Medication and Talk Therapy: Discussion

Chairman

I welcome to the meeting Mr. Ray Henry and Ms Lisa Molloy from the Irish Association for Counselling and Psychotherapy, and Dr. David Murphy from the University of Nottingham. From the Irish College of General Practitioners, ICGP, I welcome Dr. John O'Brien, vice president and incoming president, Dr. Brendan O'Shea, director, postgraduate resource centre, and Dr. Brian Osborne, assistant director, postgraduate resource centre, with special responsibility for mental health. On behalf of the committee I thank the representatives for their attendance here today. The format of the meeting is that they will be invited to make a brief opening statement, which will be followed by questions and answers.

Before we begin, I draw witnesses' attention to the situation in regard to privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.

I remind members and witnesses to turn of their mobile telephones. That is very important because they interfere with the sound system and make it difficult for parliamentary reporters to report the meeting and television coverage and web streaming will be adversely affected. I would be very grateful if they would switch their phones to airplane mode.

I wish to advise witnesses that any submission or opening statement made to the committee will be published on the committee website after this meeting. I invite the representatives to make their opening statements. We will start with Mr. Ray Henry.

Mr. Ray Henry

The Irish Association for Counselling and Psychotherapy, IACP, was established in 1981, to identify, develop and maintain standards of excellence in counselling and psychotherapy. Our work promotes best practice and development of the profession as well as the protection of the public. We are the largest counselling and psychotherapy association in Ireland with over 4,500 members. IACP provides an important link between those who seek services and those who provide services. Our vision is one where counselling and psychotherapy are an integral part of health care provision.

The IACP would like to thank the Chairman and members of the Joint Committee on the Future of Mental Health Care for the invitation to reflect on the development of talking therapies as they relate to mental health.

Let me introduce the team who accompany me, on my left is Ms Lisa Molloy, chief executive officer of IACP, and Professor David Murphy, from the University of Nottingham. Sitting behind me are the IACP representatives, Mr. Gary Culliton, communications and media officer, Ms Iwona Blasi, development and innovation manager, and Ms Bernie Hackett, vice chairman.

Let me hand over to our chief executive officer, Ms Lisa Molloy, who together with Professor Murphy, will bring the committee through our opening statement.

Ms Lisa Molloy

Good afternoon Chairman and members and the delegates from the Irish College of General Practitioners, ICGP. The IACP would like to acknowledge the work of the committee to date and welcomes and supports the increased focus on mental health and well-being. We fully endorse the integration of mental health services into the primary care sector and our accredited counsellors and psychotherapists have a key role to play in ensuring the success of this initiative.

One of the strongest messages to come out of the consultation that fed into A Vision for Change was that people with poor mental health wanted alternatives to medication, including access to counselling and psychotherapy. A Vision for Change further highlighted the under-development of our mental health services. One rural survey found that although one in three GP adult attendees presented with psychological distress, just 11% were in receipt of mental health services. According to the HSE, 54% of GPs in the north-east region said they would have preferred to have counselling available at their GP practice. The region identified a gap in availability of counselling, with many GPs reporting that they did not refer patients for counselling because of a lack of relevant counselling services, waiting lists and cost. A Vision for Change recommends the provision of an integrated, recovery focused care delivered in the community, primarily by multidisciplinary teams. To date there has been slow progress in the implementation of this policy.

In this regard the Irish Association for Counselling and Psychotherapy, IACP, proposes that the State adopt a programme for the treatment of mild to moderate depression broadly modelled on the very successful initiative known as Counselling for Depression, CfD, in Britain. The committee members will have received a separate briefing which sets out the detail of this programme. In summary, this programme trains counsellors to provide a depression specific therapy for individual clients within the National Health Service, NHS. Professor David Murphy who joins us from Nottingham University is an expert in this area and will speak in more detail to the committee about the success of this programme in Britain.

Our UK equivalent, the British Association for Counselling and Psychotherapy, BACP, developed the programme at the request of the NHS following the introduction in Britain of the national improving access to psychological therapies, IAPT programme. This programme aims to make therapy free on the NHS for low-intensity mental illness, where previously medication was almost the only option. The Irish Association for Counselling and Psychotherapy, IACP, is proposing that an initiative similar to counselling for depression, CfD, be developed in Ireland and that the IACP would partner with the HSE in developing a tailor-made solution for the Irish system. The IACP strongly believes that there is a need for greater availability of evidence-based talking therapies for people with common mental health conditions, that are accessible via primary care services and general practice. Our members are ideally placed to deliver such evidence based therapies which will serve to fill a clearly identified gap.

IACP also believes that access to counselling and psychotherapy services should be available on a universal basis to all those in need of such a service. One way to increase accessibility for the generality of the people in Ireland is to make the services more affordable. As an interim measure we request that serious consideration be given to expanding the existing supports which provide tax relief for medical expenses and also the range of health related benefits that are provided for under the PRSI system, and that this be taken into consideration as part of the wider reform of the PRSI system. Reform of the PRSI system to include options such as counselling and psychotherapy would support mental health services as well as physical health services.

I now hand over to Professor David Murphy who will speak about the counselling for depression, CfD, initiative in the United Kingdom.

Dr. David Murphy

Chairman, I am Dr. David Murphy, but I seem to have managed to get promoted. For the record I am an associate professor.

Chairman

We do that quite a bit here. Senators are suddenly Deputies.

Dr. David Murphy

I thank the Chairman and members for inviting me to speak about this particular approach to therapy.

I am part of the team of people in England who have been training therapists in a programme called improving access to psychological therapies, IAPT, within the NHS. This initiative was set to roll out evidence-based therapies in order to make it possible for people to access a range of talking therapy, free at the point of access. The particular type of therapy that I am familiar with and of which we have been part of the roll out is based on a person centred and an experiential approach to therapy. It is recognised as a high intensity therapy so that means one can work with people who have both mild and also moderate and sometimes severe depression. The therapies recommended by IAPT is approved by the NHS and was supported and developed by the British Association for Counselling Psychotherapy in conjunction with IAPT.

The therapy is manualised, so what this means is that a series of competencies have been drawn down from a framework, including drawing out from a series of randomised controlled trials of either person-centred therapy, experiential therapy and comparing that with CBT or with controls or against each. The parts of those therapies that were considered to be effective have then been put together into this manual and a training programme has been developed. This means that alongside CBT, people are able to access a choice of therapies and this has been at the heart of and roll out of IAPT.

