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Clinical Policy Title: Depression treatment during pregnancy

Clinical Policy Number: CCP.1339

Effective Date: October 1, 2017

Initial Review Date: September 21, 2017

Most Recent Review Date: October 2, 2018

Next Review Date: October 2019

Related policies:

None.

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the use of antidepressants and psychotherapy in pregnancy to be

clinically proven and, therefore, medically necessary for the treatment of depression during pregnancy

(U.S. Preventive Services Task Force, 2016; Sockol, 2015; American College of Obstetricians and

Gynecologists, 2008).

For mild to moderate depression, psychotherapy may be effective alone.

For severe depression, pharmacotherapy may be more effective than psychotherapy alone.

The benefits and risks of potential treatments being considered should be carefully weighed and

discussed in a collaborative care model.

Limitations:

AmeriHealth Caritas considers the use of the following treatment approaches to depression in

pregnancy, among others, to be investigational/experimental and, therefore, not medically necessary.

Policy contains:

Depression.

Fetal echocardiogram.

Pregnancy.

Prenatal care.

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Acupuncture.

Botulinum toxin.

Bright light therapy.

Exercise.

Mindfulness-based interventions.

Nutritional supplements.

Transcranial magnetic stimulation.

Yoga.

Alternative covered services:

None.

Background

Depression is a disabling disease that is associated with serious physical, behavioral, and social

repercussions. These include increased rates of mortality from suicide and from other illnesses; other

mental health conditions including smoking, substance abuse, and eating disorders; and absenteeism

resulting in reduced income.

A major depressive episode is defined as a period persisting at least two weeks during which a person

has a depressed mood or loss of interest or pleasure in daily activities, along with some additional

difficulties such as problems with sleeping, eating, concentrating, energy, and/or feelings of self-worth,

without mania, and not due to another physiological cause, causing “clinically significant distress or

impairment” (American Psychiatric Association, 2013). Bipolar disorder is a distinct disease from

depression. Persons who experience one episode of depression have a 50 percent likelihood of another

episode, increasing the potential for future depressive episodes (American Psychiatric Association,

2000).

Based on a national survey, it is estimated that 16.1 million adults in the United States, or nearly seven

percent of the adult population, experienced a major depressive episode in 2015 (Center for Behavioral

Health Statistics and Quality, 2016). About a third (32.8 percent) did not receive treatment (defined as

medication or some type of counseling). Among adolescents, 12.5 percent (an estimated 1.2 million

youth ages 12 to 17) said they had a major depressive episode in the previous year, and 60.7 percent

said they had not received treatment. Beginning at age 12, depressive symptoms and diagnoses are two

to three times higher in females than in males (Salk, 2012). In sum, those women at ages associated with

the highest fertility have the highest rates for major depressive episodes, yet the lowest rates of

receiving treatment.

Risk factors for antenatal depression include high anxiety and perceived stress; adverse life events;

unintended or unwanted pregnancy; low social support, income, or education; poor relationship quality;

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history of abuse or domestic violence; history of mental illness; adolescent age; and pregnancy

complications (Biaggi, 2015; Lancaster, 2010). Depression rates among women with an unintended

pregnancy are 21 percent, double the rates among women with a planned pregnancy (Abajobir, 2016).

Depression in pregnancy is associated with increased risk to both the woman and the fetus. Maternal

depression is associated with suboptimal nutrition; poor-quality sleep; preterm birth; low birth weight;

neonatal intensive care admission; and postpartum depression (Jarde, 2016; Baskin, 2015; Araujo,

2010). Prenatal maternal stress including depression may be associated with atopic conditions (asthma,

wheeze, atopic dermatitis, allergic rhinitis, and IgE) in the offspring (Andersson, 2016).

The American College of Obstetricians and Gynecologists (2010) recommends that women be screened

at least once during the perinatal period for depression and anxiety using a validated, standardized

instrument and that women with current depression or anxiety, or risk factors or history of perinatal

mood disorders, be particularly closely monitored, evaluated, and assessed.

