Professor Veronica O'Keane:

I am grateful to the committee for inviting me to give this presentation today. I am a clinical psychiatrist at Tallaght Hospital in Dublin and a professor of psychiatry at Trinity College. I led a national perinatal psychiatry service in the UK for five years. I have expertise in perinatal psychiatry and general adult psychiatry. I set up the psychiatric service in Beaumont Hospital. I have a great deal of experience of managing people with deliberate self-harm and organising services. I am here today to avail of this fantastic opportunity to explain my experiences with women who are suicidal and pregnant to the legislators of this country.

I will speak about the recommendations in the expert group report that relate to legislation and regulation for mental health grounds. It is important to say that the expert group report refers to mental health grounds, rather than just to suicide. That is slightly wider than the discussion that has taken place. There are two main areas of interest in this regard, namely, serious mental illness, which Professor Casey and Dr. McCarthy have spoken about at length, and unwanted pregnancies leading to suicidal ideation or suicidal intent. The first area - serious mental illness - has been covered by my two colleagues. It basically involves the management and care of women with pre-existing mental health problems. I refer to serious mental health problems like schizophrenia, bad bipolar disorder or severe and recurring depression. These women can become suicidal when they are depressed because of the mental illness, or sometimes because the biology of their pregnancies affects their brain function. In some rare cases, these women can become suicidal because they have unwanted pregnancies. When I worked in the UK, we managed each woman individually according to her particular problem.

I would completely agree with the evidence given by the other witnesses that the best way to manage and help women with serious mental illness is to treat the mental illness. When that has been done, these women usually go on to have babies. Unfortunately, not every pregnant woman with serious mental illness wants to continue with her pregnancy. This is as true of women who have serious mental illness as it is of women who do not have serious mental illness. Some women feel they cannot cope with the pregnancy. This is particularly true of women with serious mental illness who have had previous children taken off them and brought into care. When I worked in the UK, I dealt with a woman who had four previous pregnancies - the baby in each case had been taken into care - and was pregnant with her fifth child.

While there are rare cases of people with serious mental illness not wanting to proceed with their pregnancies, as I have outlined, cases of unwanted pregnancy and suicidality are much more common. Some women become suicidal because they cannot cope with the prospect of an unwanted pregnancy and unwanted parenthood. A person who experienced childhood abuse, particularly childhood sexual abuse, and then had an unwanted pregnancy during adolescence or early adulthood can feel unprepared and unable to parent a child. Perhaps she did not receive adequate parenting from her own parents. She might feel that she cannot give the child up for adoption because if she were to do so, she would be abandoning the child in the same way that she was abandoned when she was young. It is also quite common for serious suicidal ideation to be associated with unwanted pregnancies in cases of young adolescent girls who became pregnant while intoxicated. The culture of drugs and drink among our youth is a public health problem. I have seen very young women in my clinical practice who became pregnant - they were raped, by definition - without being aware of the circumstances in which they conceived. These girls, who are just emerging from the protection of childhood, are always terribly ashamed. They are sometimes absolutely preoccupied with ideas of self-loathing and are actively suicidal. It seems to me that the girls in these cases are often taken by their parents to London and other parts of the UK and Europe to avail of abortion services. Thus, they are no longer suicidal.

People are being presented with a scenario whereby the experts are saying that suicidality does not occur, or that abortion is never an answer or the only answer in a situation where a woman is suicidal and pregnant. That is because the experts in this area only see very rarefied cases. They only see cases of serious mental illness. If a woman or young girl is suicidal because of an unwanted pregnancy, the last place she will go is an obstetric unit. She will not check in there and say "I am pregnant". She will go to her GP. She will certainly not attend a perinatal psychiatrist because she will not have been to the obstetric services. She will go to her GP. If one studies the GP literature - Dr. Mark Murphy recently presented a study in this regard - one will see that the bulk of pregnant patients are seen by GPs. Some 97% of GPs have had consultations with patients in relation to unwanted pregnancies. That is why the discrepancy between the evidence that has been given here and what actually happens in real life exists.

I wish to discuss the recommendations of the special group with regard to the establishment of the criteria to be used when determining the risk to the life of the mother. It is important to note that the report states that "it is not necessary for medical practitioners to be of the opinion that the risk to the woman’s life is inevitable or immediate" but that the risk should be established "as a matter of probability". Dr. Anthony McCarthy addressed this point when he said that risk management is the bread and butter of psychiatry. It is central to our clinical practice. It is what we do every day. We work within the Mental Health Act, which obliges us as a legal process to assess a person's risk and to comment on their risk to themselves and to others. This is something we do all the time within legal frameworks. Written risk assessments are also done on voluntary patients who come into our hospitals. Most people in Ireland who die by suicide do not see psychiatrists. Those who see psychiatrists are managed quite well and get a fairly good deal in general. As Professor Casey said, just three of every 100 patients who attend psychiatrists and are predicted to be at risk of suicide will actually go on to commit suicide. They are managed by the service. The whole thrust of the national suicide prevention programme that the HSE is rolling out now involves getting people into psychiatric services so that risk can be managed.

It is a matter for the legal profession and for the legislators here to talk about how they might proceed to enact the legislation and the regulations. My position is that the recommendations which have been given to us in the expert group report are excellent.

Psychiatrists can act in an advisory capacity in terms of helping to form the legislation and regulations and we can help to fine-tune it afterwards in the same way that we have worked with the Mental Health Act in the past ten years since its introduction in 2002.

My final point relates to the debate about whether we should legislate rather than the subject matter of the hearings. Some 130,000 Irish women have had abortions since 1983. This amounts to 5,000 per year or approximately 14 per day. What would happen if abortion services that are available in the United Kingdom and Europe were not available to Irish women today? Inevitably what happens when there are no abortion services available is that death and injury ensue; injury and death to women and death to babies. Unfortunately, in countries where abortion services are not available this is what happens. We must remember why we are here today: we are here because of the X case. The X case is the most obvious evidence of a risk of suicide that can be real and substantial and can only be averted by an abortion.