The therapy is provided by qualified and trained therapists who then engage in this additional training in the manual. The manual is about bringing together the competencies and upskilling a workforce that already exists that might well be underemployed or underutilised within the field of psychological therapies. The training is about six to nine months but it only involves five days of contact in a training institution, the remainder of the training takes place while working on the job. Once people are through the first five days they are ready to go and start delivering this type of therapy.

The training is about bringing people up to a certain level of competence and adherence in the manual and these competencies are drawn from generic, basic, specific, model specific and adaptions and some meta-competencies as well. It means there is a whole range of therapists who can be moved into this particular manualised form of therapy and start to deliver it quite soon. This type of therapy is what we consider and what we call a high intensity therapy. That means a large number of people are able to access it. It is recommended that they access this for up to 20 sessions - certainly at the most severe end, that should be available for them.

There is a range of benefits in having a number of therapies available other than the main therapy, cognitive behavioural therapy, which was the original large-scale roll-out within the IACP. The data that is taken from those therapies as they are applied in routine practice suggest there is virtually no difference in effectiveness between CBT and counselling for depression. There is a real opportunity to develop a pluralistic field of therapies that are effective and evidence based. Clients and patients in the health service will benefit from a range of therapies. Services benefit from having a range of therapies; patients will stay in therapy if they have a choice of therapy, because they will find the right one. It saves on general practitioners if clients or patients can access the right type of therapy for them, rather than having only one type of therapy available to all people. Generally, as people become enhanced in their well-being through having a range of different talking therapies, it has a wider benefit for families, societies, communities - everyone benefits.

Chairman

I thank Dr. Murphy. Dr. Brian Osborne is going to speak on behalf of the Irish College of General Practitioners, ICGP.

Dr. Brian Osborne

I thank the Chair and the committee for the invitation to attend today's meeting.

The Irish College General Practitioners, ICGP, is the professional body for general practice in Ireland. The college's primary aim is to serve the patient and the general practitioner by encouraging and maintaining the highest standards of general medical practice. It is the representative organisation on education, training and standards in general practice in Ireland. I will invite my colleagues to introduce themselves briefly.

Dr. John O'Brien

I am the ICGP vice president and a practising GP based in Castleknock.

Dr. Brendan O'Shea

I am the director of the postgraduate resource centre, PRC, in the Irish College of General Practitioners. I am also a general practitioner based in County Kildare.

Dr. Brian Osborne

I am a GP in Galway and assistant director of the PRC.

General practice teams deliver continuing personal medical care, provided by generalist health care professionals, including GPs, practice nurses, and a growing strand of practice based allied health professionals in the fields of psychology, counselling and family therapy. When well supported and adequately resourced, GP teams can engage systematically in activities known to prevent and care for a range of mental health issues and medical conditions. This is achieved through the use of brief interventions in respect of alcohol and tobacco, lifestyle interventions in the context of exercise and stress management as well as delivering ongoing community based care.

Elsewhere in the primary care domain, the counselling in primary care service, CIPC, provides off-site counselling for people who are significantly stressed, but this only applies for people who are eligible under the primary care reimbursement scheme, PCRS, or medical card scheme. General practitioners' ability to refer to voluntary and-or private counselling services or specific services such as local addiction counselling varies depending on local circumstances and, crucially, on the ability of the individual to pay. The ICGP is of the view that there is a major lack of capacity in this area of service provision. On a system-wide basis, the volume of service provided by the CIPC is inadequate, and a majority of the population are ineligible for CIPC services. The contribution of voluntary agencies is increasingly evident and important to GPs and people who use these services.

When a person attends general practice with a mental health issue, several approaches are explored. The GP will engage in initial evaluation and diagnosis. People mostly present with mild to moderate anxiety and depression. In many instances, an opportunity for reflection, shared formulation of the issues, lifestyle advice, a cognitive approach grounded in a pre-existing understanding of the individual and their particular circumstances, signposting to relevant additional resources, and follow up at the practice level will enable many people to resolve the problems they experience. This is particularly the case when the reflection is undertaken with a GP who has a deep and long-term knowledge of the individual, their circumstances and their past medical history.

Prevention, earlier diagnosis and management of problem use of alcohol and recreational drugs, or the presence of signs and symptoms of a range of psychiatric conditions including postpartum depression, self-harming, addictions, adjustment reaction to life events, abnormal grief reactions, obsessive compulsive disorder, OCD, borderline personality disorder, chronic anxiety disorder, or clinically significant depression will result in a more formal practice-based approach, the management of which will reflect the circumstances of the practice, and the needs of the individual.

The earliest diagnosis of severe spectrum or complex psychiatric diagnoses is also undertaken by GPs, including psychoses, bipolar affective disorder and high-risk suicidality. These activities are undertaken across the full spectrum of people who attend, including those from deprived and affluent backgrounds, the young and the old. At the severe or persistent end of the spectrum of clinical presentations, treatment will extend to pharmacotherapy and-or referral to psychiatry.

When practices are operating in a dearth of resourcing, opportunities and time to engage with the people and families concerned are fewer. Less can be done in terms of prevention and earlier intervention, with increased pressure on GPs to treat people pharmacologically and to refer, regarding which many GPs are unhappy. Payment is a known additional barrier to optimal treatment for many citizens. It is a major cause of dissatisfaction where pressure of work is such that GPs are unable to spend adequate time with patients who have significant mental health issues. Onward referral to secondary care is challenging for people.

The impact of financial emergency measures in the public interest, FEMPI, cuts and sustained failure to deliver a contract for general practice has caused many professionally important activities in general practice to come under pressure as a result of competing and conflicting pressures of higher professional values set against relentless business pressures. This conflict is a major deterrent to younger general practitioners establishing in practice and a cause of burnout among older colleagues, contributing directly to medical emigration and leaving people without essential services. Our health system would appear to value machines, hospitals, and drugs over talk therapy, time to care and social support.

Being able to manage problems in the general practice setting has the added advantage of markedly reduced or an absence of stigma. GPs and the people who attend them for care of mental health issues both prefer to avoid the use of pharmacotherapy where possible; while it is quicker and easier to prescribe medication, in many instances it is neither the best nor the first thing to do.

I will hand over to my colleague, Dr. O'Brien.