The following recommendation was published by the Institute for Clinical Systems Improvement

(Triangle, 2016):

“Clinicians should screen and monitor depression in pregnant and postpartum

women…Although direct evidence of the isolated health benefit of depression screening

in primary care is weak, the totality of the evidence supports the benefits of screening in

pregnant and postpartum women, particularly in the presence of additional treatment

supports such as treatment protocols, care management, and availability of specially

trained depression care providers.”

Searches

AmeriHealth Caritas searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services.

We conducted searches on August 3, 2018. Search terms were: “depression” (MeSH) and “pregnancy”

(MeSH).

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes

and greater precision of effect estimation than in smaller primary studies. Systematic

reviews use predetermined transparent methods to minimize bias, effectively treating the

review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

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Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency

studies — which also rank near the top of evidence hierarchies.

Findings

The following treatment recommendation was published by the U.S. Preventive Services Task Force

(2016).

“Effective treatment of depression in adults generally includes antidepressants or specific

psychotherapy approaches (e.g., cognitive behavioral therapy [CBT] or brief psychosocial

counseling), alone or in combination. Given the potential harms to the fetus and newborn child

from certain pharmacologic agents, clinicians are encouraged to consider CBT or other evidence-

based counseling interventions when managing depression in pregnant or breastfeeding

women.”

The following specific recommendations and conclusions regarding pharmacologic treatment for

depression in pregnancy are from the American College of Obstetricians and Gynecologists (2008,

reaffirmed 2012):

“The following recommendations and conclusions are based on good and consistent

scientific evidence (Level A):

Lithium exposure in pregnancy may be associated with a small increase in

congenital cardiac malformations, with a risk ratio of 1.2 to 7.7.

Valproate exposure in pregnancy is associated with an increased risk of fetal

anomalies, including neural tube defects, fetal valproate syndrome, and long

term adverse neurocognitive effects. It should be avoided in pregnancy, if

possible, especially during the first trimester.

Carbamazepine exposure in pregnancy is associated with fetal carbamazepine

syndrome. It should be avoided in pregnancy, if possible, especially during the

first trimester.

Maternal benzodiazepine use shortly before delivery is associated with floppy

infant syndrome.

“The following recommendations and conclusions are based on limited or inconsistent

scientific evidence (Level B):

Paroxetine use in pregnant women and women planning pregnancy should be

avoided, if possible. Fetal echocardiography should be considered for women

who are exposed to paroxetine in early pregnancy.

Prenatal benzodiazepine exposure increased the risk of oral cleft, although the

absolute risk increased by 0.01%.

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Lamotrigine is a potential maintenance therapy option for pregnant women

with bipolar disorder because of its protective effects against bipolar

depression, general tolerability, and a growing reproductive safety profile

relative to alternative mood stabilizers.

Maternal psychiatric illness, if inadequately treated or untreated, may result in

poor compliance with prenatal care, inadequate nutrition, exposure to

additional medication or herbal remedies, increased alcohol and tobacco use,

deficits in mother–infant bonding, and disruptions within the family

environment.

“The following recommendations and conclusions are based primarily on consensus and expert

opinion (Level C):

Whenever possible, multidisciplinary management involving the patient's

obstetrician, mental health clinician, primary health care provider, and

pediatrician is recommended to facilitate care.

Use of a single medication at a higher dose is favored over the use of multiple

medications for the treatment of psychiatric illness during pregnancy.

The physiologic alterations of pregnancy may affect the absorption, distribution,

metabolism, and elimination of lithium, and close monitoring of lithium levels

during pregnancy and postpartum is recommended.

For women who breastfeed, measuring serum levels in the neonate is not

recommended.

Treatment with all selective serotonin reuptake inhibitors (SSRIs) or selective

norepinephrine reuptake inhibitors or both during pregnancy should be

individualized.

Fetal assessment with fetal echocardiogram should be considered in pregnant

women exposed to lithium in the first trimester.”

