AGAINST:
THE FAMILIES

IN MARCH 2006, Niall MacMahon stepped in front of a train at Harmonstown railway station and was killed instantly. Just days before his death, he had been released from St James's Hospital and his parents knew nothing of his mental state.

"We found out after he died that he had tried to commit suicide twice before, but we never knew anything about it, " said his father, Jim MacMahon from Dublin. "The psychiatrists in the hospital didn't tell us anything. If they had even hinted at the situation then we would never have let him go back to his apartment so soon. We feel if we had even known he was in a delicate frame of mind, we could have prevented what happened to him."

These are the sentiments that have been expressed by families all over the country who feel that if they had been told their family member was vulnerable they would have acted to prevent them taking their own lives.

"We have received numerous calls from families after a suicide who were told by the hospital that they would not discuss the after-care of a patient, " said Dan Neville of the Irish Association of Suicidology.

"But that's a very old-fashioned view that has been thrown out in the UK and the States. If a person has a heart attack, their primary carer is told how to look after them when they are released from hospital and what warning signs to look out for. Why shouldn't it be done in psychiatry?"

According to the American Psychiatric Association, informing relatives of the risk of suicide and educating them about the warning signs is an important part of suicide prevention. "There is a very old-fashioned view amongst many psychiatrists that people won't understand the issues, which really needs to be reviewed, " said Neville.

Last month, Patrick Cregan from Limerick commited suicide the day after he was released from the MidWestern Regional Hospital. The HSE refused to say what interaction took place between the psychiatric department and Cregan and the incident is under investigation.

The same thing happened to Rachel Hall, the 34-year-old mother-of-three who committed suicide two days after being discharged from St Vincent's in Dublin in December 2005. Her 18-yearold daughter Kim told the inquest last March that her mother had tried to take her life 20-30 times and was "crying out for help".

"They wouldn't even tell us when she was being discharged . . . they just put her in a taxi home, " said Kim of the hospital staff.

According to John Saunders of the Irish Mental Health Coalition, a more liberal interpretation is needed of the patient confidentiality clause to help family members caring for patients in difficulty.

"Some doctors use patient confidentiality to avoid sharing any information whatsoever with family members, " he said. "But that's a very narrow interpretation of it. The best possible solution is, of course, if the patient agrees to sharing information with a family member, but that doesn't always work out."

Instead, Saunders believes a protocol needs to be put in place by the Irish Medical Council to enable doctors to share generic information with family members. "If they can give out general information on the diagnosis, what is likely to happen and the treatment the person will be getting, then that could make a real difference for the person caring for the patient, " he said.

"At the end of the day, most people getting treatment are living at home and that's where the burden of care is.

The more the family know, the better support they can give."

"If they had even said, 'Keep an eye on him, ' everything would have been different, " said Jim MacMahon. "The hospital was very apologetic, but they said in the same circumstances they would do the same again and not tell the family anything. That needs to change."

FOR: THE PSYCHIATRISTS:

ACCORDING to the Irish College of Psychiatry, the issue of patient confidentiality is not one that can be thrust aside at the request of family members. Nor is it as simple as setting out guidelines for what they can and cannot tell relatives.

"Psychiatrists must, and do, examine the circumstances of each patient on an individual basis, " said a spokesman. "The issue of confidentiality confronts psychiatrists on a daily basis. Individual psychiatrists must find the most appropriate solutions in the best interest of the patient and family while always endeavouring to adhere to the rights of each patient to confidentiality . . . especially if the patient asks for it."

If a patient does not want relatives to be informed of their mental illness, then a psychiatrist who does so is open to legal action.

"This is a very difficult situation for families who are anxious to help and are more than willing to be involved in the patient's care, " said Dr Colm Quigley, president of the Irish Medical Council. "But if a patient doesn't wish them to be involved, and particularly if they are patently competent of making this decision, then psychiatrists are in a difficult position."

For a psychiatrist and a patient to maintain their relationship, there needs to be absolute trust. If this trust was to be damaged by a breach of confidentiality, Quigley said, the patient's care could be damaged.

"The patient has an absolute right to confidentiality, " he said. "If society was to take that right away, then there would be national outrage. If a patient is happy for the family to be told, that's no problem. But if they say they don't want anyone to know, then the family has no rights in that regard."

However, if a patient is considered to be a danger to themselves or others, psychiatrists are within their rights to inform family members of the situation . . . something that did not happen in the MacMahon and Hall cases. The problem here is that psychiatrists do not always have a way of knowing when a patient is suicidal.

"This is not as straightforward as people would like it to be, " said Quigley. "People don't necessarily tell their psychiatrist about their plans to do something and they don't always display any signs of being a danger to themselves. Psychiatrists make difficult decisions daily without the benefit of hindsight and most of the time they do very well."

The Irish College of Psychiatry agrees.

"Singling out psychiatrists for blame on the suicide issue, and doing it without a shred of justification, is most unfortunate and unhelpful, " said the spokesman. "Psychiatrists all around the country are confronted with this issue each and every day and do their best in both a personal and professional capacity to help each individual patient and family."

Nor is there any evidence to suggest telling family members will be helpful for the patient, Quigley maintains. "A lot of families do feel after a suicide occurs that they could have helped to prevent it, but I'm not sure that that is the case. It's natural after a death to think about what might have been but there is no real way to know that telling family members could have helped the patient. In fact, if the psychiatrist is breaching patient confidentiality, it could possibly harm them."

Helplines

Aware: 1890 303 302; www. aware. ie
Samaritans: 1850 60 90 90; www. samaritans. ie or email jo@samaritans. org
3Ts (Turning the Tide of Suicide): 01-2139905; www.3t. ie.
World Suicide Prevention Day: takes place on Monday 10 September and 3Ts is holding candle-lit vigils around the country that night. More on www.3t. ie.