Dr. John O'Brien

Clear and honest communication around resourcing for mental health care is essential. It is the view of the ICGP that there is an absolute requirement to increase capacity in GP-led health care, including mental health care, within the Irish health system. Three important observations are particularly relevant in this context. First, the numbers of GPs and practice nurses per capita in the Irish health system are low by international standards. The number of GPs per 100,000 population in Ireland is in the order of 64, compared to 90 to 100 in Canada, Scotland and England. There are approximately 3,700 GPs and 1,800 practice nurses working in our system, and these numbers need to be urgently increased towards 5,000 of each as we plan for a population of 5 million in the intermediate term.

Second, the proportion of total health spending on primary care in Ireland is strikingly low compared to developed economies including Canada, Australia, Scandinavian health systems and the NHS in the UK. In those health systems, about 8% to 11% of total health spending is directed into primary care, whereas in Ireland the proportion is 4%.

Third, the overall spend on health care in Ireland is in the order of €20 billion to €22 billion, and the per capita spend here is high by international standards. It is the view of the ICGP that within the Irish health system, we are historically spending excessively on hospital based care, administrative overheads, technological medicine, specialised care and pharmacological therapies. Conversely, we are spending too little on primary care and on holistic talking therapies.

Irish general practice is leading the Irish health system in the use of electronic medical records. Despite low levels of funding for primary care, most Irish citizens can access a GP on demand, or within a day or two.

Most Irish people still believe they have their own GP and have an appreciation of personal care. The ICGP, Irish College of General Practitioners, however, is of the view that better and higher volumes of care could be provided by increasing capacity in GP-led care. Recruitment and retention of more GPs would enable higher volumes and better quality of care in communities, including mental health, enabling better prevention, earlier diagnosis and better community-based care.

Irish general practices are slowly getting larger. The proportion of singlehanded GPs is now at 18%. As more GPs work in practices with three, four, or more GPs, these larger practices could usefully incorporate an on-site strand of talk therapy, delivered by GPs, practice nurses and visiting allied professionals such as counselling psychotherapists. Trend-setting practices are actively exploring the use of relevant innovative care including telemedicine, mental health and exercise apps, as well as social prescribing.

While turnover in general practice teams is low with good continuity of care, it is not the case in public psychiatry care where high levels of turnover are understood to be a problem. This creates special difficulties in psychiatry where communication and continuity are particularly important.

I want to take a clinical case scenario to highlight how general practice might run in mental health care provision. Mary is depressed. She attends her GP and she frets in a busy waiting room. She sits with an agitated man who explains he has diabetes, a mother and a baby with a cough, a gentleman with pain, as well as two other women, one of whom is clearly pregnant. Mary is anxious but it helps that she is attending her own GP, hers since she was a child. She likes him because she feels known and heard. Her GP is careful with her. Mary explains she is tired all the time and gets headaches. He listens as she describes that the headaches occur most days, she feels exhausted, cannot do things with the children and feels guilty all the time. The GP asks what she thinks might be going on. She is not fully sure but, on reflection, they both agree things are not that good in her relationship. She has three children under ten, she works outside the home and also visits her mother with whom she has a complicated relationship, who is ill and needs her attention. She knows she has increased the amount she is drinking but finds the only nights she gets a few hours of decent sleep are when she has had three or four glasses of wine, which is now happening four or five nights per week. She is worried she has a serious illness, maybe a brain tumour. How would the children cope? She is tearful and needs time to compose herself as she tells her story.

The GP evaluates the headache, does a neurological examination and measures blood pressure. She says the pleasure has gone out of her life, she feels mostly hopeless and worthless but is not suicidal. Blood pressure and examination are normal while mental state examination is consistent with mild depression and anxiety. These findings are shared and, together, they make a plan. She will reflect on the main causes of exhaustion, undertakes to get back to Pilates and go for a 30-minute walk most days. She thinks her brother can visit her mother for the next three to four weeks. She undertakes to reduce alcohol to one night per week. Bloods are arranged to check for hypothyroidism, anaemia, diabetes, liver enzymes and a menopause profile. A review is planned for two to three weeks. The GP outlines what might help such as exercise, mindfulness - the GP suggests a mindfulness app - counselling and also medication. The GP explains that medication is neither good nor bad but just one of the tools for getting out of a depression. She is nervous of medication, fearing addiction or that it may alter her personality. The GP is sure she will get back on top, having previously assisted when she had a moderate depression after the birth of her second child. This all takes between 22 and 30 minutes. It is a long consultation and this is where the pressure of time plays out.

Dr. Brendan O'Shea

We are keen to reflect on realising the potential of GP-led teams. If additional funding is made available, as per the Sláintecare report, how will this be applied and what will be achieved with it in terms of care for people with mental health problems in communities? We are not short of good policy but are incredibly bad at implementing it.

An important aspect of applying this funding is to closely consider distributing additional funding on a deprivation weighted model, which, given the level of detailed knowledge available on Health Atlas Ireland, can now be factored in with adequate detail. Additional funding should be used to increase the numbers of GPs along with appropriate supports, including practice nurses and allied health professionals in counselling and family therapy. This will enable the targeted organic growth of GP teams where they are most needed. In turn, it will enable greater provision of talk therapy services and related supports in the areas of prevention, earlier detection and better follow-up care. These are all areas which get lost in the tightness of the system which we are currently trying to operate.

In the intermediate term, this will result in improved capacity at general practice and community levels to address volumes of activity in prevention, including tobacco use, alcohol, exercise and stress management. For example, people often self-medicate with alcohol and cannabis. Their eating habits deteriorate under the stressful situations in which they find themselves. Having a greater capacity in the general practice setting will allow us to address these and will be effective in the primary prevention of a range of mental and physical health problems. Additional funding will enable GPs to incorporate a broader mix of allied health professionals. This, together with more GPs, will enable a greater proportion of mental health care to be delivered in the community.

Second, building these capacities will result in more systematic activity in the management of anxiety, depression and pain in chronic disease management. We sometimes forget this. There is another part of the jigsaw puzzle where we have a large number of older people with complex multimorbidities. We increasingly understand that the mental health aspect of these conditions is important to address. If these are ameliorated, it will lead to better outcomes for those involved. People with heart failure and diabetes who are anxious or depressed have a poorer quality of life and survival, as well as higher costs when their anxiety and depression are not properly cared for.

