Dr. Anthony McCarthy:

Thank you, Chairman. I will try to bring together the various points raised in so far as I can. There is probably more agreement among my colleagues and me than speakers have represented. There certainly are some differences, but also a great deal of common ground. That is important to state at the outset.

On the question of the numbers of perinatal psychiatrists, it is important to understand the processes involved. Women who are suicidal in pregnancy will usually present at their GP or at a Well Woman or Positive Options clinic, for example, before perhaps going on to consult a psychiatrist. On the question of whether a second psychiatrist should have to adjudicate in such cases, it is my personal view that because it will be a rare occurrence and such a difficult area, certainly initially, for a psychiatrist not to get a second opinion would be foolish. I have to disagree slightly with Professor O'Keane on that point. It is my view that the opinion of a second psychiatrist should be required.

We do not, of course, carry out terminations. An obstetrician would do so and would, therefore, obviously have to see the patient. I doubt, however, that there are too many obstetricians who would say they have a competence in assessing suicide risk. They will certainly want to see the patient but the question of whether a person fulfils the criteria in regard to threat of suicide would have to be determined by a psychiatrist. As I said, that determination should be made by two psychiatrists.

On the question of the recommendation regarding early referrals in the Centre for Maternal and Child Enquiries, CMACE, report, I should point our that I am the CMACE assessor in psychiatry in this country, although it is now referred to as Confidential Maternal Death Inquiry in Ireland. We certainly have seen a delay in referral to specialist treatment, but that is not a problem merely in pregnancy. There is a delay in referral across every specialty not just in psychiatry, and it certainly can be an issue here.

On the question of whether we could treat a woman who is suicidal in pregnancy early enough to ensure her safety while protecting the pregnancy, the reality is that the vast majority of women who are depressed in pregnancy will not come to me saying they are suicidal and that an abortion will make them better. The vast majority will say they are suicidal, miserable and feeling awful - all the typical symptoms of depression - and will want to be admitted to hospital or otherwise treated. It will not be a question of keeping them well enough to sustain a pregnancy; that will arise in only a tiny percentage of cases. I am trying to imagine what patient might fulfil the criteria speakers are worried out. Perhaps the issue might arise in cases I have seen where women have taken a very serious overdose, almost killed themselves in pregnancy and are too unwell to go home. A woman in that situation might be saying that she really wants a termination at that point in time. It may be the case, however, that at that particular moment she does not have the competence to make that decision because she is so depressed, perhaps even delusional. In a circumstance like that, we would of course keep the patient in hospital and provide treatment. Very often such a patient will get better. I certainly have seen women who were later delighted that their depression was treated and who then wanted to keep the baby.

Equally, not every woman who is suicidal in pregnancy and saying she does not want the baby is mentally ill. That is a ridiculous suggestion. Many will be seriously depressed and that depression might make them feel they want to reject the pregnancy. Some, however, are just distressed, hopeless and depressed and feel, because of socio-economic, personal, relationship or many other factors, that abortion is the only option.

Men are more likely to abuse and beat women up during pregnancy than at any other time. A woman in that situation wants out; she is not mentally ill. That is what we must recognise. These are real issues. At the moment, she is likely to go to England or Northern Ireland to have a termination of pregnancy. If that is not available there, I would be worried about a lot of these women. That is the truth of it. So long as it is there, it is going to be a tiny group and that is the reality. That is what we must face as a country, namely, what we want to do about that or whether we want to leave it as an export.

On waiting times to see perinatal psychiatrists, there are only three of us and we are all based in Dublin. Most women who are depressed are going to want to see their psychiatrists locally. It may not be a perinatal specialist. The specialism that we have is going to be rarely addressed to this particular issue. Our specialism relates to women who may previously have had bipolar illness or schizophrenia and who are on particular medication or who may have had particular obstetric experiences. These women want to see someone who understands the obstetric issues and the interrelationship between these and pregnancy and psychiatry. They do not necessarily want to come and visit in those circumstances. This is a very small group of people. If the legislation does come in and if guidelines are introduced, I imagine there will be pressure on us to see these people quickly. I do not personally look forward to that. I will be looking for more resources as a result. Those are all the answers I can give.