Several systematic reviews and meta-analyses provide evidence for the pharmacological treatment

recommendations and guidelines above. Increased risks to fetal health associated with selective

serotonin reuptake inhibitors appear to be small, and therefore may be acceptable for women with

severe depression. Selective serotonin reuptake inhibitors during 91 days before or after the last

menstrual period was associated with an increased rate of severe congenital heart defects and a higher

rate of an aggregate outcome of anomaly or stillbirth; however, the increased prevalence of all major

anomalies combined did not reach statistical significance (Jordan, 2016). There was an evident dose-

response effect such that the prevalence of anomalies and severe congenital heart defects decreased

when medication was paused or stopped preconception, and increased when more than one medication

was prescribed. A systematic review and meta-analysis found that prenatal use of selective serotonin

reuptake inhibitors was associated with a higher rate of preterm birth when compared to non-exposed

controls with and without depression and to controls treated with psychotherapy (Eke, 2016). Ross

(2013) found no significant association between antidepressant exposure and spontaneous abortion,

but did find statistically significant associations between antidepressant exposure and the pregnancy

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and delivery outcomes of gestational age and preterm delivery regardless of whether the comparison

group consisted of depressed but untreated mothers, or all unexposed mothers. However, group

differences were small and scores in the exposed group were typically within the normal ranges.

Mezzacappa (2017) found an association with prenatal antidepressant exposure and autism spectrum

disorders, while Brown (2017) did not. Brown conjectured that an observed association in some

included studies may have been due to residual confounding in the measurement of maternal mental

illness.

Significant decreases in depressive symptoms in treatment groups compared to controls were found in

both treatment and prevention studies, leading to the conclusion that despite widely varying

methodological quality of the included studies, there is strong evidence that Cognitive Behavioral

Therapy interventions are effective for treating and preventing depression during the perinatal period

(Sockol, 2015). An evaluation of Cognitive Behavioral Therapy showed a robust benefit; interpersonal

therapy showed a medium treatment effect; however, the studies were inconsistent (van Ravesteyn,

2017). Acupuncture and body-oriented interventions showed medium reductions.

A low proportion of women meet American College of Obstetricians and Gynecologists

recommendations for exercise during the third trimester, and nearly a third reported not receiving

advice from a provider about physical activity during pregnancy (Santo, 2017). Any type of exercise

intervention among pregnant women was associated with a significant decrease in depression scores

(Daley, 2015). However, this conclusion was based on a low number of significantly heterogeneous

studies with wide conference intervals. Yoga integrating pranayama and meditation or deep relaxation

was effective in reducing depression scores, while yoga consisting solely of physical exercises was not

(Gong, 2015). However, the small number of included studies limits certainty.

Meta-analyses on computer- or web-based therapies, mindfulness-based interventions, transcranial

magnetic stimulation, acupuncture, bright light therapy, massage, and omega-3 fatty acids have not

resulted in conclusive findings due to small study numbers and sample sizes, heterogeneity of study

designs and interventions, and methodological issues (Ashford, 2016; Dennis, 2013; Felipe, 2016; Hall,

2016; Lever Taylor, 2016; Shi, 2017). Injections of Botulinum toxin type A (“Botox”) in the facial glabellar

frown muscles for depression show efficacy, but meta-analyses were based on a small number of

studies and sample sizes (Magid, 2015; Hawlik, 2014). Importantly, there are inadequate data on the

developmental risk associated with use of Botox in pregnant women.

Policy updates:

In 2018, we updated one guideline and added five peer-reviewed publications to the reference list. No

policy changes are warranted at this time. Policy ID changed from 120106 to CCP.1339.

Summary of clinical evidence:

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Citation Content, Methods, Recommendations

Brown (2017) The association between antenatal exposure to selective serotonin reuptake inhibitors and autism: A systematic review and meta-analysis

Key points:

This analysis examined maternal exposure to selective serotonin reuptake inhibitors and autism in children, and assessed maternal mental illness as a confounder. Included in the meta-analysis were four case-control studies and two cohort studies.