The ICGP supports the policy elaborated in the Sláintecare report and in the recent HSE report, A Future Together. We have good policies but we need to implement them. Both of these policies underpin a shift to the left in terms of a greater proportion of health spending in primary care. In addition to building capacity in mainstream GP-delivered services, such a shift will enable the embedding of greater volumes of allied health professional care, as well as a more rapid translation of new modalities and new technologies relevant to mental health care, including telemedicine, social prescribing and evidence-based use of social media for improved care for the younger demographic.

The ICGP recognises the value and impact of the voluntary sector in the development and delivery of mental health services, as well as the importance of the work done for particular patient groups. It is the view of the ICGP that the financial emergency measures in the public interest cuts to the PCRS, primary care reimbursement service, funding model, together with a sustained failure to negotiate a new contract for general practice for 39 years, are both major impediments for the delivery of essential community-based mental health care for Irish citizens. If we can move on this, the ICGP and the GP-led part of the health care system can and will develop the necessary capacity and innovation which Irish citizens require to achieve better outcomes in both mental health and in the long-term care of frail complex individuals with comorbidities and associated mental health problems.

Through its main activities of training, research and postgraduate education, the ICGP is well placed and ready to enable capacity and innovation leading to more and better mental health care which can be delivered in communities. The emphasis will be on prevention, talk therapies and lifestyle modification, supporting greater availability and integration with allied health professionals and reduced reliance on pharmacotherapy and distant hospital and specialist services. We know what we need to do collectively. In the past, we have failed to do it. We are now at another threshold.

Chairman

In terms of this process, one of the main concerns is the over-prescribing of medications, which is the reason we invited the Irish College of General Practitioners, ICGP, and the Irish Association for Counselling and Psychotherapy, IACP, here today. While the committee supports the need for expansion of primary care members will be focusing today on the over-prescribing of medications.

I welcome the witnesses. The witnesses from the Irish College of General Practitioners appeared before us last December so they already answered some questions for me on this issue. I have a number of questions for the Irish Association for Counselling and Psychotherapy. I am on an education curve in relation to this issue. What are the top three challenges facing the association in terms of its interactions with the HSE and the system? Dr. Murphy referred in his contribution to a package that is tailored towards depression which involves a myriad of therapies. Perhaps he would elaborate on that package, including whether it would be in addition to the traditional cognitive behavioural therapy. Does the association have data on recruitment shortfall in psychotherapy in respect of current vacancies as opposed to new positions? Does the association agree that there is too much dependency on medication and are people being prescribed medication because of a shortage in therapies? I would also welcome the association's views on the proposal to designate counsellors as psychotherapists and on the use of recovery methods such as the creative arts and music therapy, which I am currently studying?

On Dr. O'Shea's reference to the use of social media to interact with young people, perhaps he would elaborate on that point. I am a member of the Joint Committee on Children and Youth Affairs, at a meeting of which earlier this morning we discussed the dangers of social media for young people. I would be interested to hear from the ICGP how it believes it would benefit from social media interaction with young people.

Chairman

I forgot to mention that each member has seven minutes each for questions and answers.

Dr. David Murphy

I will respond to the Deputy's second question first if that is okay. The therapy I was referring to is person-centred experiential counselling for depression, which is available in England as part of a suite of therapies. It is only one approach but it is the one I am trained in and familiar with. I am advocating it on behalf of the manual because I think it is a particularly good approach for this type of problem in general practice. There are others but this is the one I am here to speak about. In terms of a recruitment shortfall, my understanding, through IACP, there is an under-worked workforce of counsellors who would be ready and able to participate in this particular training if it was available to them. This is the situation in England also. I think there is too much dependency on medication but I see that as a symptom of a lack of alternative options rather than necessarily the problem itself. Within the particular approach of person-centred experiential counselling for depression there is not the same kind of dependency on the use of a diagnosis as there might be in, say, a cognitive behavioural therapy in terms of specifically identifying a diagnosis and then working in a particular way for that particular problem. This particular type of therapy is much more adaptable. It is underpinned by a theory which is a unitary theory of distress, which it is possible to apply to a range of problems. In primary care, it is ideal because, as identified in the case study referenced, some people only have anxiety or depression. Often it is the cross-cutting processes which are more beneficial to work with.

Dr. John O'Brien

I will respond to the question on medication, which is particularly topical just now. There was an article on it recently in The Sunday Business Post, which I am sure everybody here has read. Essentially, the gist of that was that between 2006 and 2016 there was a two-to-threefold increase in the use of medication such as anti-depressants and sleep medications. This is a cause for concern but it must also be recognised that this is also a global trend. Across Europe there has been a 20% increase year-on-year in the use of these medications. It is worth pointing out that in that particular timeframe the population in this country increased by 500,000 people and there were an additional 500,000 people on medical cards. As everybody will be aware it was a very traumatic period for a lot of people in terms of unemployment, excessive personal debt and a public narrative of extreme pessimism and uncertainty. Like politicians, GPs see people day in, day out and we hear their stories. All this resulted in a great deal of anxiety and depression among people presenting to general practice. I am not making excuses; rather, I am putting a context on this.

Also, there have been very draconian cutbacks in health funding in this country, particularly in general practice. Funding to general practice is down 38%, which is an awful lot of resource to lose. Consequently, the net effect is that GPs have been attending more patients with fewer funds and a dearth of back up services because the hospitals services were also under considerable pressure. Consultation rates have increased and the times available to each patient have been constricted as a result. GPs have no desire to rely solely on medication and they do not do so but in circumstances where nothing is available they are sometimes forced into positions they would prefer were otherwise. This cannot be allowed to continue. It is bad for patients and it is a waste of public money. It is also demoralising for GPs. The provision of more GPs, more practice nurses and in-house counselling within general practice is badly needed.

The ICGP has worked on a number of projects with regard to reducing medication, including the reduction in benzodiazepine use, and up to 2012 had been able to demonstrate reductions in that regard but much of that reduction relates to legacy addictions which are very slow to respond to treatment and very hard to pull back. Also, as psychiatry prescribing passes through general practice it might look like the general practice is doing the prescribing but it is not because the general practitioner re-issues the psychiatry prescriptions. To that extent, some of what is happening is not in our control. Also, in tandem with the increase in the use of antidepressants across the Europe the suicide rate was falling.

