Mental Health Board Prep

Depression, anxiety, substance use, and behavioral health are increasingly central to family medicine. Daily ABFM practice grounded in DSM-5-TR.

Mental health and behavioral medicine make up roughly 7 to 9 percent of the ABFM Family Medicine boards. The content reflects the reality that primary care delivers most mental health care in the United States: depression and anxiety treatment, substance use screening and management, ADHD across the lifespan, sleep disorders, and the psychiatric components of medical conditions. The dominant references are DSM-5-TR (2022), the USPSTF screening recommendations, the APA practice guidelines, and the ASAM substance use guidelines.

Major depressive disorder is the most-tested mental health topic. DSM-5-TR criteria require at least 5 of 9 symptoms over the same 2-week period, including either depressed mood or anhedonia, with functional impairment. PHQ-9 is the screening and severity tracking tool of choice in primary care. USPSTF recommends universal screening for depression in all adults (Grade B), in adolescents 12 and older (Grade B), and in pregnant and postpartum women (Grade B). Treatment for moderate to severe depression includes SSRIs or SNRIs, often combined with psychotherapy. Sertraline, escitalopram, and citalopram are generally first-line in primary care due to favorable side effect profiles and drug interactions. Time to onset is 4 to 6 weeks; do not switch agents prematurely.

Anxiety disorders, especially generalized anxiety disorder, are the second-most tested area. GAD-7 is the standard screening tool. Treatment parallels depression: SSRIs/SNRIs first-line, with CBT as effective as medication for many patients. Benzodiazepines have limited role due to dependence risk and are not first-line. Buspirone is an option for GAD that does not respond to or tolerate SSRIs.

Substance use disorders are a high-yield area with practical guideline-based answers. AUDIT-C and AUDIT screen for alcohol use disorder. Treatment includes naltrexone (oral or extended-release injectable), acamprosate, or disulfiram for AUD. For opioid use disorder, buprenorphine, methadone, or naltrexone are all first-line — buprenorphine is most accessible in primary care and now does not require an X-waiver. Tobacco cessation pharmacotherapy includes nicotine replacement, varenicline (most effective), and bupropion. The exam tests appropriate medication selection and counseling integration.

ADHD across the lifespan, sleep disorders (insomnia, OSA — overlapping with respiratory), bipolar disorder recognition (especially "switching" on antidepressants), and serious mental illness comorbidities round out the testable content. Suicide risk assessment is a recurring theme: ask about ideation, plan, intent, access to means, prior attempts, and protective factors. Means restriction (especially firearms) is one of the most effective interventions and is testable.

