids Replica Football Kit 23/24 From Us?
✅ Quality products, trusted by 5000+ customers
✅ Best price with the same level of the quality
✅ Personalisation with preferred name and number
✅ Free shipping available for orders over £99 with code RFK99
SKU: RFK_RM_TH_KD_No_23/24
Categories: La Liga, Real Madrid
Tags: KIDS KIT, REAL MADRID, Real Madrid 23/24, REAL MADRID THIRD KIDS, THIRD KIDS KIT
Whilst you may come across more affordable products, none can compare to the quality we offer.
We're committed to delivering the highest level of quality at the lowest possible price, so our customers can experience the best without overspending
Description of Real Madrid Third Kids Replica Football Kit 2023/24
- In the world of football, Real Madrid Third Kids Replica Football Kit 2023/24 season represents an iconic design. Reflects the team's status as an elite club. The team's crest and sponsor logo are proudly displayed on the kit which will be worn by top players. The classic blue color reflects the club's rich tradition, while the modern pattern adds a dynamic and eye-catching element.
- As a result, this shirt is a perfect choice for Southampton fans who want to show their passion for the team this season.
- As a football fan, get ready to display your loyalty and passion for your favourite team with this Real Madrid Third Kids Replica Football Kit 2023/24. The high-quality materials used to craft the kit provide both comfort and durability, ensuring it lasts for many seasons.
- Show pride for Real Madrid with our meticulously detailed kit. The team's iconic crest and classic colours are prominently displayed, making it a must-have for any true fan.
- Here at Replica Football Kits, we provide top-quality products at competitive prices for passionate football fans. Our high-quality kit look and feel like the genuine article, made with only the best materials available.
Delivery Information
- Delivery times vary by location: UK: 8-11 working days, France and Germany: 6-10 working days, US: 15-20 working days
- Other countries, please contact us for shipping options. Please note that unexpected circumstances may extend delivery times beyond the estimated period.
- As you proceed to the Shopping Cart, you'll see the option to view the Shipping Fee. Before finalizing your purchase, please review your Shopping Cart to ensure all details are accurate and satisfactory.
How do I add Personalised Name/Number:
- After selecting the perfect size for your item, you have the option to make Real Madrid Third Junior Replica Kit truly unique with your own personalisation!
- Simply click "yes" and enter your desired name and numbers into the designated box. This can be anything from your favourite player name to your own personal nickname.
- We recommend a name with a maximum of 10 letters (including space) and using only 2 digits for the numbers.
- Please note that you cannot change the personalised item once you have submitted your order, so make sure to double-check your spelling before submitting.
Real Madrid fans' personalised recommendations for this season: Karim Benzema #9, Eden Hazard #7, Sergio Ramos #4, Toni Kroos #8, Vinícius Júnior #20
More details:
- To start with, please take note that once you have purchased a Real Madrid Third Kids Replica Football Kit 2023/24 with customized printing, it is non-exchangeable. Refunds will only be granted if the kit is found to be damaged or faulty. If this is the case, please get in touch with us to discuss the issue and arrange for a refund.
- Additionally, please bear in mind that measurements may vary across different kit. Therefore, it is important to carefully select the correct size before proceeding to checkout your order.
- Finally, please note that our kit are high-quality replicas, designed to be 99% identical to the originals.
What makes the Real Madrid Third Kids Replica Kit a brilliant present for a Real Madrid fan?
- Affordability: In addition to being high-quality, our shirt is also an affordable gift option.
- Variety: With our extensive range of football shirts, customers can find a shirt to represent their favorite team, regardless of their location or league. Allowing fans to show support for their favorite teams.
- Comfort: Our Southampton Home Men Replica Shirt provides fans with comfort, perfect fit, and style during the game.
- Long-lasting: Our durable replica football shirts are made of high-quality materials for long-lasting enjoyment.
- Personalisation: Additionally, we offer the option to personalize a kit with a fan's name and number, making it a unique and thoughtful gift that they will treasure. In addition, this personalization service allows customers to add a special touch to their purchase and make it truly one-of-a-kind.
- Easy to purchase: Our Real Madrid Third Junior Replica Kit is easy to purchase online, and we offer fast shipping, making it an excellent last-minute gift option for busy football fans.
How to Contact Us:
- If you have any questions regarding your product or delivery, please don't hesitate to reach out to us. You can email us at email@example.com, and our dedicated team will be more than happy to assist you.
- To ensure you receive all important updates, please remember to check your spam folder for our confirmation email. We wouldn't want you to miss any crucial information.