There is not a right or a wrong answer to this question. There is no sweet point on which one can put one's finger, but such big increases would certainly be a cause for concern. Did Dr. O'Shea want to say something about this?

Dr. Brendan O'Shea

If the committee has time-----

Chairman

I ask Dr. O'Shea to be very brief.

Dr. Brendan O'Shea

I think we all get exercised about the use of medication. We often regard it as a failure of therapy, and perhaps it is. The science around it is a little difficult. There are two studies to which we might refer the committee. One, by Tom Fahey et al., concerns the use of antidepressant medication in Irish adolescents. The study ran from around 2010 to 2015. The authors noticed a decrease in the prescribing of antidepressants from in the order of 4.74 per 1,000 of population to 2.61. That is a significant decrease in antidepressant use in adolescents, and the paper is a good scientific study that relates to Ireland. Another question is how much antidepressants we are using in the population as a whole. There is an interesting comparative study entitled, Antidepressant Utilization and Suicide in Europe. These are two very important issues - how much drugs we are putting in and how much suicide we are having. The study looks at these two parameters across 26 countries, and it is evident from the study that suicide rates have begun to decrease while antidepressant usage rates have begun to increase. It is difficult to separate and tease this out, but one figure the authors of the study have is that one needs to treat in the order of 660 people with an antidepressant in order to prevent one suicide. We do not have a right answer to this question but we strongly concur with our colleagues in IACP about having more strands of talking therapy and that it should be diverse and in communities.

With the committee's indulgence, I wish to ask two further questions.

Chairman

We are three minutes over-----

It concerns social media and is for the GPs. It is important, and we had a long discussion about it this morning at the Joint Committee on Children and Youth Affairs. Dr. O'Shea mentioned social media and-----

Chairman

Will we come back to that? Let me just go through-----

It is only 30 seconds.

Chairman

It will take more than 30 seconds to answer the Deputy's question. I promise him, because I am a member of the committee as well-----

I have to go in 20 minutes.

Chairman

I will move on to Deputy Brassil.

I thank the witnesses for their presentations. I will try to go straight to my questions because time is very limited. We have before us what I would consider two very important organisations in the treatment of mental health. Is there good interaction between both organisations? Are there regular consultations, meetings, the kind of interaction one would hope for and expect between two such important organisations? If so, as a result, are there matching case studies, such as the example Dr. O'Brien gave, and does each organisation get opinions from the other side? I am interested to know the level of interaction there is.

Regarding the counselling for depression model that Dr. Murphy spoke of, has a costing been carried out on rolling it out in the Republic of Ireland? I am interested to know whether it is realistic or whether it is one of those things to which we aspire somewhere down the road? I have a further question for both organisations. What percentage of GP practices have counselling services? Is it a high or a low figure? They should be in every GP practice. If they are not, can we bring them about?

I have a question specifically for the IACP about registration, qualification and who is qualified and not qualified. I think many people call themselves counsellors, including me when I was a member of Kerry County Council. Is there a need for more stringent registration processes so that, for example, if a GP service refers someone, it is happy with the level to which they are referring? I would like to hear the witnesses' opinions on that issue.

Regarding the issue of referral without going through a psychiatrist, should the GPs be able to refer to a counsellor directly, or do they have to go through a psychiatrist now? Are some parts of the system hindering GPs from getting that consult done more directly?

Dr. O'Shea spoke about the use of drugs and headline programmes and what works and does not work. Is it his opinion that counselling should always be the first line, is there a need for medication or is it evaluated on a case-by-case basis? I have worked as a pharmacist for many years and seen people who have been on medication for many years and who function absolutely perfectly and live perfectly normal lives. Is that a better outcome than someone not on medication and not functioning? Does counselling work for everyone? Are we-----

Chairman

I must stop Deputy Brassil. He has asked millions of questions.

I was actually finished.

Chairman

I thank the Deputy. We have about three minutes left. I will ask Ms Lisa Molloy to respond first. I ask her to remember the time. Then I will move on to Dr. O'Shea. I ask him also to remember the time when responding to Deputy Brassil.

Ms Lisa Molloy

I will take the Deputy's question about registration, regulation and qualifications. The ICP very much welcomes regulation of the profession. As far as I understand, legislation is working its way through the Houses at present to designate and protect the titles "counsellor" and "psychotherapist". In the meantime, the IACP has very stringent standards and a very high quality of counsellors and psychotherapists. As our members, they go through a very stringent, monitored, standardised, quality-checked process on their journey to become accredited counsellors. The IACP is a self-regulating body. In the interim, until regulation becomes a reality, which I understand is a number of years away, although it is in train and is very welcome, the IACP has standards regarding the courses that are accredited, the members that are accredited, continuous professional development and supervision throughout their careers once they have become accredited members. The IACP is confident, as is the British Association for Counselling and Psychotherapy, BACP, in the UK, that its members are fully willing and absolutely able to provide this service.

Dr. Brian Osborne

The Deputy asked a question about the percentage of practices that might have counsellors on site. We do not have exact figures but it would be roughly in the order of around 15% to 20%. However, that would be in more affluent areas. In areas of deprivation and in more rural areas, counsellors would not be available. Again, it goes back to the ability to pay. Regarding referral, there is no need for a psychiatrist to see someone with a mild to moderate mental health illness in the vast majority of cases. At present we have counselling in primary care, CIPC, but not all the population is eligible for this and there are long waiting lists.

Dr. Brendan O'Shea

The Deputy asked a really interesting question. If someone is distressed or in need, who should be on the first line? We are of the perspective in the college that whatever is put in place should be evidence-based and Irish people should have a lot more choice than they have at present. At present people who are not well-off, who are deprived, have really busy GPs. Their pharmacist might have time to have a word with them. There might be something happening in the parish centre, but that is all they have. We do not see that anybody should be the first line but we see that general practitioners are good and skilful at gatekeeping who needs to go to the really expensive secondary care system.

In principle, the ICGP strongly supports having more stands of talk therapy and strongly concurs with the observations of our colleagues here that those strands of therapy should be diverse and they should be tried out. There is much research out there. We like the study by Professor Tom Fahey on antidepressants on adolescents because it was done on an Irish population.

The Deputy asked a good question of whether we have a good relationship with our colleagues here. Truthfully, and to everyone's embarrassment, we do not have a good, effective relationship. We would obviously say that it is because we are too busy and do not have time but it is because we have not prioritised proper joined-up thinking. We have developed a good relationship this afternoon.

