Professor Veronica O?Keane:

The first question Deputy Kelleher asked was the difference between being suicidal in pregnancy and being suicidal because of being pregnant and that is a very important distinction because if somebody is suicidal when they are pregnant it does not mean they are suicidal because of the pregnancy. When somebody is suicidal we would have a very open view about what is causing it.

The individual may be depressed or there may be circumstances other than pregnancy. She may have been suicidal prior to the pregnancy and the pregnancy may be an additional stressor. There are all sorts of reasons somebody may be suicidal and we are looking specifically for somebody who is suicidal because of the crisis pregnancy. It is entirely credible that somebody would be suicidal because of a crisis pregnancy. A person might also have a series of stressors and series of difficult life circumstances and adding an unintended pregnancy to that could precipitate suicidal ideation but may not be the cause.

Our intervention is always aimed at what an individual presents us with and, in assessing an individual, we look at their vulnerabilities. Some people have a vulnerability towards motherhood and that might be a long-term psychotherapeutic issue. We look at their life circumstances. If it has been caused by a rape, that is a complicated issue. We, therefore, look at all the reasons somebody might be suicidal. This legislation is directing us towards evaluating suicidal ideation in the context of just having an unwanted pregnancy and if there are other issues - which relates to what Deputy Ó Caoláin said - when the assessment takes place, it will not be a unidimensional assessment just looking at whether this woman is suicidal because of a crisis pregnancy. A psychiatric evaluation is a complex, multi-layered assessment. We look at historical events, a person's biography, current mental state, social circumstances and personality characteristics. We would assess all those and intervene at whatever level is appropriate. That could be on several levels. The complexity of the case and the care pathway will depend on what we assess as the problem and on the patient's needs. If, for example, somebody was in a crisis and that was the straw that broke the camel's back, we would try to dismantle all the other causes and deal with them separately and singly. That is the way we approach problems. We try to break them down and deal with them individually.

However, there will be cases and that is what the legislation is about. We are not minimising the complexity of individuals' psychological make up, their biographies or their lives. We are saying we will deal with all that but there will still be rare cases where a woman will be suicidal because of an unwanted pregnancy and they are the cases the legislation is intended to address. In the case of the other ladies who present, they will get treatment as usual.

The second question related to the pathways to care, which I have probably answered and the final question related to accessibility. It is important that we make sure that the service is accessible. That is why we are pushing the role of the GP here because everybody should be registered with general practice. The role of general practice will become more important in the health care provided to citizens through primary care. The primacy of primary care in an individual's health is one of the major thrusts of health policy currently. The way to make this most accessible to women is to say, "Go to your general practitioners. They know you." They will be able to evaluate whether this is a real crisis requiring an abortion or something that requires counselling to help a woman come to terms with something. The role of the GP cannot be underestimated. It is also emphasised in the legislation but I would like this to be brought into the regulations and the way the legislation is implemented in the same way it is in the Mental Health Acts. If somebody is unwell, he or she must go to a GP who then has to recommend that he or she be assessed by a psychiatrist. That answers the question about recommendation. The recommendation is if the GP thinks the woman is suicidal, she should be referred to the specialist panel for assessment of suicidality.