 I welcome everyone to the first meeting of the Public Petitions Committee in 2018. I hope everyone had a good break and I want to wish everyone all the best for the new year. I remind members and others in the room to switch phones and other devices to silent. We've had apologies from Brian Whittle today. The first item on our agenda is evidence in petition 1627 on consent for mental health treatment for people under 18 years of age. As members know, the petition was lodged by Annette Mackenzie. We last considered the petition on 7 December 2017, where we took evidence from Penumbra, the Scottish Association for Mental Health and Children in Scotland to explore support available to people under 18 years of age who experience and seek treatment for mental ill health. This morning, we will be taking evidence from Morning What, Minister for Mental Health, Ruth Christie, Head of Early Interventions, Mental Health and Protection of Rights division in the Scottish Government and Dr John Mitchell, Principal Medical Officer and Psychiatric Advisor in the Scottish Government. I welcome you all to the meeting this morning. Members have a range of questions to assist us in understanding the support that can be offered to young people who experience mental health difficulties. However, before we get to our questions, I invite the minister to make an opening statement. Thank you very much, convener, and good morning, members. First, I would like to start by offering my sincere condolences to Brittany's mother, Annette Mackenzie and all her family and friends. Any death by suicide is a tragedy that has a devastating impact on family, friends and communities. It is testament to her daughter that Ms Mackenzie has raised important issues in her petition for consideration by the committee. I thank all those who have given evidence. Before we start discussing the detail of the petition, I would just like to set out that mental health is a priority for this Government. Our 10-year mental health strategy was published on 30 March and it sets out our vision to improve mental health in Scotland. There are a number of actions in the strategy aimed at ensuring that children and young people have good mental health and that agencies act early enough when issues emerge and impact young lives. Early intervention and prevention is the cornerstone of our approach to mental health and wellbeing. Mental health needs to be something that everyone talks about and reducing stigma and promoting discussion and early action are vital to ensuring that Scotland is the best place to grow up for our children and young people, especially this year 2018, the year of young people. Any suicide is a tragedy with a deeply distressing impact on family and friends left behind. We are currently developing a new draft suicide prevention action plan. The draft action plan will be published for comment in spring 2018 and will be supported by a short series of public engagement events that are currently being planned. We will publish the final action plan later in 2018. I agree with the views that committee members have expressed and with others that have given evidence, including the Scottish Youth Parliament, that young people have a right to confidentiality when seeking medical advice and to make informed decisions about consent. To change the current system may deter children and young people from seeking help from doctors and other professionals and make them less likely to disclose the full facts of how they are feeling and their symptoms. That is the case across a range of physical and mental health conditions and must continue. I am happy to answer any questions that the committee has. Thank you very much for that. I start off by exploring the Scottish Government's views on the prescription of antidepressants. The prescription of antidepressants under 18 suggests that this is an indicator of an increase in the number of younger people seeking help with their mental health, and that was seen as a positive thing. Although we will support people of all ages who are becoming more comfortable seeking assistance with mental health as they would be for their physical health, are you content that the rise in prescription of antidepressants represents young people receiving the appropriate treatment? We are of the view that the rising prescribing in Scotland is associated with the reduced stigma, and more people coming forward for treatment and antidepressants are effective and evidence-based. There is currently no evidence that GPs are over prescribing antidepressants. In 2014, the Scottish Government's short-life working group of experts concluded that the rise in prescribing of antidepressants in Scotland is, for the most part, explained by better diagnosis and treatment of depression by GPs. The time, John, might be that you can go into that. However, that is also in line with prescribing in general for physical illnesses, too. In all areas of health, physical and mental, there are higher prescribing rates. I do not know if you want to add anything, John. The document was published in the Scottish Government website, and it is called Key Information on the Use of Antidepressants in Scotland. The reason that it was written was to explore the rising prescribing of antidepressants at a time when we were moving from a performance target that was looking at antidepressant prescribing to one to do with psychological therapies. An expert group was convened to look into that. The conclusions are available online, but the evidence from a variety of sources showed that, as far as we know in Scotland, prescribing of antidepressants, particularly by GPs, is appropriate. In particular, there was a study of a million new prescriptions of antidepressants by Scottish GPs that showed that, generally, those were being used for the right indications and were being reviewed. As the minister said, Audit Scotland did an investigation into prescribing in Scotland and found a 30 per cent increase in prescribing of all medications. The rise in antidepressants is symptomatic of more people being treated for depression. Surely, even in your own evidence, it has been said that young people should not be prescribed antidepressants at a first visit until everything else has been exhausted. Are we saying that there is a 30 per cent increase in the prescription of antidepressants after all that work has been done? The 30 per cent increase was in all medications for all conditions across all ranges, so physical and mental health conditions. For antidepressants, there has been a rise in antidepressant prescribing at a population level. The numbers for children and adolescents are much smaller, but there has been a consequential rise at the same time. It has run in parallel with the rise in people coming forward for treatment. I should say that antidepressants are certainly not the first-line treatment for depression in children. Do you know that? We have figures to show that all visits to a GP by young people at the point at which they are prescribed antidepressants is on average. We only know that, as you see, more people are presenting with issues around mental health and there is an increase in antidepressants. We do not know whether it is a first or last protocol. Is that something that the Scottish Government is willing to look at? We do not have those numbers. We have spoken to the Royal College of General Practitioners, who would say that, at the very back of their minds, there would be any prescribing if a young person was coming forward with mental health problems. That is what they have told us. We know that, in this case, the young person was prescribed tablets at the very first visit. Obviously, we want to look at the general practice of what the routine approach of GPs is, but we do not know whether it is at the end of a long process or at the beginning of the process. Would that concern you if there was evidence that, at the first visit to a GP, a young person was routinely getting antidepressants prescribed to them? I can just say that there is no evidence that having greater access to psychological therapies will reduce antidepressant prescribing. We have got to talk in the generalities here. We do not know what conversation there was between the person, the petitioner's daughter and what state she was in. If the doctor thought the first off that the person was in such a state that they needed antidepressants plus psychological therapies, which are not going to happen that day, if it was a combination of the both, you would not wait to start one without waiting for the other. Of course, we cannot second guess the clinician and if a young person was in crisis. Within our evidence, it suggests that good practice is that you do not prescribe initially, but you do it after everything else has been tried and you move on to that. I am just concerned that you seem to be seeing a correlation in a positive way by increasing prescription of antidepressant drugs and better attitudes to mental health when it could equally represent poor medical practice in that a young person is routinely given antidepressants at their first visit. Will you be willing to investigate the question about whether the policy intent is right or explicit that it ought not to be happening routinely? As I said, the publication that I mentioned earlier, which was in the British General of General Practice, was in 2012, and it looked at new courses of antidepressants being prescribed in Scotland. The figures that we have been given, which indicate or are presented as being showing that we have a better positive attitude to mental health because there are higher levels of prescribing? That research that is described in the 2014 report happened because of the rise in prescribing and because of the concerns that people had expressed. Thank you and good morning everybody. I want to pick up on the thread that Joanne has been following here in terms of appropriate treatment. I hear what you are saying and I certainly will go and have a look at that research, because often with research it depends on what the questions were that were asked, obviously. If you are asking GPs, are you making all the considerations or are you following the nice guidelines, I will say yes. However, the question that I want to explore with you is how does the Government ensure that GPs have adequate training, particularly to support young people with mental health generally, and including making prescription decisions to ensure that young people are properly informed of the side effects and the real meaning of informed consent? We know that, from the recent audit of suicides, the majority of young women actually overdose. That is their first line of choice. I think that this is a really important issue and certainly one that Joanne was exploring there. What confirmation can you give us that there is adequate training for GPs around that? All GPs are fully registered medical practitioners who have completed undergraduate psychiatry. The Royal College of GP figures show that over 75 per cent of the current total of GP trainees in Scotland have completed postgraduate psychiatry posts and over 50 per cent have worked in children in pediatrics, and around 30 per cent will have done both. The GPs who are coming through the system have a good level of knowledge and experience of mental health issues, as well as pediatrics. We know that one in three presentations to primary care have a mental health element. Therefore, GPs are very experienced in consideration of mental health and wellbeing of their patients. GPs must undertake 50 hours of continuous professional development every year. The Royal College of GPs has a free online e-learning modules in a variety of topics that include child and adolescent mental health and depression in children and young people. The Royal College of Psychiatrists, NICE and NHS Education Scotland also have resources available. All the training modules and the training evidence are there for GPs to access. I do not think that there is any evidence that GPs are not as well-versed in mental health issues as any other issue at all, but I do not know if you want to add anything, Tom. GPs are expert medical generalists. As the minister said, they have followed a general undergraduate medical training that is involved in psychiatry. The training for all GPs as part of the curriculum has information about communication, family dynamics and information about children and mental health. As the minister said, the vast majority of current GPs have done postgraduate psychiatry as well as doing their GP training. The minister has explained the revalidation for doctors in the United Kingdom, which requires all doctors to continue professional development. Those 50 hours of continuing professional development are a mixture of mandatory training and individual bespoke training, depending on what the needs of the individual are. There is an annual appraisal meeting that every doctor has where there is an opportunity for doctors to talk to their appraiser about what training they have done in the past year and what training might be appropriate for them to do. Have any concerns been raised with you that GPs are not adequately trained in mental health and that GPs need to know more about non-pharmalogical options? Has that ever been brought to you at all? We are aware of parliamentary questions and ministerial correspondence that has expressed concerns about that, but talking to the Royal College of General Practitioners and talking to primary care advisers in government, the GPs themselves say that mental health and mental health issues are very important to them. They take a keen interest and they work hard to make sure that there is training available and that they are up to date with it. The Royal College of General Practitioners would be saying that if a young person was presenting with a mental health problem that prescribing would be at the very last bit of their head, that the first thing that they would be doing would be thinking about the social environment and family environment that that child was in and thinking about what are the community opportunities to try to reach out and help that child, including potentially referring to specialist