I thank Dr. O'Shea for his honesty.

Dr. Brendan O'Shea

I thank the committee for bringing us all together.

Ms Lisa Molloy

I was going to say that I would like to thank the committee for bringing us here today. It has opened a dialogue between the two organisations.

Chairman

All this will go into our report and we will make sure that it is brought to another level too.

It seems there is consensus here that talk therapies should be an integral part of the mental health system, particularly at primary care level but also right up through the system. We are all agreed on that and that talking therapies are an alternative to medication. There is some consensus on whether we, as a nation, are over-medicated. There is some division on the question; I have a view and there may be others. I am interested to know the witnesses' view on the impact of medication on children because of the plasticity of their brains. I am particularly interested in the doctors' responses on that.

Will the Irish Association for Counselling and Psychotherapy, IACP, to speak more on its observation on availability? Does it feel that we should be going towards free counselling in terms of accessibility?

Dr. David Murphy referred to the range of therapies. He spoke about one with which he is particularly closely involved, as well as the role of family therapy, particularly for children presenting with mental health issues.

The Irish Council for Psychotherapy is also represented in the room. There are even more friends than the two people presenting. I ask that the Chairman would accept a submission from that group on the matter.

Those are my comments and questions and I am interested to hear the response.

Chairman

We would be happy to take a submission from the Irish Council for Psychotherapy.

There are about five minutes for responses. I will turn first to the GPs, as most of the questions were directed towards them. I ask that they respond as concisely as possible.

Dr. John O'Brien

The question of drugs versus talk therapy is probably the nub of what we are discussing today. As we observed in our submission, drugs are not good or bad; they just are. They are a tool that is useful when they are useful but not useful where they are not. The evidence for the use of antidepressants in mild to moderate depression is not good and there is no getting away from that. The evidence for the use of drugs in moderate to severe depression is very compelling but those boundaries are not fixed. They require the assessment and judgement of the GPs to establish where those boundaries are.

Depression, which is what we appear to be concentrating on a lot here, takes time. One needs time to hear a person, to let them tell their story, to evaluate it, to be upset, and to get a sense that the GP is interested. Patients often bring physical complaints into the conversation too, and they must also be addressed. As was laid out in the vignette earlier, it is a complicated and time consuming thing.

Because of the cutbacks that have been engendered in general practice, which I keep returning to, consultation times have shrunk. As a consequence, people are under pressure to leave out things that they really want to bring into the equation. It is not the case that one treatment is good and the other is bad, each has its place, but if GPs are not provided with the time to do the job that they do, then unfortunately, one ends up in a situation where they are backed into a corner.

Dr. David Murphy

On the range of therapies currently available in the National Health Service in England, all the therapies which are promoted and supported by the improving access to psychological therapies programme are evidence-based therapies. It is mostly taken up by cognitive behavioural therapies. Counselling for depression is the second most accessed of the evidence-based therapies. There are others which are practised on a much smaller scale. On the question about families, there is behavioural couples therapy for depression which is seen to be an effective approach.

On counselling more generally, in the English NHS system, there are many qualified counsellors but few who have been trained in the specific evidence-based approaches. This is something that is subject to a programme of change and I have also spoken to the IACP about it. Many counsellors working in the health service have not had the specific training to deliver one of these evidence-based approaches. We feel it is very important to ensure that if this is an opportunity to change accessibility to talking therapies here, that the evidence-based therapies are at the forefront of becoming available.

General practitioners arrive at an important way of thinking about people's experiences. Talking therapies and person-centred experiential counselling for depression approach adopt a very different way of understanding patients' distress than our medical colleagues, hence the difference or tension between a talk therapy or a medical response, that is, medication. The division of clinical psychology in the British Psychological Society has just released a very far-ranging document, The Power Threat Meaning Framework, which is entirely about a different way of thinking about distress which does not require the idea of diagnosis or the medicalising of people and is very much consistent with the ideas of a person-centred humanistic approach.

Chairman

That is a big conversation for another day. Does Mr. Henry or Ms Molloy wish to respond?

Ms Lisa Molloy

The Senator asked about the availability of free counselling and the IACP's view on the matter. IACP believes that ultimately, counselling and psychotherapy services should be accessible to all. In my opening statement, I mentioned one thing that could be considered in the interim but we are not there yet. First, we need to sort out primary care and address the waiting lists for current services through counselling in primary care, CIPC. As of the end of April 2017, there were 2,530 clients waiting for counselling nationally, of whom 727 or 29% were waiting less than one month, 1,183 clients or 47% were waiting between one and three months, 489 clients or 15%, were waiting between three and six months and 131 people or 5%, were waiting more than six months. That is the focus at present but ultimately, the IACP's view is that supports should be provided for access to all for services. That is where the proposal comes for support to access via the tax relief and the PRSI system.

Chairman

Thank you, Ms Molloy. I thank Deputy Buckley for agreeing to the change in the rota of speakers.

It is nice to be nice. Debates can often be heated in committees, so this one is a change. I thank all the witnesses for coming in and giving of their time. I love their honesty. I see their optimism but also their anger and disillusion, in that there is a better way to do things but nobody is listening. I am interested in what the professor or assistant professor-----

Dr. David Murphy

Associate.

In what the associate professor said. Everybody is an individual. Dr. Murphy touched on empathy and also, importantly, on people having choices. We do not hear that too often. It is like having two bars of chocolate and preferring one over the other in terms of whatever works for somebody. That relates to what Dr. Osborne said about doctors not having the necessary time to listen to patients. They are stretched. I was a member of the Committee on the Future of Healthcare and was involved in the work on the Sláintecare report, which had cross-party support and the support of those who were non-party. We genuinely believe that what is in that report can be implemented. There was no heroism around that work, rather we wanted to set down a marker for the future. I am glad the witnesses are supportive of it. Upskilling and competence was also mentioned in this. We are thinking of the people within the system. The attitude prevailing in our health system seems to be that one is a nurse, that is their job, they should do it and shut up, and, in terms of upskilling, the attitude seems to be what do they mean by saying they want to upskill, that they do not have the time, and in any event, the service is stressed in terms of the work that needs to be done. It is a toxic environment. We have always been self-centred on primary care. The first port of call is the general practitioner. Congratulations to the witnesses here, they are number one in the charts. The first port of call in England and Ireland is the GP. If the GP cannot access a place for their patient, their patient will probably get lost or the worst-case scenario would be over-medication. That is what makes me angry. I wrote the word "access" three times in my notes. We hear that raised every single say. I have seen the frustration of GPs about this. They are trying to do their best but when they get the next place for the patient, the patient cannot access it.

