Dr. Anthony McCarthy:

Unwanted pregnancies are particularly likely to be associated with considerable distress and mental health difficulties for the mother, and developmental difficulties for the child. Any woman who has such difficulties deserves compassionate professional help.

We are aware that abortion is a difficult and painful issue, not just for individuals but for the country as a whole. It is a highly divisive issue and our college is no different from other groups in society in having members with differing and opposing views on the subject. We are aware that these hearings are about the implementation of the Government decision and we will be confining ourselves to commenting on the clinical issues and organisational aspects and challenges of this potential implementation. We do not wish to add to the conflict and distress by commenting on the wider issues so passionately being debated in society.

We are also very aware that women who come to our clinics in the three Dublin maternity hospitals will themselves have widely differing views on their pregnancies and we wish to be able to provide assessments and treatments in a non-judgmental way to these women. For example, one pregnant woman referred to a clinic may have had two previous terminations but will say that for her they were pregnancies, not babies. Another may have had a miscarriage very early in pregnancy and technically the pregnancy may be diagnosed as an empty sac with almost

no foetal material but for her she was a mother, at least for a few weeks. These differences must be understood and respected by any psychiatrist assessing women in pregnancy.

The three of us who work as perinatal psychiatrists have considerable experience of assessing women with mental health difficulties in pregnancy. The fact that no maternity unit outside Dublin has dedicated perinatal psychiatry specialists is a major cause of disappointment to the college. This means that outside these three hospitals, there is no routine assessment of or screening for major mental health problems in pregnant women at a time of markedly increased risk and at a time when appropriate advice and intervention can have such vital benefits not only for the mother herself but for her bond with her new baby, whose long term development depends so much on her well-being.

The college was invited to send an additional nominee and we invited Dr. Maeve Doyle, who is a child and adolescent psychiatrist and chair of the child and adolescent faculty of our college, and is here to address any questions about children that are a regular issue for us.

The Supreme Court specifically recognised the risk of suicide as a legitimate basis for permitting termination of pregnancy where there is a real and substantial risk to the life of the mother which can only be removed by terminating the pregnancy. We understand that we have been invited here to provide expert psychiatric input into the complex issue of suicide and termination.

Suicide is rare in pregnancy, but it does happen and is a risk we always have to consider. Some figures help give a perspective on the rarity of suicide in pregnancy. In Britain, from 2006 to 2008, there were four suicides in pregnancy among more than 2 million live births, giving a rate of 0.2 per 100,000, or one in every half million births. Suicide rates are lower in pregnant women than in non-pregnant women. International studies suggest that the suicide rate in pregnancy is from a third to a sixth of the expected rate in non-pregnant women, indicating that frequently pregnancy confers a protective effect against suicide.

We are, however, always conscious of the need to be aware of, but also wary of, statistics with regard to suicide in pregnancy or the long-term effects of unwanted pregnancy, or termination of pregnancy, on mental health when dealing with any of our patients. We see real women, each of whom is an individual and must be treated as such and not as a statistic. In addition, research shows that there are differences between cultures and differences between countries where abortion is freely available and those where it is illegal.

Suicidal ideation in pregnancy is much more common than completed suicide. It is a complex issue but much of the public debate about the issue of suicide and its risk in pregnancy has, in our view, been simplistic, sometimes harsh and judgmental, frequently uninformed or misinformed, and contrasts markedly with the way suicide and its risk is usually discussed in other circumstances, particularly in light of recent discussions on cyberbullying and suicide, in which great sympathy has been shown, compared to the way some pregnant women have been pejoratively commented upon. We find that horrifying.

Although it would be impossible to discuss the issue of suicidal risk in all its complexity in a forum such as this, or in a brief submission, an introduction to some of the key concepts is important here to help inform the discussion so the language can be understood. So often suicide is talked about as a threat, and no more than that. There are very significant differences between suicidal ideation and suicidal intent and plans. Suicidal ideation means that the person has ideas in their mind about ending her life. These may be just occasional thoughts, very frequent thoughts or constant thoughts. As psychiatrists we are used to making these differentiations. The woman may be relatively unconcerned about them because she knows that she would never act on them and has had them regularly before. Alternatively, she may be very upset and worried by them. She may be terrified by them, or feel haunted by them. Sometimes, a woman may be ambivalent, oscillating between having suicidal thoughts and rejecting such thoughts. Her mental state may fluctuate considerably. Frequently, but unfortunately not always, she will seek help because she is so worried or upset by them, and she does not actually want to die but she cannot stop thinking about suicide. We know there is a risk that she may eventually feel driven to it and she certainly needs to be heard, believed, and helped.

