These days, the importance of perinatal mental health care has become more focused and recognized, and demand for such services is increasing in general hospitals. However, establishing a team and starting perinatal mental health care remain challenging among liaison psychiatrists. This paper aims to provide a practical resource in perinatal mental health care using a fictitious case. From the initial consultation to the postpartum follow-up, the case was divided into three major stages: prenatal outpatient, inpatient, and postpartum outpatient. The following sections discuss what to consider, when and with whom information is exchanged and shared in each stage, and the roles of the liaison psychiatrist. Since the content of this paper is only an example of activities at a single institution, activities at each hospital should be optimized according to the resources the hospital has, the characteristics of the community, and the surrounding environment.

We examined psychiatric assessment and information sharing methods required of psychiatrists in providing multidisciplinary support to address the needs of pregnant and postpartum women. Pregnant and postpartum women have been experiencing anxiety and social isolation because of the COVID-19 pandemic. For perinatal mental health care, online consultations and one-to-one in-person high-risk approaches are essential. The high-risk approach consists of comprehensive care provided by multidisciplinary professionals. Psychiatric assessment is necessary for optimizing the care and assessment of parental functioning. Moreover, psychiatrists should diagnose psychiatric disorders and assess the severity, the need for medication, the risk of relapse, and the effects of psychiatric symptoms and medication on parenting. In particular, the underlying pathology of self-harm, suicidal ideation, and thoughts of harming the baby should be shared among multidisciplinary professionals caring for pregnant and postpartum women. It is also important to predict the course of the psychiatric disorder during the perinatal period and prepare a crisis plan for when psychiatric symptoms worsen.

In general hospitals, psychiatrists are often expected to be involved in perinatal mental health. Having a "common language" with obstetricians, nurse midwives, pediatricians, and community health nurses allows everyone to share the task. The first common language is the Edinburgh Postpartum Depression Questionnaire (EPDS), which is used by nurse midwives, public health nurses, and other health care professionals who work closely with postpartum women, but not so much by psychiatrists. The second is "to plan for a sustainable conference". Regularly preparing a circumstance where staffs can share their opinions comfortably in a short period of time will lead to solid mutual understanding among multiple professions. The third is "to provide reassurance to other health care professionals". Although psychiatrists are mindful of providing reassurance to patients, they may not be able to do so well with medical personnel. By devising ways to provide reassurance to midwives, public health nurses, and other health care providers, psychiatrists will have less of a role to play.

In recent years, perinatal mental health care in Japan has been rapidly enhanced due to its necessity. Our facility, which is a regional perinatal maternal and child medical center that has a psychiatric department with a bed and is certified as a midwifery facility, treats various high-risk pregnant and nursing mothers. Therefore, we are creating a perinatal mental health care system with multi-professional and multi organizational. In order to support expectant and nursing mothers with mental disorders, it is important to promote communication among multiple professions and organizations within the system. In this paper, we describe four pillars that support perinatal mental health care at this facility: (1) a perinatal area, (2) a psychiatric area, (3) a pharmacy department and pregnancy and drug information center, and (4) a community-related organization. I introduce and consider the role of liaison nurses, who work together and promote communication. Although the activities of liaison nurses have had a certain effect, issues have also become clear.

The skills and experience of consultation-liaison psychiatry are immensely useful in team medicine, which is the basis of perinatal mental health care. The ‘trick’ is to use two intervention models: consultation and liaison. In the consultation model, the consulting doctor and psychiatrist often work independently, whereas, in the liaison model, the two professions work together. Mental health professionals such as psychiatrists and psychologists need to support perinatal care staff such as midwives, nurses, and obstetricians in their approach to their clients, based on the liaison model. There is a shortage of experts in perinatal mental health care, and psychiatrists and psychologists working in general hospitals are expected to participate in perinatal care. In addition, ‘community liaison’, which is consultation-liaison psychiatry in community care, offers a new way of working for psychiatrists and psychologists who have built their careers in general hospitals.