The exchange has been a breath of fresh air. I do not have questions. I listened carefully to what was said about the over-prescribing of medicine on occasion. As has been said to me many times, pharmaceuticals do not do cures, they do customers, which is a major issue. I am known to be blunt and straightforward at times but one has to be realistic. I would love to have a follow-up on this. I will ask the Chairman to pass on my contact details to the witnesses. The witnesses have an extremely achievable vision. We in this committee are trying to set markers for achieving that. I congratulate the witnesses. It is nice for a change not to be giving out. The witnesses have advocated, and it is on the record, as we have said many times, treating people with respect, giving them the time to tell their story, assessing them and giving them the right product or care to which they are entitled. Well done.

Chairman

Thank you, Deputy. Given that he did not have any questions, can we return to Deputy Neville's question about social media?

I had indicated earlier but I do not mind if Deputy Neville's question is dealt with first.

Chairman

We might just deal with that aspect first, if that is all right.

Chairman

Thank you, Deputy. Dr. O'Shea might address the social media aspect.

The point I raised relates to social media and young people. I would like Dr. O'Shea to elaborate on how it would be beneficial.

Dr. Brendan O'Shea

There are two ways one can view it. The Deputy referred to social media. It clearly represents a significant risk for a variety of reasons on one hand, and on the other hand, adolescents and young adults live, breathe and eat social media. It is part of their existence. We have an obligation to ensure it is regulated, as far as can do so, and our society is responding to that. We also have an obligation to ensure that young people are advised, schooled and safeguarded in how to use social media effectively.

Moving on to our therapies, it is not the social media that is evil; it is the way it is used. Forward-looking services will use apps and will signpost young people to useful websites or Facebook pages. The HSE will use them. We should be using these as part of our therapeutic response and as part of resilience and resource building among this demographic.

Moving to another interesting element, in general practice many members of the ICGP are innovative in their approach. Increasingly we are beginning to use tele-medicine which helps and is relevant in aspects of mental health. Social prescribing is a very interesting area and there are several pilot studies around the country on that involving GPs, including Donegal in conjunction with the HSE, and in Tallaght, where Dr. Darach Ó Ciardha and his team have involved themselves in social prescribing. It is very interesting.

What is tele-medicine and social prescribing?

Dr. Brendan O'Shea

Tele-medicine is the use of any technology, it could be a telephone or FaceTime, to develop a contact or enable contact between a therapist - it does not have to be a GP - and the client. That is tele-medicine. The person does not have to come to the centre. Social prescribing is very clever. It seems very obvious. Every community has its own resources but they are all different. It might be a club, societies, a HSE service, a sports club or another resource. The idea behind social prescribing is that the practice develops a detailed expertise about this because these things change. If my colleague or I feel that this is a person whose life has entered into a period of fallow after a loss and they are adrift, we talk to them. Dr. Ó Ciardha would refer to their social prescribing manager. That person would sit down with the individual, find out where they are coming from, what their interests are and would map them very precisely. In Dr. Ó Ciardha's practice they have in the order of 50 different agencies around the Tallaght area with links and they send individuals or they identify the services. It is bespoke social engineering, so to speak.

Chairman

We will ask Dr. O'Shea specifically for information on that in order that we can put it in our report and that it will clear to the members. I call Deputy O'Loughlin.

I thank the witnesses for their presentations and their attendance. It has been a fascinating discussion spanning almost two hours. I am completely on the same page with all the witnesses regarding everything they said. I often think about the mental health of the GPs and those who work in their practices. I acknowledge the huge pace of work and the number of people GPs see every day. As Dr. O'Shea would know, I have family in the business. I am concerned when I hear talk of 30 consultations before lunch and GPs being petrified they will miss something during that period. Our GPs and their support staff do an amazing job and we need to do what we can to help support them. My firm belief is that the local GP practice should be a one-stop shop. People, generally, have built up a good and positive relationship with their GP. I am using the term in a mild sense but if a person is feeling down or believes a family member is feeling down and he or she does not know where to go - I am aware the Minister is talking about bringing in a one-stop phone number, which is a good idea - if such a person is in a deep dark fog and does not know where to turn, it must be to his or her GP with whom he or she will have built up a relationship of understanding, compassion and relief. A consultation with a GP can be for a ten-minute period up to a maximum of 20 minutes. It is difficult for everybody involved in that very tight time space. The fact that our GP practices have extended more into primary care centres is good. There is often a physiotherapist, a tropical medicine practice, a dentist and the GP operating out of a centre.

I acknowledge what was said about a maximum of 20% possibly having somebody on hand. It should be something we aim for. I am interested in the NHS and the type of talk therapy that includes up to 20 sessions. What are the costings around that? It is the first time I have heard social engineering referred to in the context of thinking about positive mental health as opposed to mental health as an issue. It makes sense and there is much we can do on that. Ballymore Eustace does not have its own GP. Sean Fogarty, a very entrepreneurial post office owner, provides access to a tele-doctor service. It is better to go in and talk to a GP face-to-face but it is a great system for a community and village that does not have one. People can go into the hub where they have privacy.

Talk therapy is hugely important. In Kildare, there are referrals to HOPE(D), which gets no State funding whatsoever. It is wonderful to be able to support it. It is something we need to grasp. What are the witnesses' views on the issue of dual diagnosis? What are the difficulties from the witnesses' perspective in terms of trying to deal with that? What is their appraisal of the CAMHS system?

Chairman

There are an awful lot of questions. The witnesses may not cover all of them.

Chairman

The questions will be in batch form. I will go straight to Senator Devine.

I will be very quick. I thank the witnesses for their presentations. One of the witnesses mentioned that the suicide statistics decreased in the ten years after 2006. I disagree with that because it was the period of the lost decade and there was an increase in suicide in this country. Greece was first because of all the turmoil there. I disagree on that but perhaps we have caught up and steadied. There are remaining pockets of increased suicide in deprived areas. It is areas of deprivation that are still seeing an increase in those rates.