Some women report a passive death wish. They do not have suicidal thoughts but indicate that they wish they were dead. Others indicate a desire to harm themselves but again deny any thoughts of actually ending their lives. I am going into this detail because there is almost a notion that psychiatrists say "suicide" and tick a box. I want to provide some sense of the complexity of the issues and our ability to makes these differentiations.

Suicidal intent is different. Here the person has an intention or plan to kill herself; it is no longer just an idea. She may or may not seek help or inform anyone about it. If she does, she may have little faith that she can be helped - it may be a last resort - and here, sensitive and skilled professional assessment is vital. The intention may be immediate or impulsive, or a more long-term plan sometimes contingent on a particular event or happening. Suicidal ideation may or may not be associated with mental illness. Completed suicide is typically associated with major depression, bipolar affective disorder, schizophrenia arid alcohol dependence syndrome, but not exclusively so.

The term "threatening suicide" is often used loosely to describe both suicidal ideation and suicidal intention. It may apply to either, but psychiatrists use this term to describe the way ideation or intention is communicated rather than as a separate category in itself.

Psychiatrists are specially trained to assess the risk of suicide and to treat patients who are suicidal so as to minimise that risk. We are trained to assess whether patients have suicidal ideation or intention or both, to diagnose whether the person is suffering from a mental illness, and to make or recommend appropriate therapeutic interventions and plans.

Of course we cannot eliminate all risk, as we cannot foretell the future. However, despite comprehensive assessment, suicide is difficult to predict and absolute predictive power is extremely limited. There will always be both false negatives and false positives. Some people who will appear to have a low risk of suicide or deny such a risk will go on to kill themselves, while others who may appear to have a high risk will not complete suicide. Psychiatrists are best placed to make such assessments and decisions and do so on an everyday basis as part of their

work.

There has been some well-publicised comment that psychiatrists will be manipulated by women threatening suicide. All psychiatrists are very familiar with a small but real group of people who will attempt to manipulate us. This may happen in many different situations in which we work. For example, an addict may threaten to kill himself unless we prescribe the methadone that he alleges was stolen from him, while another might threaten to kill himself unless we admit him to hospital. Others try to convince us that they are mentally ill and suicidal when actually they may be trying to avoid a court hearing. The vast majority of people who present to us for help, however, are very genuinely distressed or depressed, are seeking help and need appropriate compassionate and skilled professional help. Women in pregnancy are no different in that regard.

The issue that psychiatrists will be asked to address if the legislation is implemented has two elements. The first is whether there is a real and substantial risk to the mother's life because of suicidal ideation or intent, which I have just covered. The second element, and one that only a small number of psychiatrists in Ireland have been presented with, is whether that risk can only be removed by terminating the pregnancy.

As perinatal psychiatrists working in maternity hospitals with over 40 years' experience between us, we have seen many women who are depressed or distressed and have suicidal ideation and sometimes intent in pregnancy. We have seen women who have harmed themselves in pregnancy, sometimes seriously, some of whom have tried to kill themselves, their babies or sometimes both. We regularly see women who have had terminations of pregnancy and describe many different reasons for this, including depression and other mental health issues. However, we have not had the experience of seeing any women who were suicidal where the appropriate treatment for their suicidal feelings would have been a termination of pregnancy. We also see many women with unplanned or unwanted pregnancies for whom termination is not a choice they would ever consider. We know that huge numbers of Irish women go to Britain in these situations.

There was no psychiatric input to inform the Supreme Court decision in the X case. However, given that the decision to legislate and regulate has now been taken, it is the State's intention to introduce accessible, effective and timely procedures so that women in these situations can be appropriately assessed.

Clearly if very many of these women were to present to psychiatric services now who did not present before, this would be a considerable extra burden on already over-stretched services. However, we are not expecting a significant number of women to come to us because they will continue to go to the United Kingdom.

Particular consideration will need to be given to the challenges that could be faced in assessing pregnant girls who would need to be assessed by child and adolescent psychiatrists, and in assessing women with significant learning disabilities or those who may not have mental capacity. An assessment of capacity would be required, given the level of emotional distress and the possibility of mental illness being present. It must be remembered that any woman who is mentally distressed or depressed in pregnancy and who has suicidal intent or ideation requires sensitive, compassionate, skilled and non-judgmental assessment. In most circumstances they may need urgent care and treatment. If the woman is profoundly depressed and mentally ill, she would be advised not to take any major life decision at that time, and frequently admission to hospital might be advised. Ongoing review and monitoring would typically be required.

A psychiatrist should have the right to conscientious objection and of course in this area we would follow the very helpful Medical Council ethical guidelines. However, we then respect that all psychiatrists would still be responsible for ensuring appropriate and timely transfer of that patient to another psychiatrist.

We are very grateful for this invitation. We hope our submission is helpful and we will be happy to answer any questions.