It is important to cooperate physical and psychiatric departments for COVID-19 patients who require psychiatric treatment, such as mental illness and delirium. However, there are few reports of psychiatrists directly examining patients in the red zone of the unit for treatment of COVID-19 in general hospitals. We have conducted liaison activity within the red zone since December 2020, and we performed a retrospective chart review of the activity. It turned out that the need for psychiatric medicine is high because there are psychiatric patients, dementia patients, and many delirium patients in COVID-19 units. Liaison activity within the red zone by a psychiatrist provided accurate information even with various limitations, enabling management while checking the status of in COVID-19 units. In addition, delirium frequently appeared after extubation in severe patients requiring intubation. When antipsychotics are administrated to manage delirium, the frequency of aspiration pneumonia and reintubation increases, so it was considered desirable to avoid the use of antipsychotics as much as possible.

We report a case of a patient with schizophrenia who experienced precipitate delivery after discontinuing antipsychotics without medical advice. The episode highlights the need for adequate preconception care and pharmacotherapy. Psychiatrists, as well as patients and their families, are often worried about the use of antipsychotics during pregnancy and lactation. However, previous studies suggest that the benefits of taking antipsychotics during pregnancy and lactation may outweigh the risks. Special attention should be given to the preconception pharmacotherapy of psychiatric patients of childbearing potential. In the current case, the results may have been different if the psychiatrist had discussed appropriate preconception pharmacotherapy with the patient and family. It is necessary for psychiatrists to have sufficient knowledge on antipsychotic drug use during pregnancy and to have sufficient knowledge on antipsychotic drug use lactation. Additionally, psychiatrists should work with patients, their families, and other medical professionals to ensure a safe pregnancy and childbirth.

A schizophrenic male patient suffered a paralytic ileus after daily oral administration of blonanserin tablets even though he continued daily oral administrations of 4 types of laxatives. Two months after the ileus was treated, daily oral administration of blonanserin tablets began again and changed to brexpiprazole tablets. Thereafter, the 2nd paralytic ileus occurred one month after the restart of blonanserin tablets followed by changing to brexpiprazole tablets. The ileus was treated, and the brexpiprazole tablets were restarted. Then, the 3rd paralytic ileus occurred one and half months after the restart of brexpiprazole tablets. After the ileus was treated, daily percutaneous administration of blonanserin patches began instead of oral administration of antipsychotic drugs. Thereafter, paralytic ileuses did not occur, but 9 months later the patient suffered a strangulation ileus by a sigma volvulus. These results suggest that no occurrence of paralytic ileuses during the 9 months prior to the sigma volvulus was related to the alteration in the administration route of antipsychotic drugs. The relation of their percutaneous administration to the sigma volvulus is unclear.

Mirtazapine significantly reduces suicide risk and is likely to cause an increase in appetite compared to other antidepressants. No known causes of suicide attempts or risk factors for increased anxiety and agitation after mirtazapine administration have been reported. In this report, we discuss a case of increased appetite that resulted in a suicide attempt. The patient, a man in his seventies who had been diagnosed with depression, was admitted to the hospital and treated with 30 mg of mirtazapine and electroconvulsive therapy (ECT). However, he did not go into remission. After being discharged from the hospital, the dose of mirtazapine was increased to 45 mg. A week later, his increased appetite became noticeable. Additionally, he sustained injuries when he leapt from the second floor of his house. He was transported to our hospital, and his consciousness was clear at the time of the initial examination. He informed us that his increased appetite was the catalyst for his attempted suicide. His anxiety and agitation were obvious, and we had to interrupt the interview several times when he complained of increased appetite. We suspected drug-induced anorexia, discontinued the mirtazapine, and started 10 mg of escitalopram. Following that, his complaints of anxiety, agitation, and increased appetite were significantly reduced. Later, he was admitted to a rehabilitation hospital. Through our experience with this case, we learned that one of the causes of suicide attempts is increased appetite and agitation.