services and including the provision of psychological therapies. GPs have said to me from the Royal College of GPs that they would not default to prescribing, but they would do that. As you identified earlier, you do not have figures that show us that, which I think is one of the challenges that we have, because most of that sort of evidence is anecdotal rather than evidence-based, which I think is something that we may need to look at going forward. Can I just ask finally around safeguarding? In amongst all this mandatory training and optional training around CPD, where does safeguarding fit? Is that a mandatory annual renewal or bi-annual renewal? The mandatory arrangements vary from place to place. The safeguarding, the fundamental risk assessments that doctors do on all sorts of issues and the fundamental issues to do with confidentiality and consent that are part and parcel of all clinical encounters are something that doctors know is instructed by the GMC in terms of what is laid out in the principles of good medical practice. There will be places where there are aspects of it that are mandatory and places that there are not, but generally mandatory training, primary care, they try to have as little as possible to allow as much space for the individualistic training that is required. Most of the mandatory training tends to be on issues such as fire safety, child protection and things like information governance, handwashing and health and safety issues. The principles of the GMC would be the overarching way that would guide doctors in terms of safeguarding and managing risk in thinking about consent capacity. For most professions, in terms of breaking confidentiality, for example, around escalating of information for a youngster that is considered to be vulnerable at risk, how is that then communicated? How is that training? Obviously, there have been significant changes from the rules around child protection to the term of safeguarding and the manner in which that is escalated and the sharing of information, which has been a massive point of discussion. How is that training? How is that now communicated and how do doctors, GPs, particularly engage in that? There is GMC guidance on this. On confidentiality, the guidance says respecting patient confidentiality is an essential part of good care. This applies when the patient is a child or young person as well as when the patient is an adult. Without the trust that confidentiality brings, children and young people might not seek medical care and advice and they might not tell the doctor all the facts needed to provide good clear. On disclosure, the GMC guidance makes it clear that disclosure without consent is only permitted if there is an overriding public interest. For example, if there is someone who drives a vehicle and they may have experienced blackouts or something like that, you have to tell the DVLA. When it is in the best interests of the patient who does not have the maturity or understanding to make a decision, for a child diagnosed with a serious illness such as cancer, for example, the GP would inform parents and carers because they would need treatment and support. When it is required by law, for example, for child protection reasons like child abuse, but all of this was as a result of the Age of Legal Capacity Scotland Act 1991 when people are considered adults over the age of 16. I will close just as a comment and then I will come off. When a child or a young person is likely to take their own life under normal circumstances, that would count as the need to disclose for every other profession. That is the knob of the question for us here. When for a GP does that become a need to disclose? I worked in children's services as a nurse. I was duty bound to disclose when I felt that a child was potentially at risk of taking their own life. I completely agree. I think that any clinician who believed that the person in front of them was expressing active suicidal ideas that that level of risk would trump any concerns about confidentiality. That whole direction of travel in Scottish Government, when you consider things like the chief medicals, the officers, realistic medicine and realising realistic medicine, it is much more now about treatment and prescribing being as a result of a conversation between the patient and the medical practitioner rather than just in a day's past when we would just expect that the doctor knew everything best. You just took what the doctor said. I can think of things when I've said, no, I don't want that. Thank you very much. People now need to realise that they've got the whole thing about the relationship between the GP and the patient now is more about having that conversation. I think that that's the direction of travel. You can't talk about specifics of individual cases, but you said that if it was a general case, if you imagine a person who is 16 years of age, it's in such crisis that you go against the usual assumptions that you wouldn't prescribe in the first visit, you would try other things, that would be a point of last resort. The person is prescribed on their first visit and yet they're deemed able to have a conversation as you describe it. Do you not think that that's simply not what would happen in the real world and that a young person in those circumstances is not in an equal relationship with the doctor to start with, as by your definition is in such crisis that they have to override all of these things and yet it doesn't involve looking to how you said if it were cancer the family would be brought in and told in order to give support, but because it's a mental health issue the family's not brought in. At the nub of this case is that if the family had known they feel they would have been able to support the young person better, even if it were simply to be the prescriber to manage the drugs for the young person. As you've said, convener, we don't know the circumstances in this case, we don't know if... That imaginary case that I'm describing, some days in such crisis they override all of the normal practice, which is last resort and all the rest of it. Surely in those circumstances it would... It's theoretical example of somebody in such crisis, they're only 16 years of age, they've not got any correlation with the doctor, they haven't been discussed this before. If you put a safeguard in for a cancer patient, why would you not put it in for a young person with mental health challenges? They're so severe, they're going against this normal practice of prescribing as a last resort. As I've said, I don't think... We don't know what went on in this specific case and we can't surmise. They're obviously going to be an investigation. I'm not asking it with respect, but I'm not asking... Yes, I understand that. Minister, you let me finish the point. We're all very sensitive to the fact that this young girl's family probably are following this closely, so we're not talking about that specific case. We've all got respect for that and we understand that we don't know the individual circumstances. I'm asking you to think about a circumstance where a young person of 16, as you said, was in such crisis that they couldn't wait for the other therapies that they had to be prescribed there and then. Do you seriously think that that is a circumstance where you're going to have a conversation about what best meets your needs and why would you not, if you thought it appropriate, for a cancer patient to ensure that family is round about them, that you wouldn't have family round about them when you were prescribing those drugs? I think that we should also not assume that the young person is any less aware of what's going on than an older person. I mean, young people talk much more about mental health problems now than we ever did before. John, do you want to take over? I think that the principles of realistic medicine are about good communication, about health between patients and clinicians. I think that the specific situation that you're describing is one of urgency and great concern. I say that it's urgent because the doctor in deciding in this theoretical example has overridden all good practice, which is that you don't do it immediately, you try everything else first, and there's almost a presumption against antidepressants. That's how serious it is in this theoretical example. The normal thing about let's have a conversation with us would surely not, if you imagine yourself into those circumstances, because I'm not saying that it's that serious, but it must have been or it must be for you to override all those policies, so the normal thing about let's have a conversation with us would you accept that, wouldn't apply, and what safeguards then would you put in place? I'm just trying to understand what the situation would be, so if a young person presented to a GP for the first time and the nature of the conversation meant that the GP was immediately concerned that this young person was actually severely mentally disordered or in severe distress or had a level of severe risk, a GP wouldn't say, I'm going to treat you with an antidepressant and do no more. A GP would recognise that risk and seek specialist help and support, and that might be available through an emergency referral to a child and adolescent mental health service, for example, but it wouldn't be that guidelines and processes would be breached or would be changed. The level of concern would rise so that the GP would think, well, I'm not going to just manage the situation on my own. I can't imagine a clinical situation where any person presenting acutely distressed, potentially mentally ill, potentially suicidal would simply be given an antidepressant and that would be that. There would be much more concern and support put in place around somebody who has done an emergency that day situation. I see that happening in my own clinical practice. I have been working psychiatry for 25 years now and would routinely be receiving referrals from GPs in exactly those situations of somebody presenting to them that they feel is a psychiatric emergency. I would like to follow on in the issue of consent and confidentiality, because I think that that is at the core of the petition. The submission from the Government mentioned review of the consent process, and I wonder if you could provide me with an update of that review. As part of realising realistic medicine, which was the 2015-16 CMO annual report, the chief medical officer announced that working with the GMC and the Royal Academy of Medical Colleges that there would be a review of consent in Scotland. That has been happening, and the intention is that the product of that review will be coming out for consultation in March. Just to follow on from that, one of the submissions from Fiona French states that she does not believe that the owner should be on the patient to give informed consent because, by the very nature of it, there is a very vulnerable time in their lives. If you magnify that into a young person of 16, I think that, to be quite honest, when this petition first came to us, everyone on the committee was alarmed and shocked that a young person of 16 could be given strong drugs without anyone else's knowledge. I wonder if I could have your view on that. Aside from the guidelines, what do you feel about the fact that a young person of 16 was prescribed those drugs? Do you think that she should have been capable of giving informed consent? I cannot talk about the individual circumstances of that case, but I agree with evidence that you have received from many other parties, such as the youth Parliament and professional bodies, that young people are able to give informed consent about the treatment for various conditions. In the same way that, for example, a young person has a right to confidentiality on the prescription of contraceptives, a young person has the right to confidentiality for the treatment for medical conditions and for mental health conditions. We do not know the circumstances of that, but the situation was that the child was prescribed a beta-blocker medication, which is not an antidepressant. It is a medicine that is used for other purposes and is used to prevent heart disease and high blood pressure and to maintain your pulse at a regular rate. If that child had been presenting for a physical health problem and had been prescribed a medicine like this, which is primarily a physical health medicine, a universal opinion would be that children have the right to be able to make those decisions with their GPs. Again, GPs have told me that they routinely, in all circumstances, think about whether the young person in front of them is capable or have capacity to make the decision that they are weighing up. I think that it is possible that young people are able to give informed consent, and I think that that should be still permitted. If I could broaden out the questioning to turn to the issue of CAMHS, which has already been touched on slightly, we understand that the scope of CAMHS differs between NHS boards and that that creates a risk that some people may fall through the gaps in certain areas. Now, when we took evidence a few weeks ago, there was a suggestion made by SAMH to extend CAMHS up to the age of 25 for those already in the system and, in the longer term, to establish a specialist 16 to 25 service. Could I ask what your views are on that suggestion? We announced in the programme for government this year that we are committed to exploring the potential flexibility of those aged 18 to 25 to continue their care and treatment within CAMHS. Work to explore the expansion of CAMHS to age 25 is under development at the moment, and that will form part of the remit of the Youth Commission, led by Young Scott, which we announced on 6 December. The young people involved in the commission are going to do their research, identify issues that are important to them, speak to experts, policy makers and service providers to look at areas for improvement, and they will present recommendations to ministers. I think that the general direction of travel will be to extend that specialist service of CAMHS to age 25. In my discussions, for example, on Monday this week, with year five medical graduates who are doing CAMHS