Professor Veronica O'Keane:

I thank the Chairman and members of the committee for inviting me. I hope I can be of help to them in their task of interpreting the findings of the Citizens' Assembly. I have been asked specifically to give my opinion as an expert in the field of mental health. My current role is a joint academic and clinical one, as consultant psychiatrist in the service of the HSE at Tallaght hospital and professor of clinical psychiatry at Trinity College Dublin where I lead a research programme in perinatal psychiatry. My previous experience includes leading a national perinatal psychiatry service in London for five years at the Maudsley Hospital which covered all of the United Kingdom. Concurrently with that position, I was head of the perinatal psychiatry section at King's College GKT School of Medical Education where I led a research programme in perinatal depression. I have had papers published in the scientific literature on the subject of perinatal depression and written a book on the topic. I co-authored the standard clinical assessment tool for perinatal psychiatry disorder in the United Kingdom and served as an expert for the National Institute for Clinical Excellence in devising guidelines for clinicians on the management of perinatal depression. I set up two hospital psychiatry services, including the suicide prevention service in Beaumont Hospital. I was an expert witness at the two Oireachtas hearings which led to the introduction of the Protection of Life During Pregnancy Act and also privileged to serve as an expert witness at the Citizens' Assembly. Last March I co-hosted, with the National Women's Council of Ireland, the World Congress on Women's Mental Health at the RDS in Dublin.

I begin by thanking the members of the Citizens' Assembly for their work. The process and governance of the assembly in its consideration of the eighth amendment were an example of the best of democratic principles in action. Its conclusions were solution-focused and not ideologically driven. Most of the recommendations made are relevant to mental health, but they have been spelled out in a very helpful way that leaves no room for ambiguity. That clarity is one of the strengths of the document. A majority of the citizens recommended 12 reasons for which termination of a pregnancy should be lawful in Ireland. For each general health reason listed, a parallel mental health reason was given. For example, where 99% voted that abortion should be lawful when there was a real and substantial risk to the life of a woman, 95% voted the same where there was a real and substantial risk to the life of the woman by suicide. Similarly, 93% and 90%, respectively, of the citizens supported abortion where there was a serious risk to the physical health of a woman and a serious risk to her mental health. The same applied to a risk, as opposed to a serious risk, to physical health and mental health, with 79% and 78%, respectively, voting that abortion should be available to women in these circumstances.

There are two particular points I wish to highlight in respect of the assembly's recommendations. The first is that, as I have outlined, support levels for the provision of abortion care for medical and mental health reasons were very similar. In fact, 72% of members recommended that a distinction should not be drawn between the physical and mental health of women. That recommendation was an enormous relief to me and my colleagues. The mind-body dualism division has plagued our society and created much unnecessary suffering, leading to stigmatisation of and discrimination towards those who suffer with psychiatric disorders. Separation of mental health from physical health has been at the heart of the debate about abortion for the past three decades, following on from the 1992 ruling in the X case that suicide risk constituted grounds for an abortion. We have had two referendums, in 1992 and 2002, where suicide was upheld by a majority of voters as a legitimate reason for an abortion. We had a very difficult debate on the suicide provision leading up to the enactment of the Protection of Life During Pregnancy Bill in 2012 and 2013. It is now recognised in law that suicide constitutes a risk to the life of the woman in the circumstances of an unwanted pregnancy. The Citizens' Assembly understood there was no distinction between physical and mental health and made its understanding explicit. The importance of that recommendation cannot be underestimated and changes everything.

I will comment briefly on dualism which has been a very destructive force in society's understanding of health. It might seem evident, but it is important to point out that the brain controls the body. While one may feel sad in one's heart or anxious in one's gut, these feelings are directed from the brain. The dialogue between the body and the brain is never stronger than during pregnancy because the pregnant uterus produces hormones which cross into the pregnant woman's brain and modify the emotional brain. Emotional changes also occur because pregnancy is very challenging and parenthood is probably the most serious challenge any of us will face in our lifetimes.

My research group has looked at rates of depression during pregnancy, the first such study to be conducted in Irish maternity hospitals. We found rates of 16%, which is slightly higher than EU norms. Being depressed when pregnant is a very serious problem. Not only is the woman intensely distressed, but the stress hormones alter the baby's physiology such that the foetus is growing in a high-stress milieu and at increased risk of being born earlier and with obstetric problems. Depressed pregnant women are often unable to attend to their own needs and do not present as regularly for outpatient appointments as non-depressed women. Infants born to women who are depressed during pregnancy are more likely to suffer from childhood learning and behavioural problems and depression in early adulthood. All of this demonstrates that the emotional brain is important not just to the general well-being of the pregnant woman but also to the subsequent health of her baby and that baby's trajectory throughout life. The treatment of psychiatric disorders in pregnancy is seen as a priority for this reason.

An unplanned or unwanted pregnancy increases the risk of depression during pregnancy.

A US study of more than 100,000 women was published earlier this year. The study examined the relationship between unwanted pregnancy and perinatal depression. The study showed that an unwanted pregnancy increased the rates of perinatal depression by 50%. It must be said that in this study, as in all other published studies from OECD countries, the option of legal abortion was available for these women.