In the case-control studies, the adjusted pooled odds ratio (aPOR) values were 1.4 (95% confidence interval [CI], 1.0 - 2.0) (exposure in any period) and 1.7 (95% CI, 1.1 - 2.6) (exposure during first trimester). In analyses adjusted for maternal mental illness, only first trimester exposure remained statistically significant (aPOR = 1.8; 95% CI, 1.1 - 3.1). In maternal mental illness-restricted analyses, neither exposure period was statistically significant.

In the cohort studies, relative risk values adjusted for maternal mental illness were 1.5 (95% CI, 0.9 - 2.7) (any period) and 1.4 (95% CI, 1.0 - 1.9) (first trimester only). In maternal mental illness-restricted analyses, exposure to selective serotonin reuptake inhibitors at any time during pregnancy was not significant.

Mezzacappa (2017) Risk for autism spectrum disorders according to period of prenatal antidepressant exposure: A systematic review and meta-analysis

Key points:

This analysis aimed to assess the association between autism spectrum disorders and fetal exposure to antidepressants during pregnancy for each trimester of pregnancy and preconception. The primary outcome was the association between antidepressants during pregnancy and autism spectrum disorders. Secondary outcomes were the associations between antidepressants in each individual trimester or before pregnancy and autism spectrum disorders.

The literature search identified 10 relevant studies with inconsistent results. For prenatal exposure, the meta-analysis on the six case-control studies (117,737 patients) provided evidence for a positive association between antidepressant exposure and autism spectrum disorders (odds ratio [OR], 1.81; 95% CI, 1.49 - 2.20). The association was weaker when the analysis controlled for past maternal mental illness (OR, 1.52; 95% CI, 1.09 - 2.12). A similar pattern was found for any trimester of exposure considered (first trimester: OR, 2.09, 95% CI, 1.66 - 2.64; second: OR, 2.00, 95% CI, 1.55 - 2.59; and third: OR, 1.90, 95% CI, 1.20 - 3.02. When the analysis controlled for past maternal mental illness, the findings were: first trimester: OR, 1.79; 95% CI, 1.27 - 2.52, second: OR, 1.67, 95% CI, 1.14 - 2.45; and third: OR, 1.54, 95% CI, 0.82 - 2.90). No association was found when the two cohort studies were pooled (772,331 patients) for the whole pregnancy (hazard ratio, 1.26; 95% CI, 0.91 - 1.74) or for the first trimester. Additionally, preconception exposure to antidepressants was significantly associated with an increased risk for autism spectrum disorders (OR controlled for past maternal illness, 1.77; 95% CI, 1.49 - 2.09).

There is a significant association between increased autism spectrum disorder risk and maternal use of antidepressants during pregnancy; however, it appears to be more consistent during the preconception period than during each trimester. Maternal mental disorders in preconception treatment rather than antenatal exposure to antidepressants may be a major factor in the risk for autism spectrum disorders.

van Ravesteyn (2017) Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis

Key points:

This analysis aimed to understand all available treatments for antenatal mental disorders. Twenty-nine trials on antepartum mental disorders involving 2,779 participants were found. Trials studied patients with depressive disorders (number studies = 28), and anxiety disorders (number studies = 1) during pregnancy. No controlled pharmacological trials were detected for inclusion.

The results showed that a form of psychotherapy, like Cognitive Behavioral Therapy (g = -0.61; 95% CI: -0.73 to -0.49, I2 = 0%; number studies = 7) or interpersonal

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Citation Content, Methods, Recommendations

psychotherapy (g = -0.67; 95% CI: -1.27 to -0.07; I2 = 79%; number studies = 4), holds robust benefit for pregnant women with major depressive disorder.

Body-oriented interventions (g = -0.43; 95% CI: -0.61 to -0.25; I2 = 17%; number studies = 7) and acupuncture (g = -0.43; 95% CI: -0.80 to -0.06; I2 = 0%; number studies = 2) showed medium-sized reduction of depressive symptoms. Bright light therapy (g = -0.59; 95% CI: -1.25 to 0.06; I2 = 0%; number studies = 2), and food supplements (g = -0.51; 95% CI: -1.02 to 0.01; I2 = 20%; number studies = 3) did not show significant treatment effects.