- Rest assured, we will keep you informed with regular email updates. If you notice that you're not receiving our messages, kindly take a moment to check your spam folder, just in case.
- We appreciate your trust in us as your go-to destination. Your satisfaction is our top priority, and we look forward to providing you with an exceptional customer experience.
We sure you will may also find interesting in:
- Real Madrid Replica Home Men Football Shirt 22/23
- Real Madrid Replica Away Men Football Shirt 22/23
- Real Madrid Replica Third Men Football Shirt 22/23
- Real Madrid Replica Goalkeeper Football Shirt 22/23
- Real Madrid Replica Home Junior Football Kit 22/23
- Real Madrid Replica Away Junior Football Kit 22/23
- Real Madrid Replica Third Junior Football Kit 22/23
Additional information
Additional information
Weight | 250 g |
Dimensions | 40 × 40 × 40 cm |
size | 16 (3-4 yrs), 18 (4-5 yrs), 20 (5-6 yrs), 22 (7-8 yrs), 24 (8-9 yrs), 26 (10-11 yrs), 28 (12-13 yrs) |
Reviews (1)
1 review for Real Madrid Third Kids Replica Football Kit 2023/24
Rated 5.00 out of 5 based on 1 customer rating
(1 customer review )
Rated 5 out of 5
Margaret –
This kit is a true standout. The color combination is bold and vibrant.
Add a review Cancel reply


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Know your gear
The DriveCore Install series amplifiers is a complete line of high performance installation amplifiers based on the proprietary DriveCore technology. DCi Series amplifiers are designed, engineered and manufactured to the industry's highest quality standards, and provide system integrators with the advanced features and flexibility required for challenging 21st century installed sound applications. Versatile, compact and highly energy-efficient, DCi Series amplifiers continue the unbroken Crown tradition of leadership in professional and commercial power amplifier technology.
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The muppets- puppets washi
Regular price
The muppets- puppets washi, silver foil
Includes One 15mm washi
Important: Limit of 3 rolls per order. Any number of orders can be placed.
- Colors on the screen will differ from the actual product depending on monitor settings. See Shop policies for more information.
- This product comes with tracked shipping option only
All designs are copyrighted and and cannot be reproduced or altered in any way without obtaining written permission from us. Items and design are for personal use only, not for resale. You are welcome to give them as gifts :) Distribution or reselling of these graphics is strictly prohibited.


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"Great customer service. The folks at Novedge were super helpful in navigating a somewhat complicated order including software upgrades and serial numbers in various stages of inactivity. They were friendly and helpful throughout the process.."
Ruben Ruckmark
"Quick & very helpful. We have been using Novedge for years and are very happy with their quick service when we need to make a purchase and excellent support resolving any issues."
Will Woodson
"Scott is the best. He reminds me about subscriptions dates, guides me in the correct direction for updates. He always responds promptly to me. He is literally the reason I continue to work with Novedge and will do so in the future."
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"Calvin Lok is "the man". After my purchase of Sketchup 2021, he called me and provided step-by-step instructions to ease me through difficulties I was having with the setup of my new software."
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April 04, 2023 1 min read
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Research Highlights
Model Sensitivity Studies of the Decrease in Atmospheric Carbon Tetrachloride." Atmospheric Chemistry and Physics 16 (2016): 15741-15754.
"Role of OH variability in the stalling of the global atmospheric CH4 growth rate from 1999 to 2006." Atmospheric Chemistry and Physics (2016): 7943-7956.
"Growth in stratospheric chlorine from short-lived chemicals not controlled by the Montreal Protocol." Geophysical Research Letters 42, no. 11 (2015): 2015GL063783.
"TransCom N2O model inter-comparison – Part 1: Assessing the influence of transport and surface fluxes on tropospheric N2O variability." Atmospheric Chemistry and Physics 14, no. 8 (2014): 4349-4368.
"Impact of transport model errors on the global and regional methane emissions estimated by inverse modelling." Atmos. Chem. Phys. 13, no. 19 (2013): 9917-9937.
"Off-line algorithm for calculation of vertical tracer transport in the troposphere due to deep convection." Atmos. Chem. Phys. 13, no. 3 (2013): 1093-1114.
"TransCom model simulations of methane: Comparison of vertical profiles with aircraft measurements." Journal of Geophysical Research: Atmospheres 118, no. 9 (2013): 3891-3904.