psychiatry, I think that flexibility needs to be in there because there are some children. Yesterday, I was at the junction for a youth project in Leith, meeting children. One girl, for example, with her eating disorder, said that she would not children with eating disorders feel quite childlike and do not want to go on to adult therapy, so moving to 25 might be appropriate for them, but other children, maybe with anger management issues, feel that they are more adult and want to move on. I think that flexibility needs to be in the system, but we will wait and see what the research shows, but that would be the general direction of travel. Am I correct in understanding that there is an increase in funding to CAMHS as part of the 10-year mental health strategy? I am sure that I saw that somewhere. Yes, the whole direction of travel in the mental health strategy is for early intervention and prevention, so the emphasis on children and young people is there. As part of the set-out in the draft budget, we intend to increase our direct support for mental health and innovation improvement to £17 million, which is a 32 per cent increase. That includes the money for CAMHS transformation and our commitment to increase the mental health workforce by a next 800 workers over the next five years. Obviously, CAMHS target lists have a very high profile, and as I have said on many occasions, I am not happy with those boards that do not meet their targets. We have the mental health improvement team from Health Improvement Scotland working with a number of boards to redesign their services, if necessary, to upskill those who are already working in CAMHS, and to increase the number of people working in CAMHS. That work is on-going, and I hope that it will show improvement. For example, in Forth Valley, where they were one of the first boards to work with the health improvement team, we saw an immediate increase in the number of children being seen. A couple of people left the team and fell back again, so there is fragility in the system that we need to work out. We know that CAMHS is intended to be a four-tier system, however the stats and targets only exist for tiers 3 and 4, which are the more intensive sectors. Does the current data provide a comprehensive representation of mental health demand for young people in Scotland? If not, does the Government have any plans to develop data in this area? It would be extremely difficult to capture data on tiers 1 and 2, because that service is provided over a wide range of organisations. It could be in schools, youth groups or anywhere. It would be quite difficult to capture that, but you are absolutely right in your direction of questioning that we want to make sure that children are given help at a very early stage, rather than have to necessarily wait for tiers 3 and 4. There will be, as John said, people who need to go directly into tiers 3 and 4, but, by increasing the number of people who have, for example, mental health first stage training, if we can identify people who are showing signs of depression or distress and can have lower intensity counselling sessions earlier on, we can perhaps prevent those people having to go to tiers 3 and 4. That is why one of the other streams of work in the mental health strategy is the review of personal and social education in schools. With regard to help for children at an early stage, you will probably be aware that the Scottish Youth Parliament noted its members' favour and increased focus on social prescribing opportunities such as peer-to-peer support, talking to youth workers, information centres and counselling, either as an alternative or to complement medical interventions that are already in place. What is your view of those suggestions and have you undertaken any work to develop those alternatives? Absolutely. We are all on the same page. That is what we all want to achieve. As I said, we are working very closely with youth groups to take that forward. Any examples of where it is happening already? The Scottish Youth Commission that I mentioned is part of the work. There is work going on, for example, on rejected referrals, which is a piece of work being undertaken by Young Scott and Sam H in conjunction. They will collect statistical data on rejected referrals and recruit young children to give us an idea of what their journey has been in the field. That is not something new because the previous mental health strategy also had actions in the field. It is on-going work, so we have to keep that in mind. Did you want to add anything? The previous mental health strategy had a commitment in it about trying to improve social prescribing opportunities, particularly as options for primary care. As the minister said, the audit of rejected referrals is going to provide us with very rich data about what happens to young people if they are not taken on by specialist CAM services. We will be getting quite detailed landscape of the alternatives to specialist child and adolescent mental health, for example, the peer support and other community agencies. Will you look at the reduction support, for example, in a community setting or in a school setting, when the education committee was out and about on Monday? We had a number of focus groups, and one of the groups that I was with was around teachers. One of the things that they spoke probably was one voice on was, first, the frustration and difficulty to get a CAM's referral, but at the same time that the supports within schools are reducing. I do not know whether there has been a conversation with the education department about the importance of not reducing those but increasing them. We are working together with the education department on the review of PSC in schools. On Tuesday night in Parliament, when Sam H had his annual reception in Parliament, he launched his campaign to make sure that children and young people have that early access to early intervention. As I said previously, we want to make sure that a wide variety of people working within the education service and youth service have those skills to be able to identify people who are showing signs of anxiety and depression, but also to know where they can get counselling or to know where to direct them to. We have good examples of that happening in the country already, the one that perhaps you will have seen in the news, as well as high school in Stirling. I want to clarify one thing with Dr Mitchell. You said that those better blockers that were mentioned in the petition were not anti-depressant drugs, but is it the case, however, that they are seen as an anti-anxiety treatment for mental health presentations? Do you want to give an idea of what need to think? It was not a physical health problem. The medication was been provided for, it was for a mental health issue. I am assuming that that is the case. I do not know the circumstances of what happened, but pranolol is, as I say, primarily used for treating high blood pressure and for preventing heart attacks. It is used in treating anxiety because it has the symptomatic effect of holding your pulse at a steady rate. For example, if you knew that you were going to have to come and give evidence at a parliamentary committee, and tachycardia or rapid pulse rate was hugely problematic for you, then that might be something that you would use to keep your pulse at a steady rate to reduce that. It is used in treating anxiety, but not used in treating depression. So, if you were prescribing it, you would be prescribing it to somebody who is in crisis? I would not imagine so, because it does not have an immediate function beyond what is described in, as I say, reducing symptomatic feelings of rapid heart rate and, therefore, subjective feelings of anxiety. It would not be an emergency treatment, except in cardiac health. It is interesting, because as we go through this, I must admit that I sit here and feel some discrepancies in what I see on the front line and some of the commentary. CAMHS services, for example, have been reduced in the way that I have been working. One of the things that we do know is that evidence shows us that most mental health problems begin in adolescence, and if they are not caught early, they go on into adult life and cause tremendous problems. During the evidence that we have taken so far, there have been quite a number of concerns raised that there is not enough emphasis and clear emphasis on early intervention and tackling problems at adolescence level. I wondered how you would respond to that. I want to wrap into that as well. The fact that, when you look at sign guidelines, the evidence that we were given also suggests that only about half of GPs had indicated that they were familiar with the sign guidelines around mental health. Again, that does not quite concur with some of what you have been saying around GPs' knowledge and understanding. There does seem to be discrepancy in people's experience and some of the evidence that we have been given so far. I wonder how you would respond to that. We were talking earlier about anecdotal. We cannot work on an anecdotal. John as the mental health leader in the Scottish Government gets a better picture overall and has more conversations with GPs and people working in the field throughout the country. In terms of all the things that we mentioned in terms of previous questions in relation to all the guidance that GPs have access to in the continuous professional development and the fact that one in three of people presenting to GPs practices will be with a mental health problem, I think that GPs and health practitioners are well versed in dealing with that as they are with physical health problems. In terms of absolutely right that most mental health problems occur in adolescence or even earlier, and that is why 14 of the actions in the mental health strategy are concerned with early intervention and prevention. That is the key to minimising the prevalence and incidence of poor mental health and the severity of the lifetime impact of poor mental health. It is also important to stress that recovery is key and is possible in managing the condition is key in most situations on mental health, but you are absolutely right that early intervention and prevention is what we must make sure that we do in terms of making sure that Scottish people can expect to live with good mental health and wellbeing. Can I just ask then, in terms of measuring the success of your strategy with an emphasis on early intervention? Dr Mitchell, you said earlier that you couldn't imagine a situation where a doctor wouldn't seek help when somebody was presenting in crisis and had suicidal tendencies and you couldn't imagine that somebody would just prescribe as a result of that. When we know that GP appointments run for about 10 minutes, that is the general allocated time. We also know that a psychiatrist or a psychologist wouldn't do a 10-minute appointment. We also know that mental health is not diagnosable by a test in the same way that a lot of physical illnesses, so it is much more of a judgment call. When you are looking at measuring the strategy, you said earlier that prescribing you saw as a positive indicator that people were seeking help. If your strategies work, do you expect then prescribing to plummet as an indication that your strategy has been successful? Surely, if we are treating mental health effectively at an early intervention level, prescribing should disappear to a great extent. The success of our strategy will be about people being able to access the treatment that they need when they need it. Depression can happen to anyone. Many mental illnesses may have—your pre-morbid mental health and your development is a significant contributing factor, but mental illnesses can happen just day-novo out of the air. For example, your experience as a child may not have any implication on whether you later develop schizophrenia or dementia or some other severe mental illness. Mental illnesses exist, and there are pharmacological and psychological and social treatments for them that we know work. Just like with physical illnesses, where we would treat a physical illness with some medications that we know work, increasing the access of people to that treatment does not necessarily mean that the use of medications in prescribing would fall. A lot of mental illnesses are just in the same way as we think of physical illnesses in that sense. In terms of a success in people generally accessing all health and improving all health, we would not expect to see that leading to our drop in the prescribing of all medications, nor should we expect that for mental health. One of the stumbling blocks or the difficulties for us exploring this, for you being grilled about it and for the population in general, is how does a GP, when presented with a patient, particularly a young patient, make the decision between whether what they are looking at is a clinical depression that may require pharmacological intervention or a normal course of life, because everybody will suffer from depression at some point in life. I think that you would probably agree, but for most people they do not require pharmacological intervention. How do you make that decision when somebody walks into your surgery and talks about how they are feeling as to whether that is something that needs pharmacological intervention? That is where I am struggling slightly and I am sure that my colleagues are, as to surely that requires much more investigative conversation to ascertain what kind of depression, what level of depression and therefore what treatment that needs and therefore is it appropriate at GP level to be making that decision around pharmacological intervention? We know that poor mental health and wellbeing is related to poverty and deprivation and that those living in poor communities are more likely to experience mental health, ill health and depression and many of them just accept it as a way of life instead of coming forward. We have got to make sure that more people feel able to come forward in terms of living with poor mental health, but that is precisely why more GP practices are becoming multidisciplinary teams and that is why we are expanding the link worker programme to make sure that there