Findings show a robust moderate treatment effect for Cognitive Behavioral Therapy for major depressive disorder during pregnancy. A lesser treatment effect was found for interpersonal psychotherapy. Positive medium-size treatment effects were found for the alternatives of body-oriented interventions and acupuncture, and no evidence was found for bright light or food supplements.

O’Connor (2016)

The association between

antenatal exposure to

selective serotonin reuptake

inhibitors and autism: A

systematic review and meta-

analysis

Key points:

This study assessed the benefits and harms of depression screening and treatment, and accuracy of selected screening instruments, for pregnant and postpartum women. The outcomes examined were depression remission, prevalence, symptoms, and related measures of depression recovery or response; sensitivity and specificity of selected screening measures to detect depression; and serious adverse effects of antidepressant treatment.

Among pregnant and postpartum women 18 years and older, six trials (n = 11,869) showed 18% to 59% relative reductions with screening programs, or 2.1% to 9.1% absolute reductions, in the risk of depression at follow-up (three to five months) after participation in programs involving depression screening, with or without additional treatment components, compared with usual care.

Based on 23 studies (n = 5,398), a cutoff of 13 on the English-language Edinburgh Postnatal Depression Scale demonstrated sensitivity ranging from 0.67 (95% CI, 0.18 - 0.96) to 1.00 (95% CI, 0.67 to- 1.00) and specificity consistently 0.87 or higher. Data were sparse for Patient Health Questionnaire instruments.

Pooled results for the benefit of Cognitive Behavioral Therapy for pregnant and postpartum women with screen-detected depression showed an increase in the likelihood of remission (pooled relative risk, 1.34 [95% CI, 1.19 to 1.50]; number of studies = 10, I2 = 7.9%) compared with usual care, with absolute increases ranging from 6.2% to 34.6%.

Observational data showed that second-generation antidepressant use during pregnancy may be associated with small increases in the risks of potentially serious harms.

The authors concluded that direct and indirect evidence suggests that screening pregnant and postpartum women for depression can reduce depressive symptoms and the prevalence of depression. Evidence for improvement among pregnant women was sparser but was consistent with the evidence among postpartum women regarding the screening and treatment benefits, and screening instrument accuracy.

Eke (2016)

Selective serotonin reuptake

inhibitor (SSRI) use during

pregnancy and risk of

preterm birth: A systematic

review and meta-analysis

Key points:

This study assessed the risk of preterm birth with exposure to prenatal selective serotonin reuptake inhibitors. The primary outcome was the incidence of preterm birth <37 weeks. A subgroup analysis of studies in which controls were defined as women with depression but without selective serotonin reuptake inhibitors exposure during pregnancy was also planned.

Eight studies (1,237,669 women) were included: 93,982 in the exposure group and

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Citation Content, Methods, Recommendations

1,143,687 in the control group. After adjusting for confounders, the incidence of preterm birth was significantly higher in the group of women treated with selective serotonin reuptake inhibitors compared with controls (i.e., both women with depression but without selective serotonin reuptake inhibitors exposure and women without depression) (adjusted OR 1.24, 95% CI 1.09 to 1.41).

In the subgroup analysis of studies in which the control group was defined as women with depression without selective serotonin reuptake inhibitors exposure during pregnancy, an increased risk of preterm birth (6.8% versus 5.8%; OR 1.17, 95% CI 1.10 to 1.25) in the selective serotonin reuptake inhibitors group was found compared with depressed women treated with psychotherapy alone).

Women who received selective serotonin reuptake inhibitors during pregnancy had a significantly higher risk of developing preterm birth compared with controls. This higher risk remained significant even when comparing depressed women on selective serotonin reuptake inhibitors with women not on selective serotonin reuptake inhibitors.

Jordan (2016) Selective serotonin reuptake inhibitor (SSRI) antidepressants in pregnancy and congenital anomalies: Analysis of linked databases in Wales, Norway and Funen, Denmark

Key points:

This international analysis included 519,117 deliveries in an examination of selective serotonin reuptake inhibitors and congenital anomalies. Fetuses terminated for congenital anomalies and data covering pregnancy and the preceding quarter, including 462,641 cases with data covering pregnancy and one year either side, were included.