"TransCom model simulations of CH₄ and related species: linking transport, surface flux and chemical loss with CH₄ variability in the troposphere and lower stratosphere." Atmospheric Chemistry and Physics 11, no. 24 (2011): 12813-12837.


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- Fonds
- 1900-1995
There have been six accruals. Four accruals from the 1970s have been combined and consist of stage plays, radio and television material, his thesis on T.S. Eliot and other related works, articles and book reviews, poetry, and correspondence. The fifth accrual consists of stage, radio and television plays, poems and short stories, a book about creative writing, and correspondence. Sound recordings, moving images and photographic slides also form part of the fonds. They are been removed from their accruals and are stored separately.
Winter, Jack


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Sharlene Treherne | Memories | Fairhope, AL
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Did you order photo shoots, did portrait, family or personal photos from Sharlene Treherne | Memories | Fairhope, AL ? Then you can write, submit & share your experience and opinions about this photographer, about their services, prices & more. Your review will become a very useful information for other visitors. All reviews will be verified by administrators at Photo-Studio.Co.


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Jan Philipp Jenisch is registered with the Ministry of Corporate Affairs as a Director in Indian Companies. The DIN (Director Identification Number) of Jan Philipp Jenisch is 07957196.
Currently, not known to be associated with any company.
Following are the directorship details of Jan Philipp Jenisch
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*Industry classification is inferred. If the company has changed line of business without intimating the Registrar or is a diversified business, classification may be different. We make no warranties about accuracy of industry classification
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Includes access to the 20,000 sq. ft. Oasis clubhouse
The Retreat at Champions Gate
5 bedrooms (sleeps 10)
4 bath (2 en-suites)
Calendar in use
Property ID: 6073
From (GBP) £1379 / week
Contact details Claire - Villas In Florida 2 Rent
PLEASE NOTE - I'm currently on holiday and won't be replying to enquires until my return on the 29th July. +44 07419 821288
Open Plan Family Room with Kitchen and Dining Area | Upstairs TV Den | 5 Double Bedrooms with a Relaxing Nautical theme throughout | Minutes from Disney Theme Parks
6 bedrooms (sleeps 12)
6 bath (5 en-suites)
360° Virtual tour
Property ID: 5668
From (GBP) £2155 / week
4 bedrooms (sleeps 8)
3 bath (1 en-suites)
Property ID: 6071
From (GBP) £1195 / week
Open Plan Family Room, Kitchen and Dining | Additional TV Den | 3 Double Bedroom and 2 Twins | Includes Unlimited Free Access To The New Oasis Clubhouse / Water Pa
4 bath (3 en-suites)
Property ID: 6065
From (GBP) £1865 / week
Tron Game Room | Connected Avengers & Moana Kids Rooms | South Facing Private Pool & Spa | Walk to Oasis Clubhouse | Free Baby Amenities | 2 Living Rooms with Big Screen TV's | All Rooms Themed
6 bedrooms (sleeps 13)
6 bath (4 en-suites)
Property ID: 7450
From (GBP) £2100 - £5700 / week
Contact details Patrick
+1 407 2790868
Call US from UK +001 407 2790868
Property ID: 6069
Open Plan Family Room, Kitchen and Dining Table to seat 8. Includes Unlimited Free Access To The New Oasis Clubhouse / Water Park!
Property ID: 6060
Sleeps up to 20, 9 bedroom/5 bath, Marvel and Minecraft themed 8 twin bunk beds
9 bedrooms (sleeps 20)
5 bath (4 en-suites)
Property ID: 7407
From (USD) $2200 - $4700 / week
Contact details Thuy
+1 704 2770316
Call US from UK +001 704 2770316
Open Plan Family Room, Kitchen and Dining | Additional TV Den | 3 Double Bedroom and 2 Twins | Includes Unlimited Free Access To The New Oasis Clubhouse / Water Park!
Property ID: 6064
Close to Clubhouse
Property ID: 6067
Champions Gate villas and vacation rentals on the Retreat in Orlando, Florida. NO SERVICE FEE
Over 150 Champions Gate Florida villas on the Retreat at Champions Gate located only minutes from Disney World, Orlando. Close to shops, restaurants and supermarkets the Champions Gate resort is an ideal place for your dream holiday. The main entrance to the Champions Gate is located on HWY27 in Davenport almost opposite Tuscan Ridge if you are familiar with this community.
There is another entrance to the Champions Gate Resort via HWY54 (Ronald Reagen Pkwy). It's almost opposite the entrance to the West Haven community. When heading along HWY54 turn down Westside Blvd and follow this around until you see the entrance to the Champions Gate Resort. Personally this is the entrance we use as it's closer to all the shops, restaurants and I4 exit.