is a link worker in every GP practice starting off with those in the deprived areas so that the GP ones have seen them can, as you say, we have got to get to the root cause and that is where the link worker will come in, have that longer conversation and find out why people are feeling depressed and what the root cause is. Now, as John says, that does not mean to say that they shouldn't necessarily be prescribed, but to make sure that we are taking a holistic approach to people's condition and finding out how it can be helped in other ways. It might be where the link worker makes sure that the person is receiving all their benefits or that their financial situation can be improved or if there are signs of early adverse childhood experiences that we can get to the root cause, which may be childhood sexual abuse or whatever, and that the person is given the right help in those areas. So, yes, it is a multidisciplinary intervention that is required, but we should never forget that poverty and deprivation are a huge problem in terms of people's ill health. I think that what you say is absolutely right. I think that mental illnesses are difficult to diagnose because we can't do a blood test or do a brain scan to confirm them, and that's why there is a medical training and a clinical training to allow people to identify those things. People presenting in distress who are unhappy or perceive them to be depressed, clinicians won't necessarily jump to thinking that this is a diagnosis of clinical depression. They would consider the social environment of someone, but to try to aid diagnosis, it is generally understood, clinically understood, that there are some hallmark features of clinical depression, which is more than just the pervasive lowering of mood, but with sleep disturbance early morning, awakening, a typical diurnal variation of mood being worse in the morning than in the evening, a change in concentration, a change in how we think to more pessimistic thinking. Those hallmark features are diagnostic characteristics that a GP would know in the same way that a GP would know that somebody presenting with joint pain how they go about diagnosing rheumatoid arthritis, what would be the features that would point them towards a physical diagnosis. We do have some rating scales as well, I should say, that assist with that. For example, in trying to screen for postnatal depression, we nationally use the Edinburgh postnatal depression rating scale, which assists clinicians in being able to identify people who are above a threshold that is likely to then require a clinical intervention, which may not be a pharmacological intervention. Would you accept, would it be reasonable to say that identifying that in adolescence with all the issues around adolescence is more complicated than in a mature adult? I think it is, yes. I think it requires a sort of sensitive understanding of what it's actually like being an adolescent nowadays and an understanding, I suppose, of the developmental pathway that we all go through in terms of growing into an identity of ourselves. On top of that, I suppose, the other hallmark features that I have described require a certain degree of subtlety. As I said, the conversations that I had with the Royal College of General Practitioners around this, what they were saying was that they see people coming, turning to them in distress and turning to them in problems very routinely and they are used to starting off by not thinking in a medical way but thinking actually in a social environmental way to explore with people what the problems are in their life and what they can do about them without necessarily thinking about medical interventions and medical diagnosis. Do you think that, therefore, there is a gap in the sign guidelines in terms of the relation to dealing with adolescence with mental health coming to a GP? Do you perceive a gap in the guidelines and a need for strengthening those guidelines and strengthening the instructions to GP's in terms of what to do, particularly around prescribing when it comes to young people? The guidelines are guidelines. The fact is that, for a GP who is treating all physical mental health conditions, they have recourse to literally hundreds of different forms of guidelines, whether they be sign guidelines, UK-wide NICE guidelines, local guidelines from their own health boards or, indeed, best practice information, which the Royal College of GPs and the Royal College of Psychiatrists will have on their website. Looking at the information that is available for treating depression, there is a very detailed, very thorough NICE guideline, which is UK-wide on treatment of depression, which was last revised in 2016 and has reviewed the evidence to date at that point on all aspects of treating depression, including antidepressants and children and young people. The sign guidelines in Scotland are about non-pharmacological treatment for depression. As I say, they are available and they are current. The short answer is that I would not see currently that there would be a need for a revision of the extant guidelines that are available to clinicians. On the guidelines issue, do you or does the General Medical Council have any way of monitoring GPs who do not appear to be following those guidelines? Or does that have to come in the form of a complaint from the patient or from the patient's family? The monitoring of doctors' practice is through this process of peer review to appraisal to revalidation and re-licensing, which is laid out in the GMC and is a UK requirement for doctors. In terms of the 50 hours of continuing professional development, the way that that is checked that you have actually done what you have said you are going to be doing and to have the conversation about what might be sensible for you to do next year and how that process works is that you meet a group of peers who are usually organised at a health board level to then look back at what you have done and look forward at what you have done and to take the time if you like to check that what you are saying is accurate. That information then gets informed both to your all college but also to your annual appraisal meeting. The annual appraisal has to bring that information as well as information from other sources. GPs receive individual information about their prescribing, for example, which may or may not be discussed. The presence of any complaints would also be something that would be discussed at appraisal with the reflection on those complaints and what actions an individual did. That material then feeds into a GMC revalidation process. Is that kind of self-governing then? Only at the level of the peer review, the peer review is to look at the continuing professional development but the actual appraisal, which is the GM, which is a national process, that has an independence. It is not your local peers that do that. It is a nomines appraiser, who has a special training that is allocated to people to appraise on an annual basis. Is there any sort of sampling of case reviews occur? Anything particular? I am not aware of that, no. If I could just go back to the schools-based counselling. In your review of the counselling, are you giving any consideration to the system of schools-counselling that has been developed elsewhere, such as in Wales or anywhere else? Are you using— In terms of the review of personal and social education, we hope to get the review of the findings towards the end of this year. Obviously, we will be looking at what happens in other areas, such as Wales has been mentioned. It may not be the sort of system that we want to introduce in Scotland, but we will absolutely be looking at what we can learn from other areas. That is part of the review. The current position is that it is for local authorities to decide what best support services fit the needs of their local schools and circumstances, and not all schools will take up the same. It will be down to different schools having different approaches. Some may use school nurses, some may train teachers, some may take counsellers, and it would not be appropriate to advocate a one-size-fits-all approach to that. We will wait and see what the review of PSC has, and we will have a workshop to see what recommendations we can make. As I said earlier, we can also learn from best practice that is happening already in Scotland. From my experience and my constituency, on the point of one-size-fits-all, the problems that people and families have in accessing mental health care in my experience is that it can be very confusing the system and they do not have a single point of contact. They may have four or five people who are dealing with a specific case, and when they are trying to get the communications poor, will there be any consideration given to trying to streamline the process so that families know who to contact when and they are not dealing with four different people? That is a huge problem that I have found. Well, it depends on what the problem is, if it is a problem with school work. What is the problem with the referral to mental health services? In the first instance, if you have a mental health problem, the port of call will be your GP practice. Beyond that, once it is established that they need a referral, there can be half a dozen people who can contact. They do not seem to have a single point of contact. That will depend on what services are available in your local area so that there might be a variety of youth groups or third sector organisations that have a different way of dealing with different aspects. That is why we have a plethora of organisations working in this field in different local authority areas or health board areas. It is making sure that GP practices are aware of all the different organisations that work in this field. They have had conversations with the people running those organisations and know where best to refer to. For example, as I said yesterday, I was down at the junction in Leithan, Edinburgh, and GPs refer to the junction as well as schools and youth groups. Is it down to the local authority to organise the best? Can you understand why that can be confusing to somebody who does not know the system, who has never had to enter it before? There are all those people who are involved, but all of a sudden, who do I contact? That is why a link worker in a GP practice will be a person who has an oversight of all the different organisations that are available. I do not know if Andy Watt wants to add anything. The only thing that I would add is that getting it right for every child is the system that is rolling out in Scotland. Through that system, there should be single points of contact and ways of ensuring that all the professionals involved in a child's entirety of a child's life are being co-ordinated and that there is a single child's plan as well if the child requires that. It is not happening in my area, but hopefully that will come. The reason is that a named person has a big role to play. One person will be responsible for 400 young people, and the name person might be a challenge in order to do that. You said that it would not be one size fits all, but would it be reasonable to expect that at school level there should be a minimum standard? I was quite surprised at what you said, that access to third set of whether it would be through a GP feels like a massive burden. Go back 20 years, I ran what was called a joint assessment team, where you worked with families, teachers, whomever it was around a child, including the child themselves, identified what support they needed and then accessed that support. It feels a very medical model to say that you have to go to a GP to then get referred back to those things. I am not sure, but I am not convinced that the school-based councillor model should be councillors within schools, but would you not accept if that were properly funded at school level? Of course, for young people outside the school system, that is a different matter, but if there were expertise at school level to direct young people to the appropriate support that is out there in the community, that would give certainty. It is not one-size-fits-all, but it is a minimum standard that any young person in Scotland could expect. I did not say that everybody should go through their GP. I decided to depend on the level of severity. As John has said, some people will be experiencing anxiety and distress, but they may not have a clinical diagnosis or be clinically depressed. What we are getting back is that there is already good practice in some schools and in some areas. Schools have access to a variety of people through school councillors, through educational psychologists, and it will not be for us to prescribe because that is not within our remit, but local authorities, after they have seen the review that we are carrying out, will be able to decide what is best practice for them in their schools. In response to the question of Rona Mackay, the point of contact was the GP. That is one of the points of contact. It does not answer the question when there is three or four different—where do you go—that idea of somebody within the school setting, for example, has absolute responsibility for ensuring and taking you through that journey. The first point of contact would not be the GP. If a child in school goes to their guidance teacher, the guidance teacher, in my view, should have the skills through perhaps mental health first aid training and through the training that they do for guidance to think about what would be the best course of action in conjunction with the child and perhaps the parents as to what should happen to take forward counselling or whatever is required for that child. What we need to make sure is that everybody in that local area knows with the available resources, whether it be in the third sector, the voluntary sector, through the local authority, what is available in terms of services available for that person. That leads us on very nicely to the fact that during the sessions that we had with the voluntary sector, we heard that a target previously existed that 50 per cent of front-line staff should receive mental health training through applied suicide intervention training and skills-paced