Selective serotonin reuptake inhibitors prescription 91 days either side of the last menstrual period was associated with increased prevalence of severe congenital heart defects (34/12,962 [0.26%] vs. 865/506,155 [0.17%] OR 1.50, 1.06 to 2.11), as well as with a composite adverse outcome of “anomaly or stillbirth” (473/12,962, 3.65% vs. 15,829/506,155, 3.13%, OR 1.13, 1.03 to 1.24). The increased prevalence of all major anomalies combined did not reach statistical significance (3.09% [400/12,962] vs. 2.67% [13,536/506,155], OR 1.09, CI 0.99 to 1.21). Adjusting for socioeconomic status left ORs largely unchanged.

The prevalence of anomalies and severe congenital heart defect was reduced when selective serotonin reuptake inhibitors prescriptions were stopped or paused preconception, and increased when >1 prescription was recorded, but differences were not statistically significant. The dose-response relationship between severe congenital heart defect and selective serotonin reuptake inhibitor dose (meta-regression OR 1.49, CI 1.12 to 1.97) was consistent with selective serotonin reuptake inhibitor-exposure related risk. A sub-analysis in Wales suggested no associations between anomalies and diagnosed depression.

Sockol (2015) A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression

Key points:

Forty randomized and quasi-randomized controlled trials evaluated the efficacy of Cognitive Behavioral Therapy during pregnancy and one year postpartum in both treatment and prevention studies.

Cognitive Behavioral Therapy interventions resulted in significant decreases in depressive symptoms compared to control conditions in both treatment and prevention studies.

Postpartum interventions showed higher efficacy than prenatal interventions. In prevention trials, individually administered treatments were more effective than group interventions and greater reductions in depressive symptoms were found in studies that included higher proportions of nonwhite, single, and multiparous participants.

Methodological quality of included studies varied widely among studies eligible for inclusion. However, overall, there was strong evidence for efficacy of Cognitive Behavioral Therapy interventions for treating and preventing depression during the perinatal period.

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Citation Content, Methods, Recommendations

Ross (2013) Selected pregnancy and delivery outcomes after exposure to antidepressant medication: A systematic review and meta-analysis

Key points:

Aim: To determine whether prenatal antidepressant exposure is associated with risk for selected adverse pregnancy or delivery outcomes. The meta-analysis included 23 studies.

No significant association was found between antidepressant medication exposure and spontaneous abortion (OR 1.47; CI, 0.99 to 2.17; borderline significance). Gestational age and preterm delivery were statistically significantly associated with antidepressant exposure (mean difference in weeks = -0.45; CI - 0.64 to - 0.25; and OR 1.55; CI, 1.38 to 1.74, respectively). This held true regardless of whether the comparison group consisted of all unexposed mothers or only depressed mothers without antidepressant exposure.

Antidepressant exposure during pregnancy was significantly associated with lower birth weight (mean difference in grams = -74; CI - 117to- - 31). However, when this comparison group was limited to depressed mothers without antidepressant exposure, there was no longer a significant association.

Antidepressant exposure was significantly associated with lower Apgar scores at one and five minutes, regardless of whether the comparison group was all mothers or only those who were depressed but not treated with antidepressants.

Conclusion: While statistically significant associations between antidepressant exposure and pregnancy and delivery outcomes were identified, group differences were small and scores in the exposed group were typically within the normal ranges.

References

Professional society guidelines/other:

American College of Obstetricians and Gynecologists (ACOG). Use of psychiatric medications during pregnancy and lactation. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Apr. Reaffirmed 2018. (ACOG practice bulletin; no. 92).

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text Revision - Fourth. Washington, D.C.: American Psychiatric Association; 2000.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. Excerpt on dysthymia downloaded from: http://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_PersistentDepressiveDisorder.pdf. Excerpt on depression downloaded from http://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf. Accessed August 3, 2018. U.S. Preventive Services Task Force. Final recommendation statement: depression in adults: screening.