Speaking of Champions Gate restaurants we have put together a blog post listing the main restaurants available. Our favourites are Millers Ale House and Chilis.
The Champions Gate Orlando villa community is made up of smaller sub-divisions much like nearby West Haven. We currently have vacation rentals on The Retreat at Champions Gate, offering rental homes from 6 - 9 bedrooms.
The Retreat at Champions Gate community has between 600-700 Orlando vacation rentals as well as a stunning 16,000 sq ft clubhouse called the Oasis at Champions Gate. Inside the Oasis clubhouse there is a state of the art fitness room, dance studio, kids play room, 26 seater cinema, computer room, small shop selling soft drinks and snacks as well as kids arcade games. There is also a full restaurant serving food from 11am daily.
As part of the Oasis clubhouse there is a water park which has a large resort pool with private cabanas, water slides, lazy river, kids splash park, Tiki Bar, kids play area and volley ball courts, they also have daily entertainment run by the onsite staff. The Oasis Clubhouse and Water Park is open to all on site guests who have unlimited use.
The Oasis clubhouse at ChampionsGate is open from 8am - 10pm daily, pools open from 10am - 10pm with food and drinks from 11am - 10pm.
We visited the Champions Gate Oasis clubhouse and water park and have captured lots of photos and videos which you can view on our blog at The Retreat at Champions Gate / Oasis Clubhouse.
Below is a aerial video shot by a local Orlando realtor which shows you the Oasis Clubhouse and waterpark as well as an overview of the whole Champions Gate villa rental community which I hope you agree looks very impressive.
As well as being a great location for holidays these luxury vacation rentals work well for business travellers attending a conference at the nearby Omni Champions Gate hotel. So why not mix business and pleasure and stay in one of our luxury spacious Champions Gate villas next time you are in Orlando.
We will be adding more Champions Gate villas and reviews as they become available but the current Orlando vacation rentals we have are able to sleep up to 16-20 guests in comfort. This is great location for your next Orlando vacation with SeaWorld and Universal Studios less than 20 minutes, Orlando International Airport (MCO) around 30 minutes and Sandford Airport about an hour.
Within 60-90 minutes you also have Tampa on the Gulf Coast with the beaches of Clearwater, Fort DeSoto Park and many more. If you like to surf, then on the Atlantic Coast you have Cocoa Beach and the whole stretch of the A1A highway which has miles of beaches. This is all within 90 minutes of the vacation rentals at Champions Gate making a great day trip or mini overnight break during your stay in Orlando.
To book one of our luxury VRBO Champions Gate villas please contact the owners direct using the contact form on each of the listings. You only need to enter your dates and details once and they will be copied from one page to the next making it quick and easy to contact multiple owners. We hope you enjoy your stay at these Champions Gate rentals.
The Country Club at ChampionsGate golf course is open to the public with green fees from $40 - $90 per round depending of the time of day you play. I expect these rates to be lower in the summer months but during the winter golf is always more expensive in Florida.
I was lucky enough to play The Country Club at Champions Gate course 3 times in the first two weeks of opening and was very impressed with the layout of course and the condition, which was excellent. The fairways are wide and running which is unusual for courses in this area as they all tend to be pretty soft so play longer than the yardages suggest. The greens are very fast and undulating which takes some getting used to but I founf them a fantasic surface to putt on.
I would say The Country Club at Champions Gate is currently one of the best courses in the area and a must if you are looking to play some golf while on your Orlando villa holiday.
We have luxury Champions Gate villas available so if you are looking for a short golf break this would be an ideally base for you with other nearby courses like Highlands Reserve, Southern Dunes, Mystic Dunes and of course the other Champions Gate courses which are Greg Norman designed. Interestly this course (The Country Club at ChampionsGate) is nothing to do with the other Champions Gate courses even though they share similar names.
The nearby Omni Champions Gate hotel is ideal for a one or two night stay but if you are looking for an exteneded stay then these spacious luxury villas are a great alternative.
If you can't find what you are looking for on the Retreat at Champions Gate then below is a list of other nearby Orlando rental communities.
Most of our Florida villas will either have door alarms on any exterior door that leads to the pool area or a pool safety fence surrounding the pool. Some even both, we have put together a blog post and video showing you how to use the fence. If there are no children in your party then you can take it out and rolling it up in the corner if you prefer but please put it back when you leave the villa, ready for the next guests.


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