training on risk manager. The good news is that that target was achieved. The bad news is that there is no longer a target in place and only 50 per cent receiving it means that 50 per cent have not. We also know that there is a turnover of GPs, new ones coming or going. Where are you with that and what assessment has been made of the outcomes being achieved by the delivery of that target? Is there any intention to review a target and bring one in and ensure that that training is taking place? Just in general terms, heat targets are reviewed all the time so that there is not overload of heat targets. Priorities change from time to time. The former heat target on suicide prevention training for key front-line staff ended in 2010 because that had been exceeded in all board areas. At least 50 per cent of front-line staff across Scotland had been trained in suicide prevention awareness techniques. As a matter of good practice, NHS boards continue with this work in order to maintain at least 50 per cent of front-line staff trained in suicide prevention awareness techniques. NHS boards who are interested in suicide prevention training should always contact NHS Health Scotland. We are currently discussing with NHS Scotland their plans to refresh and reinvigorate their suite of training programmes in both suicide prevention and wider mental health awareness. As I said earlier, we are currently preparing a new draft suicide prevention action plan and we are going to be undertaking public engagement in the spring with a view to publishing the final version in the summer. This engagement process will afford stakeholders the opportunity to contribute their views and their aspirations on action to support suicide prevention. We should recognise that there has been a 17 per cent reduction in suicides in Scotland, and we want to continue that trend. The action plan will reflect what needs to be done, reviewed and revised to take that forward. As you are probably aware, the way in which inspections take place of children's services now has changed and they look across the board. When they come into school now, they are not just looking at the school, they are looking at all the associated services, voluntary sector, and as part of that there is case sampling. When social workers are inspected, there is case sampling to look at whether the decision process and the handling of that child's case is correct and to give an idea of the quality of the services that are being delivered. You said earlier in response to Rona Mackay's question that there is, to your knowledge, no routine sampling of cases for GPs. Do you think that there is a gap there in terms of looking at the decision making processes and the treatment decisions that are applied through GPs? GPs all, as part of their appraisal, have to write a series of reflective commentaries on things that have happened in their practice. The expectation is that any complaints or critical incidents, any adverse events, would be subject to those reflective considerations, and those would be discussed as appraisal. That is an opportunity to provide the time and space to look at and reflect on when things have not gone as well as they could do with GPs and with other specialists. That is what I would recognise as clinical supervision in terms of reflecting on your own practice, which is very different to an independent sample review of case management. That is the bit that I am querying, because your reflective practice is a choice thing around looking at what you have noticed as not being good or not being bad, or how you feel about something, whereas an independent review of case management is slightly different. I am just asking the question whether you consider there is a gap there in terms of that independent reflective review of case management. There will be a review of situations such as the one that we are describing in this position. In terms of health boards, their review prescribing from GP practices is an individual GP's prescribing practice. If there are any outliers, they can identify that, same as they can identify GPs who are sending more people into hospital and to consultants. That is all monitored by the board, and they can bring that up at the annual appraisal. The idea of sampling case management would be challenging in the sense of the case management of what. If you were talking about the case management of all mental health presentations of people of a certain age, that would be very difficult to define, because, as we were saying earlier, what is problems in your life seeking help and what is a mental health contact and what is a mental disorder contact? The problem is in the definition for me of what exactly you would be sampling. I think that we have got to the end of our questioning, although I have got a lot of questions left in my head that are subsequent to reflect on in terms of the evidence that we have heard. I also want to invite members to discuss what we think we should do with the petition. I would like to thank the petitioner again. I realise that we are talking about a general issue that she is talking about in her family. She is talking about her daughter, which has obviously had a massive and devastating effect on all of them. If Annette Mackenzie and her family are able to make another response to the petition, I think that that would be extremely helpful. We are very aware of how painful that must be for her, but we do hope that—and I think that the purpose in her taking this forward was to try and inform thinking so that perhaps other families do not have to suffer in the same way. I am just interested in the people's views on what we should be doing. We should contact the petition in the first instance. Anything else? It is an extremely complicated subject. As Dr Mitchell pointed out, the point of contact and the decision-making at that point of contact when it comes to mental health is particularly difficult. In terms of crisis, I think that the exploration of that decision is somebody in crisis and therefore should you resort straight away to a pharmacological intervention is very challenging, but I wonder whether or not that needs some more exploration around should there be a specialist, a requirement to have some sort of specialist consultation before you put a young person on to a prescription. The questions that I have had with GPs have said to me in the past the way that the system operates and they weren't talking about mental health issues in particular. I can give a prescription, but I cannot give time because the pressures are so massive. I am very interested in whether there is evidence or whether we should be getting evidence on the correlation between first visit with anxiety or distress and prescription. Is that what is happening or is it at the end of a longer period? I must say that I am concerned about seeing simply an increase in prescription as a positive because people are talking about mental health. When I am old enough to remember when they talked about the housewives' little helpers, when women went to the doctor and they were routinely given valium or whatever it would be. I think that medical GPs have moved on from that and thank goodness for that. We would be concerned if there are pressures that might bring that back together. I would be interested in the stabs and how we would get that kind of evidence. I would be very concerned to be clear that in no way are we implying that GPs are not doing their job, but we have to recognise that the time in which they have to see a patient and the time in which they have to draw a conclusion is around 10 minutes per visit. Even if they saw that person four times, they are still only talking about less than an hour to make that judgment call. As Dr Mitchell replied in response to my question, you would not a psychologist or a psychiatrist would not expect to do it in such a short period of time. I think that something that needs some consideration with the rise in mental health issues, with the rise in the number of people seeking help, which is a positive thing. I accept that the minister has commented on that. It is really important, but we cannot just walk away from and say that 10 minutes is an adequate diagnostic time. I was interested in this thing about we can see the logic of a young person who has been diagnosed with cancer having their family round about them and immediately putting supports in place, but this question of confidentiality comes. I understand that I have worked with young people who did not want their families to know what their concerns were, because some of those things were in mesh around the family and all that kind of thing, but I would be interested to explore further with the medical profession the difference between the two. That was my point. I think that part of the core of this petition is about confidentiality in cases like this. The correlation between if it was a physical illness, the family would be involved and the fact that it is not—we need to ask whether the general medical council would consider looking at that again in terms of the GP taking a decision on how serious it was if, in that instance, the family could be involved, because there seems to be a disconnect between the two, although I respect a young person's right to confidentiality. I think that that is something that we need to explore, because that is at the heart of this. The family is knowing that it is about having a responsible person that can talk to you, that can oversee and be aware of what is going on with them. There is also an issue around informed consent. You cannot possibly give informed consent without knowing all the potential consequences side effects. Again, in my experience and most people's experience, you do not get a complete rundown on what a drug may or may not do to you when a prescription is handed over. I think that that is a big issue. Thank you. Clearly, we need to reflect further on a future meeting on the evidence that we have heard today. One of the salient points that has come out of the evidence session is that we need stats on when or at what stage antidepressants are prescribed. If those stats do not exist, that would seem to be the case. We need to ensure that they are available in the future and that, if there is any indication at the current time, that they are shared with us. I suggest that we ask the clerks to draw together the issues that were highlighted by reflecting back on the evidence and then we can look again at what that means in relation to taking further evidence. I think that that would be worthwhile, but I think that at this point, again, we are grateful to the minister for the time that she has taken on the questions this morning, but also that there are some further questions that we would want to explore. Is that agreed? Agreed. Okay. In that case, can I suspend briefly? Call me back to order. Our second agenda item is evidence and petition 1651 by Marion Brown on prescribed drug dependence and withdrawal. We last considered this petition on 7 December 2017 and agreed that we would wish to seek oral evidence from the minister. Both the minister for mental health and Dr Mitchell have remained with us, so thank you. I also welcome Jenny Simon's policy officer, mental health and protection of rights division, Scottish Government, for this evidence session. As members will know, we have received a large number of submissions on this petition, primarily from people who wish to let us know about their experiences in relation to prescribed drug dependence and withdrawal. I would like to extend our thanks to all those who have taken the time to provide their views. As members know, our role is not to look into the circumstances of any individual case, but submissions such as we have received do convey the strength and depth of feeling that exists on this issue for a range of people. I am sure that I speak for everybody on the committee to say that that was a very— just reading through the submissions in preparation for the committee had a very significant impact on me, and I am sure that it did, and everyone else, and we are genuinely very grateful because we know that people are not writing but something theoretically writing about their own direct experience. As with the previous session, I invite the minister to make some opening remarks before we turn to questions from the committee members. Thank you, convener. I also start by thanking the petitioner, Marion Brown, on behalf of recovery and renewal for having brought this petition. Prescribing drug dependence and withdrawal is an important issue. As you said, convener, demonstrated by the level of response to the petition, and I am grateful to the respondeers who have taken the time to share their own personal experiences, many of which I read, too. Psychological therapies have an important role in helping people with mental health problems who should have access to effective treatment, both physical and psychological. I welcome the opportunity to discuss this issue in more detail. The Scottish Government has and will continue to emphasise the importance of parity in physical and mental health services. People with mental illness should expect the same standard of care as people with physical illness and should receive medication if they need it just as someone would receive medication for a physical illness. The Scottish Government has worked hard with partner organisations to reduce the stigma faced by people with mental health problems, and that has been reflected in the rise in demand for mental health services across Scotland. As the stigma declines, we see more people coming forward to seek help from their GPs for problems such as depression. As a consequence, we have seen more people being prescribed antidepressants, but that has been accompanied by better diagnosis and treatment of depression by GPs. The responses to the petition also highlight the issue of appropriate prescribing. In terms of guidance for prescribing of mental health drugs within Scotland, the sign guidelines provide evidence-based clinical practice guidelines for the NHS in Scotland. Sign guidelines are designed to bring new knowledge into action to meet our aim of reducing variations in practice