Rockville (MD): 2016 Jan. Downloaded from

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-

adults-screening1 . Accessed August 3, 2018.

Peer-reviewed references:

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Andersson NW, Hansen MV, Larsen AD, Hougaard KS, Kolstad HA, Schlunssen V. Prenatal maternal stress and atopic diseases in the child: a systematic review of observational human studies. Allergy. 2016;71(1):15-26. doi: 10.1111/all.12762. Araujo DM, Vilarim MM, Sabroza AR, Nardi AE. [Depression during pregnancy and low birth weight: a systematic literature review]. Cadernos de saude publica. 2010;26(2):219-227. Ashford MT, Olander EK, Ayers S. Computer- or web-based interventions for perinatal mental health: A

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Lever Taylor B, Cavanagh K, Strauss C. The effectiveness of mindfulness-based interventions in the

perinatal period: A systematic review and meta-analysis. PloS one. 2016;11(5):e0155720.

doi: 10.1371/journal.pone.0155720.

Mezzacappa A, Lasica PA, Gianfagna F, et al. Risk for autism spectrum disorders according to period of

prenatal antidepressant exposure: a systematic review and meta-analysis. JAMA Pediatr.

2017;171(6):555-563. doi: 10.1001/jamapediatrics.2017.0124.

Mitchell J, Goodman J. Comparative effects of antidepressant medications and untreated major

depression on pregnancy outcomes: a systematic review. Arch Women's Ment Health. 2018. doi: doi:

10.1007/s00737-018-0844-z.

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Molenaar NM, Kamperman AM, Boyce P, Bergink V. Guidelines on treatment of perinatal depression

with antidepressants: An international review. Aust N Z J Psych. 2018;52(4):320-327. doi:

10.1177/0004867418762057.

Nillni YI, Mehralizade A, Mayer L, Milanovic S. Treatment of depression, anxiety, and trauma-related

disorders during the perinatal period: a systematic review. Clin Psychol Rev. 2018. doi:

10.1016/j.cpr.2018.06.004.

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment

of depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US

Preventive Services Task Force. JAMA. 2016;315(4):388-406. doi: 10.1001/jama.2015.18948.

Ross LE, Grigoriadis S, Mamisashvili L, et al. Selected pregnancy and delivery outcomes after exposure to

antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry. 2013;70(4):436-

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Meta-analyses of diagnoses and symptoms. Psychol Bull. 2017;143(8):783-822. doi:

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advice during pregnancy. BMC Pregnancy Childbirth. 2017;17(1):286. doi: 10.1186/s12884-017-1460-z.

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Affect Disord. 2018;232:316-328. doi: 10.1016/j.jad.2018.01.018

Thombs BD, Arthurs E, Coronado-Montoya S, et al. Depression screening and patient outcomes in

pregnancy or postpartum: A systematic review. J Psychosom Res. 2014;76(6):433-446. doi:

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National Coverage Determinations:

None identified as of the writing of this policy.

14

Local Coverage Determinations:

None identified as of the writing of this policy.

InterQual®

InterQual Clinical Evidence Summary: Depressive disorders

InterQual 2015: BH: Adult Psychiatry. Adult Depressed Mood (Concurrent Review); (Initial Review)

InterQual 2015: BH: Adult Psychiatry. Adult Depressed Mood (Concurrent Review); (Initial Review)

InterQual 2015: BH: Adolescent Psychiatry. Adolescent Depressed Mood (Concurrent Review); (Initial

Review)

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

CPT Code Description Comments

90868 - 90869 Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment;

subsequent delivery and management, per session

97810- 97814 Acupuncture, 1 or more needles; with/without electrical stimulation

96825-96828 Doppler echocardiography

ICD-10 Code Description Comments

O99.340 Other mental disorders complicating pregnancy, unspecified trimester

O99.341 Other mental disorders complicating pregnancy, first trimester

O99.342 Other mental disorders complicating pregnancy, second trimester

O99.343 Other mental disorders complicating pregnancy, third trimester

HCPCS

Level II Code Description Comments

S9454 Stress management classes, non-physician provider, per session