I was quite interested in the incidence of the prescription of psychotropic medication. The answer was it was neither good nor bad but I have a great concern about over-medication and the reliance on it, given the pressure on all system points in all areas of our health service. Hopefully at some stage I will get some more data on that to give us an idea of the situation. I know of seven year olds being prescribed Prozac. I do not know the incidence of that throughout the country. It is contraindicated at such a young age. It seems to be a last measure option. It would be interesting for us to know how we are treating our young children. Can we steer well away from medication as much as possible?

I agree on the issues of community-led social prescription and community activism. Instead of using the term "low intensity mental illness", we have to start using the term "well-being" because that is what it is about. We do not want a diagnosis. Will Dr. Murphy repeat what he said about The Power Threat Meaning Framework and that there is no need for a diagnosis for the majority of us because the majority of us have issues with well-being at different stages in our lives? We do not need to be diagnosed, we just need to be supported in our communities by GP practices, counselling or community facilities such as clubs or sports. A knitting club would be one of my suggestions but not everybody is into that. I am interested in that link. We have to blow the water on all of us. A large portion of those on waiting lists are suffering from mental ill-health. We just need to simplify community life and community well-being services

Chairman

Before I pass the witnesses onto Deputy Browne, I want to throw in my tuppence ha'penny worth. One of the comments Dr. O'Brien made was about the suicide rates and the decrease possibly due to the increased use of antidepressants. That is a very naive comment because there are many inputs into suicide intervention and prevention and looking at antidepressants alone is probably the wrong thing. When people are prescribed medication it does not have an immediate effect in the first two, three or four weeks but it can have a very immediate effect and create symptoms such as suicidal ideation, which these medications can create. A lot of people have gotten in touch with us on that very topic.

I will pass the witnesses on. There were a million other questions. All the questions that are not answered now will be put into a letter for the witnesses to answer. We are running very late. I will pass on to Deputy Browne.

I will be very quick. I understand that the issue of opioids and benzodiazepines which was raised in The Sunday Business Post was addressed. When I asked parliamentary questions on this issue several months ago, I was surprised by the high percentage of people on medical cards who were on these types of drugs. Is the number of those attending privately the same? Is the number of people on medical cards who have been prescribed these drugs higher in one sector than in the other?

In Wexford we have several charities such as Talk to Tom and It's Good 2 Talk. Do practitioners engage with these charities? Anecdotally, I know that some do and some do not. What is the level of engagement with these charities? Some are section 39 organisations and some are not. Some organisations are doing brilliant work but their availability is ad hoc.

Chairman

I ask the witnesses to be as succinct as possible. We will ask the questions again but we are running out of time. I am looking at the GPs for these answers.

Dr. John O'Brien

Can I get in on the suicide end of things because I may have misled the committee on my views on it? The whole business about the European-wide fall in suicide rates and the European-wide increase in antidepressants was just a statement of fact. No one can make the link between that fact and its causality. The causes and mechanics of suicide is a much more complex story than can be dealt with here. I am certainly not making the statement that upping the use of antidepressants will drop the instance of suicide. I am not saying that; I am merely making a global point.

Chairman

Do other witnesses want to answer any of the questions? They should be brief.

Dr. Brian Osborne

I will respond to the question on GPs and how they manage stress. The college has a health in practice programme and it also runs a GP "take care" programme of well-being at all its conferences. A question was asked about what we do if a GP is stressed and if there is a stressing event personally or professionally. In the current situation, especially in urban deprived and rural areas, we cannot even get a locum, so the GP cannot even take a day off. It comes back to recruitment and retention. Deputy O'Loughlin mentioned there is no GP in Ballymore Eustace. That will become more significant because there will be vast swathes of the country without GPs. Deputy Michael Harty's "No doctor, no village" campaign was quite apt in that context. When people are travelling 50 mile to 60 mile round journeys for their 80-year-old depressed grandmother, there will be an outcry and it needs to be addressed. It comes back to recruitment and retention.

FEMPI is driving young doctors out of the country and forcing older doctors to retire.

Dr. Brendan O'Shea

There are figures. We are spending north of €400 million per year on psychotropic medication. Balance that against €9 million or thereabouts on counselling in primary care. Sometimes we must make things very complicated and sometimes we must make things very simple.

Chairman

I think Deputy Brassil wanted to ask a question. He will not get an answer but it will be recorded so we will let him know.

I do not believe I heard about the cost of the CfD so could the witnesses forward it to me? Is play therapy on the witnesses' radar? A few people have contacted me about it and it seems a very good early intervention technique. When Dr. O'Shea appeared before the Committee on the Future of Healthcare, he strongly advocated for a new GP contract as being critical to any progress. We are a good year down the road. Has any progress been made and is there anything we can do as elected members to help him get this critical factor over the line?

Chairman

Before Dr. O'Shea answers, Deputy Neville will put a question.

I can get an answer outside the committee. It concerns therapy relating to the creative arts and music therapy.

Chairman

That question about cost was put to Dr. Murphy could perhaps we get a one liner and then we will ask the witnesses for all their input and answers to these questions. I am so sorry but I will be shot if I do not finish up shortly.

Dr. David Murphy

Providing counselling for depression in England using the IAP data looks like it is a better choice in terms of the cost to provide it than it is to roll out with just one type of therapy as CBT. Usually, according IAP's own data, those providing person-centred counselling for depression need to see people for fewer sessions than CBT therapists. A recent study showed that there was a significant difference in terms of improvement after just two sessions compared with CBT.

Chairman

We are really looking for ballpark figure. If Dr. Murphy does not have that, perhaps he could provide us with it. Someone is obviously advising him there.

Dr. David Murphy

It works out at roughly around 17% cheaper for counselling for depression than it does for CBT.

Chairman

We would still need a figure. We do not know what 17% is.

Dr. David Murphy

That is to train each individual therapist-----

Chairman

Will Dr. Murphy provide us with that when we send him that request?

Dr. David Murphy

Yes.

Chairman

I thank Dr. Murphy. I am sorry for rushing him at the end but we will follow up with all those questions, which we will include in the report. Dr. Murphy has no idea what input he is giving us. We will have an interim report in a few weeks time that will include all the witnesses' statements and there will be an overall report. I know reports tend to gather dust but as I said before, we will not let happen with our report.

The joint committee adjourned at 3.35 p.m. until 1.30 p.m. on Wednesday, 14 February 2018.