and improving outcomes. Those guidelines are produced in collaboration with patients, carers and members of the public and include sign 114 on non-pharmaceutical therapies encompassing psychological therapies, structured exercise and lifestyle interventions and a range of alternative and complementary treatments in the management of depression. Often prescribing involves not just drugs. While we ensure that those who need medical education continue to receive it, we are also committed to improving access to psychological therapies that increase choice and best accommodate patient preference. We are undertaking a range of actions in our 10-year strategy to transform mental health services in Scotland to respond to that. Those include working to improve access to services, developing new models of care within primary health services and a national roll-out of cognitive behavioural therapy, as well as developing intervention responses to those in crisis through the distress brief intervention pilots being funded across Scotland. Furthermore, while medical student teaching now emphasises that medication has an important place in treatment, that should not be overused or continued indefinitely and decisions should always involve the patient so that they understand both the potential benefits and risks of making a decision to take them. That needs to be within an enabling environment where support and a range of information sources are already accessible by the patients. Our guiding ambition for mental health is simple but if realised will change and save lives, that we must prevent and treat mental health problems with the same commitment to passion and drive as we do with physical health problems. We want to create a Scotland where all stigma and discrimination related to mental health is challenged and our collective understanding of how to prevent and treat mental health problems is increased. We want to see a nation where mental healthcare is person-centred and recognises the life-changing benefits of fast, effective treatment. A theme of the submissions that people are concerned about being prescribed drugs without adequate explanation of the consequence of it, without any other supports being available and then being left on for a long period of time without support to withdraw. That is the underlying concern that is being identified by the petitioners and others. I can ask in the previous evidence session we discussed the issue of GP training in relation to prescribing decisions. There is a related question for this petition regarding training available to GPs. The petitioner has commented that GPs are being held responsible by everyone but they do not have expertise, knowledge or training to support people safely to withdraw from those prescriptions. Do you have a response to that view? As we said in answer to the last petition, in 2014, the Scottish Government published key information on the use of antidepressants in Scotland. What that illustrated was that the quality of antidepressant prescribing appears to have improved in recent years from being too often used in less than effective doses for too short periods of time to longer, more appropriate durations of treatment at higher-average doses, which are more effective and reduce the risk of recurrent bounce of illness in the long term. The briefing paper also highlighted that the rise in prescription of antidepressants in Scotland is, for the most part, explained by better diagnosis and treatment of depression by GPs. Research from within academic centres in Scotland confirms that antidepressants are being prescribed in line with current endorsed clinical guidelines and improvements in this will continue. There is consistent evidence of undertreatment of depression and we know that the personal and economic costs of having depression are high and we need to continue to work on ways to improve its recognition and effective treatment. The use of antidepressants by an individual is a dynamic process and varies due to the relapsing and remitting nature of the illness and individual treatment preferences. They do not work for everyone but for those who respond, the evidence for antidepressant treatment reducing relapse is strong. There is no evidence that having greater access to psychological therapies will reduce antidepressant prescribing rather access to appropriate and effective treatments, which will include antidepressants, is improved. I am concerned by that response, because what you seem to be saying is that the problem is the way that it is being addressed is by giving people stronger drugs and leaving them one them longer. When what the petitioner is saying is that people are giving drugs without the appropriate information about the consequence of it, they are left on it without other supports and they are then left and they are not the GPs who do not have the expertise in supporting them to withdraw. That is at the core of the petition, but specifically on the question that asked you, which was, what support do you believe GPs have been given? What expertise do they have in supporting people to withdraw from those drugs? Because that is more clinical, John, you can answer that. Yes. The drugs that we are talking about, the drugs that can cause problems in withdrawal, include obviously the painkillers, particularly opiate medications, which may be prescribed not just by GPs but by specialists in hospitals, for example, in cancer care. The sleeping tablet drugs such as benzodiazepines and the Z-drugs, which are anti-anxiety and sleep medicines, and again might be prescribed by GPs or by specialists. Those two types of classes of drugs cause dependence in that, as you stay on the drugs, your body becomes tolerant to them and you have to increase the dose to continue to have the effect. When you stop taking the drugs, you get withdrawal symptoms, and that is the definition of dependence. Antidepressants themselves have withdrawal side effects. They have discontinuation reactions, but they are not dependent in the same way as the other drugs in that there is not tolerance associated with them. You do not have to keep pushing the dose up to get the same effect. The point that you were making, I suppose, first of all is about the decision-making relationship between the patient and the prescriber. That is something that the realistic medicine is at the heart and soul of realistic medicine and the work that is going through that. Not only is the work on consent that we talked about in our last evidence, but there is also a revision of the health literacy plan in Scotland, which is about how we have conversations with people about the treatments that we provide for them. Just to address the point that you made about GPs being on their own with that, it is not so much the GP who is responsible for the prescribing of all of those drugs and potential side effects and potential withdrawal, but really the prescriber who is responsible for that. There are a whole variety of different sorts of prescribers now, so there are, obviously, specialists in hospitals who may be doctors or may be pharmacists. There are prescribers in primary care, and, indeed, advanced nurse practitioners are prescribing for some conditions. I do not think that there would be an expectation that a GP would be left ever feeling that they were on their own managing the complications of prescribing across that range, but, certainly, for a medication that a GP has initiated, that that GP would be responsible for that treatment. Can I clarify from the minister and yourself, do you accept the premise of the petition that there are people who have been—we are not given proper advice about the consequence of taking those particular prescriptions, so that that idea of informed consent is a challenge? They put on them, they are not given other supports, and they are left on those drugs, and that the GP would not necessarily know how to support them to withdraw from those drugs. That is the fundamental premise of the petition. Do you accept that that has happened? It does happen, and does it concern you that it happens? I would not accept that it routinely happens. Obviously, in terms of those that have written in relation to the petition, in some cases, the petitioners feel that that has happened, but we would not accept the premise that it routinely happens. Pardon? Does it happen? Well, as I have said, in relation to the petitioners that have responded to the petition, they feel that that has happened. I am asking you whether you think that it happens. It does not have to happen routinely for us to be concerned about it. Does it happen? Are GPs—do they not have the right support? If you do not accept that it happens, that is fine, but if you do accept that it happens, what is the response of the Government in order to address the concerns that I like to be the petitioner? I think that the people's perceptions of their care—I am happy to accept that that is what people's descriptions of their care have been. Do you believe them? Do you accept? There is a difference between saying that somebody thinks that that is how they feel, or that they feel that something is legitimate. You do accept that it is legitimate. Yes. I think that the descriptions that people have had of the problems that they have had with prescribed medication, I recognise and accept. I think that those don't represent the normal or the average. I think that they are situations that people have chosen to tell us about. In terms of, I suppose, people's feeling about what the quality of the consent and information conversation that they had with the prescriber is, I am perfectly happy to accept that there will be occasions where those conversations are not happening as well as they could do. I think that there will be other conversations that happen extremely well in terms of explaining to people what their options are and discussing the pros and cons with those. On the issue of support for GPs, GPs are inside a primary care team of people. They have access to guidance, as we discussed earlier. They can pick up the phone and speak to specialists should they wish. They have the opportunity, which they describe regularly, of talking to each other about clinical situations that they are involved with. Specifically, for prescribing, we are rolling out improved pharmacy both in the community but also in primary care. Health boards tell us that, by March 2018, we will have 200 new whole-time equivalent pharmacists in addition to 50 pharmacy assistants in practices all across Scotland. GPs are not isolated in having to struggle with complicated prescribing issues. The support is there for them, and they would describe using that. Rona Mackay, can Jenny just add a bit about the matrix? Also to highlight the NHS Scotland has developed a psychological therapies matrix. It is an evidence based resource that highlights different combinations of therapies and approaches to treating a range of different conditions. Depression has been a large part of the guidance within that. It is how you can combine medications and different approaches to therapies and other sources of support, which doctors also have available to them, which might be worth highlighting, as well as the sign guidance that has also been developed within Scotland for GPs and other practitioners and clinical staff to refer to as well. Just on that, do we have statistics on the number of people suffering withdrawal from antidepressants? Or from drugs generally, whatever, prescription drugs. Because we do not have a unified number that describes that, the Royal College of Psychiatrists did do some research into discontinuation reactions from antidepressants and they published that on their website. I can find the numbers for you. I think that the experience of discontinuation reactions from antidepressants is actually really quite common and pretty much affects every antidepressant from every class, but in general the actual discontinuation reactions, the symptoms, are mild and self-limiting. So, the nature of how severe this is and how challenging this is, we cannot really define that, but as I said, the Royal College of Psychiatrists do have information from a sort of survey. We are perfectly happy to accept that. Those are real symptoms that people have. Certainly, for people who are on the dependent drugs like opiates and benzodiazepines, without careful handling, almost 100 per cent of people would have withdrawal reactions to that. That is why there is guidance and information clinically available to help people to work at how to cut down drug doses and how to reduce drug doses. For antidepressants, the Royal College of Psychiatrists says that the tapering should take place over a four-week period in order to allow the body to adjust to those medicines. Do you feel that the patient has been given enough information about the possible side effects and withdrawal and is it down to the doctor to manage that, the GP to manage that? The prescribing of a medicine and then what happens with that medicine is the responsibility of the person who is doing the prescribing. For doctors, the GMC again is quite clear about the responsibilities on doctors in that respect. Clearly, the people who have given us evidence have described situations where they have not felt that they have been listened to or involved or properly informed, but I would have to say from my clinical experience and from talking to other doctors whether the representatives are professional bodies or not. People want the best for their patients. No clinician wants a patient to suffer either because of a disease or because of a problem with the treatment for that disease. Doctors will work hard to try to make sure that they are delivering information in a way that is understandable and is a tolerable amount of information for people so that they can come to a true decision about what they want. People who have given submissions to us were not aware of the possible withdrawal and side effects because I would imagine that no one would agree to take a drug that will have that effect when they come off it. They just would not do it, so they were not told or it was not explained clearly enough to them. Would you accept that? I do not