Submission to the Oireachtas Hearings May 20th 2013 , Dr Jacqueline Montwill

Introduction:

Chairman, members of the committee, ladies and gentlemen, thank you for the opportunity to address your committee, on this important issue.

Head 4 of the proposed Bill, “risk of loss of life from self-destruction”, is seriously flawed ; the treatment it proposes is not a treatment , the treatment it proposes is never the only treatment , and if truly suicidal with mental illness, the patient may not be able to give a valid consent .

1)The treatment it proposes under law is not an Evidence based treatment .

There is no evidence to support the view that Abortion has any mental health benefits, there is evidence to support that in some women Abortion may be associated with small to moderate increases in risks of mental health problems including suicidality. There is an ethical problem in offering a procedure as a life saving treatment to a suicidal woman, where that intervention also poses risks of suicidality as an outcome.

2)It is absolutely incorrect to say that Abortion could ever be the only treatment for stated suicidal intent.

Suicidality is multifactorial. Our treatment packages are multifactorial.We have worked in Multidisciplinary teams for over 20 years and the different skills from all our team members are essential for the full assessment and treatment of our patients.Best Practice treatment for mental illness is, and always will be ; appropriate full assessment, psychological support or intervention , and medication if needed.

Remember we have social workers, occupational therapists and psychiatric nurses who work with people in their own homes and communities. When discharged from hospital, we continue to work with the patient in the community as long as it’s needed. The proper care of a suicidal pregnant woman will entail support and treatment throughout her pregnancy , delivery and in the post partum period. Longer term intervention may be required , depending on the circumstances.

We are very aware that Mental Health Intervention must include assessment of all the stressorsin the patient’s life at the time in question .

These stressors can include relationship difficulties , poverty , unemployment or lack of occupation during the day , accommodation issues , difficult dynamics within the family currently or in the past , and lack of other supportive relationships .

It is within this holistic view that the treatment package for a suicidal pregnant woman would be appropriately assessed and delivered.

Therefore , it is completely illogical to say that the only treatment for suicidal intent during pregnancy would be an Abortion.

3)Valid consent to an Abortion may not be possible while acutely suicidal due to mental illness.

  • It is most important to outline to you clearly that a Psychiatric Emergency or Crisis is fundamentally different to any other medical or surgical emergency. This is because of the nature of the Disorder. In a true Psychiatric Emergency, the patient’s judgement is frequently impaired.Our role at that time is to administer the most appropriate psychiatric treatment and support. It would be highly inappropriate to impose an irrevocable intervention at that time, when the patient may not have sufficient mental capacity to give a valid consent to that intervention. The patient ‘s right to bodily integrity is paramount . It cannot be argued that a Termination is a life saving procedure in suicidal states in mental illness, as suicidality responds to other treatments .It can also never be argued that a Termination must occur at that time , as suicidal intent can fluctuate over time , and resolve. There is no inevitable decline to suicide that can be accurately predicted.
  • It is my view that if a Termination was prescribed and given at that time ;the patient would be in a strong position to accuse their treating team of failure in their duty of care. It could be rightly claimed thatwe as Psychiatrists, failed in our duty to adequately protect the patient during a period of mental illness. Do not forget that mental illness responds to treatment. Acute crises respond to treatment and they settle down, often in a short period of time. Any impairment of judgement in these situations will resolve with treatment.
  • Even in mild Depression, not necessarily in a suicidal state , a patient can have very negative thoughts about their life. During such periods, we routinely tell our patients: “Do not dump your boyfriend. Do not leave your job at this time. Do not make any major life decisions now. When your mood has lifted in a few weeks time, you will see things differently.” In a state of true suicidal intent, these negative feelings are exaggerated even more , but with treatment and time , they will also resolve.

A particularly effective Psychological treatment that works for patients who feel hopeless and helpless in their life is CBT, “Cognitive Behavioural Therapy. “ which teaches Patients to recognise how their mood affects their thoughts and behaviour, and how to change this . This is an example of how psychological intervention for a brief period of time , empowers the patient to have a markedrole in their recovery.

With this law, the focus will be directed away from a full and proper assessment of the patient and directed instead to an assessment for a direct Abortion. As treating Psychiatrists , we do not assess suicidality for any reason other than to prescribe the appropriate psychiatric treatment. Society should do the same. Society should validate an expression of extreme psychological distress, not normalize it. Mental illness is just as important as physical illness , perhaps even more so . Because it affects your thinking , your relationships and your ability to function .It is exceptionally important to state : The proper response to stated suicidal intent should always beappropriate evidence-based clinical treatment. Direct abortion is not a clinical treatment, it is a social solution.

  • We must be very clear, this law will do damage way beyond the boundaries of simply legislating for a medical treatment that is without the foundation of medical evidence and good clinical practice. It will directly target and profoundly damage the very nature of the doctor-patient relationship. The interaction will change from therapy to judgement interviews for an Abortion .It will put the patient in an impossible situation where outside demands will impact on her treatment , taking her out of the proper therapeutic alliance with her psychiatrist and treating team.

We have discussed where patients have mental illness with suicidal ideation and intent . It has been correctly stated that suicide in pregnancy is very rare. When it occurs it is due to mental illness, and the appropriate treatment , not an Abortion , would have saved those lives . However , in my opinion , these are not the patients who will be asking for an Abortion under the proposed Law . The majority of patients who will avail of Abortion in this way are most likely to be those who have no mental illness , and do not wish to be pregnant. We have no tools to predict who will kill themselves . It is likely that requests from these patients will be processed through the proposed Law , and this will result in widespread direct Abortion .

In conclusion ; for those patients with Mental Illness ;

There is no evidence that Abortion is a treatment for suicidal intent ,

there is no situation where it would be the only treatment indicated , and the issue of valid consent to an Abortion while truly suicidal due to mental illness,poses serious ethical concerns.

In my opinion, the patients who will avail of termination of pregnancy through this law are most likely to be those patients who have no mental illness, but who do not wish to be pregnant.

Dr Jacqueline Montwill , MRCPsych Consultant Psychiatrist

My name is Dr Jacqueline Montwill, I have worked in Psychiatry for 17 years , over 8 years at Consultant level. I am a Member of the Royal College of Psychiatrists and I am on the Specialist Register for Psychiatry of the Medical Council of Ireland and the General Medical Council (UK ).

I have worked in services both in Dublin and outside Dublin . I have provided a Consultant liaison service to the Obstetric departments in the Hospitals I have worked in , and would also have managed many patients in our clinics throughout their pregnancies , before and after delivery .

I have worked in Addiction services in Ireland and the UK , and been involved in the management of pregnant women with Addiction disorders and mental illness . I have also worked very briefly as a Consultant in a Perinatal Psychiatric Service.

Treatment plans and delivery of psychiatric care always involve the Multi-Disciplinary Team . Routine practice for Consultant Psychiatrists working in services where there are no Perinatal Psychiatry services would include accepting referrals from GPs , Public Health Nurses and Obstetricians & Gynaecologists .Conditions assessed and treated would include women considering pregnancy or in any of the Trimesters of pregnancy presenting with Anxiety Disorders , Mood Disorders and Psychosis . Occasionally women are referred who have been traumatised by previous difficult or distressing pregnancies or deliveries. These patients are managed through their next pregnancy and often have a very good outcome .