Updated for 2026
FNP mental health: depression, anxiety, ADHD, and primary care psychiatric prescribing
Mental health conditions are among the most common presentations in primary care. The FNP manages depression, anxiety disorders, ADHD, and substance use in the outpatient setting, and must recognise when psychiatric specialist referral is appropriate. FNP certification exams test screening tools, first-line pharmacotherapy, monitoring parameters, and safety assessment.
Educational purpose: This content is for exam preparation and professional development only. It is not intended for clinical decision-making. Always follow current guidelines, institutional policies, and scope of practice.
Major depressive disorder — screening and primary care management
USPSTF screening recommendation: Screen all adults ≥18 years (B recommendation) and adolescents 12–18 years (B recommendation) for depression using validated tools. PHQ-9 (nine-item; scores 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe) is most widely used. PHQ-2 (two-item) as a brief initial screen.
First-line pharmacotherapy: SSRIs are first-line for MDD in primary care. Sertraline (Zoloft) is commonly preferred for: favorable side-effect profile, few drug interactions, efficacy across multiple conditions (MDD, GAD, OCD, PTSD, PMDD). Escitalopram (Lexapro) — most selective SSRI, excellent tolerability. Key SSRI teaching: takes 4–6 weeks for full antidepressant effect; suicidality risk may increase in first 2 weeks (particularly patients <25); do not stop abruptly (discontinuation syndrome); sexual dysfunction is common; QTc prolongation risk with citalopram/escitalopram at high doses.
Monitoring: PHQ-9 at 4 and 8 weeks after initiation. If inadequate response after 6–8 weeks at adequate dose — augment (add bupropion or aripiprazole) or switch to a different antidepressant. Adequate dose trial: 6–8 weeks at full therapeutic dose before switching.
Referral criteria: Bipolar disorder suspected, psychotic features, active suicidal ideation with plan, treatment-resistant depression (>2 adequate trials), complex comorbidities requiring specialised management.
Anxiety disorders — GAD, panic disorder, and social anxiety
GAD diagnosis: DSM-5 criteria: excessive anxiety about multiple domains for ≥6 months, difficult to control worry, ≥3 symptoms (fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance, restlessness), significant functional impairment. GAD-7 ≥10 = possible GAD (sensitivity 89%, specificity 82%).
First-line treatment: SSRIs (sertraline, escitalopram, paroxetine) or SNRIs (venlafaxine, duloxetine). Buspirone is an alternative non-habit-forming option (takes 2–4 weeks to work — not PRN). Cognitive behavioural therapy (CBT) has equivalent efficacy to pharmacotherapy and combination is superior to either alone. Benzodiazepines: short-term only, use with caution (dependence, cognitive effects, falls in elderly). Hydroxyzine: useful for acute anxiety without dependence risk.
Panic disorder: Recurrent unexpected panic attacks + persistent concern about attacks or maladaptive behavioural changes. First-line: SSRIs, SNRIs, or CBT. Avoid benzodiazepines as monotherapy. Alprazolam (Xanax) is high-potency, short-acting, and carries high dependence risk — avoid in primary care if possible.
ADHD diagnosis and management across the lifespan
Diagnosis: DSM-5 requires symptoms present in two or more settings, onset before age 12, ≥6 symptoms (≥5 if ≥17 years old) of inattention and/or hyperactivity-impulsivity, duration ≥6 months, significant functional impairment. Use rating scales (Vanderbilt for children, ADHD Rating Scale, Conners) and collateral information (parent/teacher report for children, partner/employer for adults).
Pharmacotherapy: Stimulants are first-line: methylphenidate (Ritalin, Concerta) and amphetamine salts (Adderall, Vyvanse). Schedule II controlled substances. Monitor: BP, HR, weight/growth (children), sleep, appetite, substance use history (diversion risk). Non-stimulants for patients with substance use disorder, bipolar disorder, stimulant intolerance, or tic disorders: atomoxetine (SNR mechanism), guanfacine (alpha-2 agonist), viloxazine.
DEA Schedule II requirements: No refills, written or electronic prescription per state regulations, quantity limits. FNP must have DEA registration to prescribe. Monitor for signs of misuse or diversion, especially in college-age patients.
Frequently asked questions
- What is the USPSTF recommendation for depression screening in adults and adolescents?
- USPSTF recommends depression screening for all adults ≥18 years (B recommendation — moderate certainty of substantial net benefit) and for adolescents aged 12–18 years when adequate systems are in place for accurate diagnosis, treatment, and follow-up (B recommendation). The recommendation applies to general primary care populations without signs/symptoms of depression. Screen using a validated tool (PHQ-9 for adults, PHQ-A for adolescents, or Edinburgh Postnatal Depression Scale in pregnant/postpartum women). There is insufficient evidence to recommend for or against screening in children <12 years.
Clinically reviewed by NurseNest Clinical Review Team · Last updated 2026-06-10 · For educational purposes only · Review policy