know what happened in individual conversations. I think that if you were put on any opiate painkiller, you would expect to be told that that painkiller is very strong and that when you stop it or when you come off it, we will need to do that carefully. I think that people have a general understanding about painkillers, probably about sleeping tablets and antidepressants. It is really the responsibility of the people prescribing to make sure that people are aware of potential side effects, including the withdrawal side effects. Should a member of the public want to find out more about that, there is a leaflet, for example, about coming off antidepressants on the Royal College of Psychiatry website. There is information on NHS Inforum that gives quite a lot of detail for people with medication problems and coming off medicines, but people need to know that that information is there. That is good clinical practice. As is described by the GMC, the relationship that a clinician has with their patient in how they are mutually following a course of action to the betterment of that patient's situation. There clearly is a problem when, and that would presumably only be a small percentage of people who have experienced severe life-limiting side effects and it is happening so that the system is not perfect. No system is going to be perfect. I would accept that. I think that the life-limiting consequences are very rare. If a person had on-going major severe difficulties as a consequence, then support is available to help with that. That is another case where statistics would be useful to find out exactly how many, or to get an idea of how many people were suffering these severe symptoms. Again, it would be difficult to set a threshold for that. As I say, we know that discontinuation reactions are very common, but the issue is when is that something that is self-limiting and that people will manage through good communication with the prescriber. When do we have an unusual situation where more help is needed? It is difficult, because where would you draw the line across that spectrum of experience? Can I ask the minister on the 10-year mental health strategy that she outlined at the beginning, you mentioned new models of care. Could you expand on what that might be within the strategy? In terms of the strategy, it is making sure that people have the range of therapies available to them. As we have talked about in the previous petition, immediately being put on anti-depressions, but following the discussion with the GP, there will be a range of therapies, including psychological therapies, might be computerised cognitive behaviour therapy. It might include exercise, because there is a correlation between exercise and depression. I do not know if you have spoken to the Scottish Recovery Network, but it has a range of treatments and interventions that are useful in terms of recovery from mental illness. It is about making sure that all the different combinations of treatments are available to more people who are coming forward with mental illness. A warning that we have to stop in terms of the roles of the department by 2022, I would like the question to finish by half past. We can just keep a focus in that, make sure that we cover all the areas. I am the only one who has been stirring from it so far. I want to stay with the strategy, and I wonder if you could explain how it relates to the delivery of the national performance framework and the mental wellbeing indicator. I would highlight that what we have heard so far has sent me into a bit of mental confusion, because you stated that the 2014 review showed that the quality of prescribing has improved. You were moving to longer, higher doses, and there was consistent evidence of under-treatment. You said that the use of anti-depressants is a dynamic process, and that no evidence that having greater access to psychological therapies will reduce pharmacological prescribing. You have just been talking about the importance of having alternatives and moving it forward. I wonder whether you could explain where the strategy is actually going and what it is that you are trying to achieve there, because it seems to be a contradiction in the statements that you have made so far. As we discussed earlier, the short-life working group that John Chaird did come to the conclusion that various articles and journals have come to the conclusion that, in order to treat depression in certain types of mental illness, it is better to have a higher dosage for longer—I am not the clinician here—but that we know that medical prescribing in conjunction with other therapies may have a better outcome, so we have to make sure, as Scottish Government, that those alternatives are available. If I understand you correctly, you are suggesting that non-pharmalogical options should be combined with prescribing, so you do not see the strategy as moving towards reducing prescribing. That is not for a strategy to have. That is a clinical decision, so that would be to the clinicians to answer it, given their knowledge. It was my predecessor that chaired the expert group, rather than myself. What we are saying is that we want people to get the treatment that they need for their condition. As I explained in the previous evidence, the reason that my predecessor set up that expert group and wrote the report that was published was because of a concern about rising prescriptions, but also because we were in that changeover from a heat target, which was about prescribing of antidepressants to a heat target, which was about psychological therapy delivery. There was a question at the time, would the increase of psychological therapies mean that there would be a reduction in antidepressant use? The available evidence that that group found from a variety of sources, which are cited in the paper, did not support that. What that implied was that if you treat a condition like depression better, there will be more people who have medication, because medication works for some types of depression. There will be more psychological therapy, because psychological therapy, cognitive behavioural therapy, has a strong evidence base for treating depression. You should have more social therapies and social support, because again we know that that improves. All of the things go hand in hand, that improving access and improving treatment is not one thing that means that you get less of another. In actual fact, you get an uplifting of all of it together. In talking about adults presenting with depression in the generality—again, a GP—before they reach for a prescription pad, they are going to be thinking about the social environment, the occupational environment, the family environment and what that person can do, for example, with sport or with reducing their alcohol consumption, that would improve their mood if alcohol was problematic. Before they even started thinking about might you want to go and talk to somebody about this, because we have the resources available for you. Before they might say to somebody, I think that you need to go on an antidepressant, and the only situation where that would really be trumped would be, for example, in specialist care. If I had a referral from a GP of Sunday with depression who was not eating, not drinking, actively suicidal and psychotic, then I would be saying that this person needs to go on medicine now, because life medicines in some situations are life-saving. What then looking at the mental health strategy, what do you perceive it as saying in regard to the physical wellbeing of people with mental health disorders that are put on antidepressants, for example? Was any consideration given to that link about the physical wellbeing of people? Absolutely. One of the key threads through the whole of the mental health strategy is that doctors and others should look at the whole person as the mental health as a result of a physical condition that is not being treated or is the physical condition a result of having a mental health condition. We know that people with mental health conditions are likely to have less longevity, 15 to 20 years, and that is an inequality, a health inequality that we must address. That is clearly one of the reasons for that thread running through the mental health strategy. It is about doctors and others having the time and the space and, hopefully, the new GP contract will give them that to make sure that they can address and look at the person as a whole. In terms of those people who have been on antidepressants and who are experiencing some problems when it comes to withdrawing, we have had some suggestions that tests such as or spec scans of the brain can assist with that. Can you tell us, as a committee, anything about that? I am not aware of any published evidence that brain scanning has any therapeutic effect in relation to medication withdrawal. Do you have any options at all about how to manage withdrawal or recommendations about what should be done around those issues? If people are going to be on those drugs and the recommendations that they should be on them for longer and on higher doses, is there anything in the strategy about how you then bring people off them again? What needs to be done with regard to that? The strategy is more high-level than telling doctors how to do things, but that is why Jenny mentioned the matrix, because the matrix was produced along with Education Scotland. That is a stepped guide to planning and delivering evidence-based psychological treatments. For example, there is a section on depression, and there is a section on ADDHD. We should not forget that, with each medicine that you get, you get a leaflet telling you how to use it and the dosage and what to expect of that. Do you have anything on the basis of reading this? Maybe a lot of people do not read them, but I have had cause to read things in relation to some anti-depressants. Those things are available, and NES has produced a booklet for the general public, which is psychological therapies in Scotland information for service users and carers. The matrix will set out the therapies, but, in terms of anti-depressants, at stages, the general public will have a review consultation with the patient. If there is a decision to take a person off that, that will be done with the patient in conjunction with whoever the prescriber has been. The committee is aware that the BMA clearly recognises that there is an issue with prescribed drug dependence, as it is called for a number of policy changes, including a national 24-hour helpline. The Scottish Government has stated in its written submission that, although there is merit in such a helpline, resources to help people with addictions have already been allocated. What engagement has the Scottish Government had with the BMA in relation to the establishment of a helpline, and what services are currently in place to support people with addiction to prescribed medication? We are aware of the BMA's call for a helpline, but, in discussing this petition, we would like to strongly indicate that the best person to help with the withdrawal from anti-depressants is the person who prescribed them in the first place. They know the clinical history of the person who has been on the drugs. However, that said, if people want to seek other advice, NHS 24 and NHS Inform operate within Scotland, and community pharmacies are also in a position to give advice, you have been in touch with NHS 24 specifically about that. As I said, the problematic withdrawal is best managed by the day-to-day services, rather than on a helpline where a person does not know the history of the person. That would be the strong recommendation that we make. Nevertheless, John Smith had a conversation with NHS 24. We have obviously seen the BMA's evidence to the committee, and we are aware of the work of the all-party group in Westminster. The BMA has written to them with quite a detailed letter that is in response to the Department of Health's proposal that telephonic support should be through their 111 NHS telephone service. The BMA's comments about the English 111 service and the English NHS choices website and information on that have been read with interest. I have discussed with colleagues in the Department of Health and I have spoken to NHS 24 in Scotland to ask what would be the response now in Scotland in the situation in which somebody who is struggling with a medication or coming off that medication really of any sort phoned them or contacted them for help. NHS 24 has said that they receive those calls, that they have a nursing telephonic service, that they have material on the NHS informed website and that they also, in NHS 24, have a pharmacy in NHS 24 to give a higher level of advice. At the moment, what they were saying is that beyond that call that is made, the advice that they would give a Scott phoning up would be, as the minister said, the first and foremost to discuss this with the prescriber of the original medicine and to seek advice from a pharmacy, if needs be, from a community pharmacy, if they wished, or, as I said earlier, inside a primary care team from the pharmacy supporting the primary care centre. Have you had any discussions with the BMA to that effect? We haven't spoken directly to the BMA. I tried to contact the Scottish Secretary this week who's on annual leave but haven't spoken to them. Attempts have been made. The Royal College of Psychiatrists recognise this issue and they have a leaflet on the website coming off antidepressants. If I could turn to or go back to the issue of sign guidance, the written submission from the Scottish Government makes reference to alternatives to medication as referenced in the sign guidelines. However, the petitioner has stated that, waiting times for availability of non-pharmacological treatment make a mockery of the application of the existing sign guidance. How would you respond to those concerns? We recognise that in the mental health strategy. Just a couple of months ago, I went to NHS 24 and I've given them an extra £500 million to develop their online services, including computerised cognitive behaviour therapy. We are aware that, for some people, certainly not all, but using online services is a preference that they have. We've got to make sure that they are more widely known and available. NHS 24 indeed has an on-going counselling service as part of their overall service over the telephone, which many people have found extremely helpful. There will be a further expansion of the services online, including the funding packages that we have in terms of the mental health strategy in order to develop and enhance the supply and training of the workforce in developing evidence-based therapies. If I could move on to one other issue that has come up in a number of submissions, on off-label prescribing of medication. I understand that that means medications that are being described to treat symptoms or conditions that are outside the terms of the licence of that medication. I'm curious as to whether you recognise that issue and if so, do you consider that there are any actions that the Scottish Government should take if that is the case? Licensing in the United Kingdom is through the Medicines Regulatory Council. The decisions that they make then translate into the information in the British national formulary, which is the UK-wide go-to book for prescribers that says that the medicine that you would use at this drug for those conditions and not for those conditions and give you information about that. The best practice for clinicians is that they follow the British national formulary and licensing arrangements. The research is sometimes behind the curve in terms of finding out or knowing what a medicine might be able to be worked for. The reason for that is that generally the trials that are done on medications require huge numbers of people and to be valid trials need to really compare the drug with a placebo or treatment as usual. There are clinical situations in which it is simply not possible, either because of numbers or because of other issues, to be able to do research. A good example of that would be anti-depressant use in children. Because anti-depressants are prescribed so seldom to children, and currently we have tens, 20s of anti-depressants that we use, that trying to do a randomised controlled trial where we randomly associated a child with depression to a medication versus a placebo or a different treatment would be something that we wouldn't get the numbers required to be able to know whether it was a true finding or not. Indeed, there would be huge consent and ethical issues in doing that. As medications become more widely used, academic centres and experts may well choose to try these medicines out in situations that they are not licenced for and that there is not an evidence base that shows that it works for that condition. However, anecdotally, experts and academics might find evidence that those treatments work. Specialists, who are often managing complex situations, would then apply their expertise to think, how can I best help my patient? They would, of course, use things from a licensing background, medications that are first-line British national formulary, but if those medicines don't work, then there are situations where clinicians, with the agreement of the person, would say, look, this medicine isn't licenced for your condition, but there is evidence that it might help. Do you want to try this or not? Best practice would mean that that conversation would be open and transparent. Any prescriber who was then going to be using a medicine for an off-license indication would make that very clear to the person who was taking that treatment and should record why they are doing that in the case notes. That is an unusual situation, but it is far from rare. That is a very interesting response, given another petition that we have with regard to thyroid replacement treatment. That is something that we can look at in the future. My question relates to one that was touched on earlier by Dr Mitchell in answer to Michelle Ballantyne. The petitioner refers to what she calls catch 22 situation, where she says that doctors sometimes feel under pressure to prescribe drugs where someone is maybe contemplating suicide, and they are doing that on the basis that non-pharmological treatments cannot be immediately accessed. There is a perception that prescribing medication is more defensible than not. In other words, they are taking a safe route for that patient. Can you expand on that, your concerns? I recognise that. As a doctor, if you had a patient who you felt was actively suicidal in front of you, you would seek emergency specialist help for that. You would not think that somebody is actively suicidal—I will give them an antidepressant and put them out the door. Sorry, I thought that that is what you responded earlier to Michelle Ballantyne. You said that in the case where it appeared to be so serious, you would prescribe. I thought that is what you did. I would do that as a consultant psychiatrist, and that might be a situation in which I had somebody who was an inpatient in a psychiatric hospital. I think that somebody's safety comes first, trumps everything. I think that a situation that is described of a patient who is not eating, who is not drinking, whose life is at an immediate risk—yes, I would prescribe a medication for them, but I would be doing that as an inpatient for that person. I would be admitting them, and I would be giving them that medicine in a controlled and safe place. If you put yourself in the position of a GP and you have a patient that comes to you and says, I can't take any more, I'm feeling suicidal, you would not prescribe or you would just send posts to them? I'm not a GP, but my experience is that a GP would be contacting the local community mental health team and saying, I need this person seen now, and a community mental health team would be responding to that. Are you confident that the response would be quick enough and there wouldn't be a delay in that? That is the nature of community mental health teams. There is a lot of work that is done that is routine and scheduled, but a great deal of the work is considered to be urgent or emergency. Usually, community mental health teams work on the system of emergency referrals, means drop everything and deal with it right now, and urgent means it needs to be seen within 24 hours. More often than not, referral forums from GPs will explicitly say on it what level of intervention they are seeking. In a situation where a patient was with a GP saying that they were actively suicidal, no community mental health team would be waiting for a typed up referral letter. You would deal with the practicalities of it there and then. It would be nice to get some information, but you deal with the risk in the moment. Just to summarise, you don't believe that GPs are using it as a kind of safe option for them and for the patient to say, well, just in case, I'll prescribe in case this is going to get out of hand or whatever. You don't think that that happens generally. No, I don't really recognise that. I mean, I think you could actually argue it the other way round if you were a GP, that if you had somebody who was in and they were sort of you were concerning you about their level of suicidality and you were asking them, are you thinking of ending your life? And they were saying, no, I'm not. And this is quite a common situation and you would be thinking, do I trust what they're saying? You know, your gut feeling is actually this person is high risk, even although they're saying, no, doctor, I'm not suicidal and I'm not thinking of ending my life. That actually your concern about that might be that, well, for you just to say, well, they're not actively suicidal, I'll give you an antidepressant in a way you go. That really might lead to greater criticism than not prescribing. Okay, and two things that I would like to mention in relation to this. One is the distress brief intervention pilots that were running in six areas across Scotland so that there is immediate access to councillors for anybody who presents to A&E or have become known to the police or are in police custody, that there is immediate access within 24 hours to a councillor in those situations. The pilots just started in October. There's already some good feedback when I went to Lanarkshire to see what they're doing there. And the other thing is that the commitment for an extra 800 mental health workers are precisely in those areas so that we can make sure that, even out of hours, obviously, if somebody presents that, there is immediate help. Thanks very much. One last point, I suppose, that I would want to make. You spoke earlier, minister, about any drugs come with a little leaflet. I wonder if you accept that the little leaflet has no authority in comparison with the authority of the GP. Should the GP almost humanise what that little leaflet says so that people do really know what the consequences are? Absolutely. I think that we all know when we go to the GP what, if the doctor prescribes something, they usually tell you what to expect from the prescription, but I accept that there may be cases where that's not happening. Again, just for clarity, I wondered if you could comment with you, accept the statements that were given to us in evidence. 10 per cent of the population of Scotland takes an anti-depressant on prescription. Of those, between 80 and 90 per cent are on treatment for more than a year, many for over a decade. I would ask the question, do you think that that is because it is good treatment or because dependence is occurring? The second statement, at present rates of anti-depressant use among adolescents in Scotland, especially among women, is rocketing. Those drugs are on their way to being the most commonly used prescription drugs by Scottish adolescents. Do you recognise, would you agree or disagree with those statements? I don't recognise much of that. I think that certainly anti-depressants are commonly used medications. The guidance, the evidence base for treating depression is that if you go on an anti-depressant and it works for you and it's your first episode of depression, you should stay on it six months before you come off it. If you have a recurrence, you should stay on it two years. That's internationally accepted and based on evidence. So that there is effective treatment of people with depression, then if people respond to those drugs, they should be on them for those sorts of timescales. They are not medicines that are effective for a month or two months. As I said, the study that was done on Scottish prescribing of anti-depressants, which I was granted as six years old now, did indicate that the longer periods of time, which were the appropriate lengths of time, were being more applied by GPs because it was new prescriptions of anti-depressants that were being examined and what happened to those new prescriptions. I thank the minister and our officials very much for that. I appreciate that you have done a double shift today. I think that that has been really useful. I suppose that we would want to emphasise to anyone watching, we recognise the importance of mental health, that there has been huge progress, but the challenge that the petitioners are presenting is that there are issues within that that we need to address. I am very grateful for your attendance day. I am happy for you to remain for the past 10 minutes while we are having a conversation about how we take that forward, but I am also equally happy if you have other commitments that you need to meet. We now need to think again about the petition. I am assuming that we do not want to close it, but I would be interested in members' views on how we take that forward too. I think that we obviously need to reflect on the evidence that we have heard today, but I would be keen to find out what we have heard from Dr Mitchell. I would be keen to hear what the BME's current position is with regard to the helpline. Clearly, Dr Mitchell explained that NHS 24 discussions have highlighted that a service is there, but I would still be keen to hear the BME's response. The most effective thing to do is to get the clerks to reflect on the evidence where we highlighted things and we want more information on. There is quite a lot around the last points that were made by Michelle about prevalence of antidepressants and the length of time that people are on. If the contention of the petitioner is that people are on and they are not supported, that would be something that we would want to explore further. Of course, we would hope that the petitioner would again reflect on the evidence and, if she so chose, to provide more evidence to us. Is that acceptable, Lizeth Nales? I think that the important thing is to get the petitioner's response and then to pick out the individual things that came up during evidence that we asked for, and that would be useful. I do not know much about this, but in terms of GPs and hearing from GPs, whether what we are hearing from both sides, whether it is a gulf in the evidence and propositions, what their experience of it is, we need to reflect on how we can do that. The extent to which there is a pressure and whether we have spoken about this in another context altogether, which is defence of practice, where people feel for the want of something guaranteed that they would do this, that would be perfectly understandable. It may be again that we would want to take that, but I think that underneath all of this we recognise the challenges that health petitioners have in terms of pressure and managing their time and so on. I disconnect that many GPs feel now that quite often when they are seeing a patient, trying to look at them holistically is now much more difficult than it was, because they used to know them in the context of the society in which they lived and worked. Now quite often they only see them as a patient 10 minutes. They do not know the family, they do not know the wider circumstances, they do not know how they live, so it has become a much more complicated process. I think that those are useful, but if we can ask the clats to bring that together, and obviously any further responses from the petitioners would be welcome in informing our further action. Again, thank the minister and officials. I am very much appreciated. All those who have responded to the petition and on that basis close the meeting.