High-yield mental health topics

• Major depressive disorder diagnosis and first-line therapy. DSM-5-TR: 5 or more of 9 symptoms over 2 weeks (depressed mood, anhedonia, weight change, sleep change, psychomotor change, fatigue, worthlessness or guilt, concentration, suicidality) with functional impairment. First-line: SSRI (sertraline, escitalopram) or SNRI (venlafaxine, duloxetine). Pair with psychotherapy when available.
• PHQ-9 and GAD-7 in primary care. PHQ-9: scores 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, 20 to 27 severe. GAD-7: scores 5, 10, 15 are cutoffs for mild, moderate, severe anxiety. Use for both screening and tracking response. Treatment threshold is generally PHQ-9 of 10 or higher.
• Suicide risk assessment. Ask directly about ideation, plan, intent, access to means, prior attempts, current substance use. Means restriction (especially firearms in the home) reduces suicide death. Hospitalize for active intent, plan with means, recent attempt. Safety planning intervention is evidence-based for outpatient management.
• Alcohol use disorder pharmacotherapy. Naltrexone (oral 50 mg daily or extended-release injectable monthly): reduces heavy drinking and craving. Acamprosate (333 mg three times daily): supports abstinence after detox. Disulfiram: aversive therapy, requires high motivation. Combine with behavioral therapy. AUDIT-C and AUDIT screen and stratify severity.
• Opioid use disorder treatment. Buprenorphine (sublingual or extended-release injectable): primary care accessible, no waiver required since 2023. Methadone: only at federally licensed clinics. Extended-release naltrexone: requires opioid-free period before initiation. Treat as a chronic disease; medication-assisted treatment reduces mortality more than abstinence-based approaches.
• Tobacco cessation pharmacotherapy. Varenicline (most effective): 0.5 mg daily titrating to 1 mg twice daily. Combination NRT (long-acting patch plus short-acting gum or lozenge) is comparable. Bupropion: also effective, lower seizure threshold. Combine pharmacotherapy with behavioral counseling for best outcomes. Quit dates 1 to 2 weeks after starting medication.
• Bipolar disorder recognition. Suspect when antidepressant treatment causes "switching" to mania or hypomania, in patients with episodic mood elevation, decreased need for sleep, grandiosity, and pressured speech. Mood stabilizers (lithium, valproate, lamotrigine) and atypical antipsychotics are mainstays. Refer to psychiatry for diagnosis confirmation and management.
• Insomnia management. Cognitive behavioral therapy for insomnia (CBT-I) is first-line, more effective long-term than medications. Sleep hygiene alone is not sufficient. Short-term medication options: melatonin agonists (ramelteon), low-dose doxepin, or non-benzodiazepine hypnotics (zolpidem) used cautiously. Avoid chronic benzodiazepines.

ABFM exam tips

Anchor on PHQ-9 thresholds. Score of 10 or higher generally warrants treatment. Score of 20 or higher is severe and may warrant medication, psychotherapy, and consideration of psychiatric referral. The exam uses PHQ-9 numbers in vignettes and expects you to act on them.

For depression treatment, sertraline is the safest first-line in most contexts. Few drug interactions, well-tolerated, available at low cost. Escitalopram is similar but slightly more drug interactions. Avoid citalopram doses over 20 mg in patients over 60 due to QT prolongation risk.

SSRIs take 4 to 6 weeks for full effect. Do not switch antidepressants at 2 weeks for "non-response." If partial response at 6 weeks, increase the dose first. Switch to a different agent only after adequate trial at adequate dose.

Recognize bipolar features before starting an antidepressant. Episodic mood elevation, decreased need for sleep, grandiose thinking, pressured speech, hypersexuality, and impulsivity in the past suggest bipolar. Starting an SSRI in an undiagnosed bipolar patient can precipitate mania. Screen with mood disorder questionnaires when suspicion exists.

For substance use, motivational interviewing is testable. The five A's (ask, advise, assess, assist, arrange) and motivational interviewing (open questions, affirmations, reflective listening, summarizing) are the evidence-based approaches. Brief intervention plus pharmacotherapy beats counseling alone.

Suicide risk is a "do not miss." Direct questions about suicidal ideation do not increase risk and are essential. Ask about plan, intent, and access to means. Means restriction (firearm storage, medication safety) is one of the few proven population-level interventions. Hospitalize for active intent with plan and means.

Common pitfalls

Do not start a benzodiazepine for chronic anxiety. Benzodiazepines treat acute anxiety but cause dependence with chronic use, increase fall risk in older adults, and are associated with cognitive decline and increased mortality. SSRIs/SNRIs and CBT are first-line for chronic anxiety. The exam tests this restraint.

Do not stop SSRIs abruptly. Discontinuation syndrome (flu-like symptoms, dizziness, electric shock sensations, irritability) is common, especially with paroxetine and venlafaxine. Taper over weeks to months. Patients on SSRIs longer than 6 to 8 weeks need a tapering plan.

Do not miss alcohol withdrawal in admitted patients. Patients with significant alcohol use are at risk of withdrawal seizures and delirium tremens 24 to 72 hours after the last drink. CIWA scoring and prophylactic benzodiazepines (in this acute setting only) prevent severe withdrawal. Outpatient AUD treatment is a separate question.

Do not use bupropion in patients with seizure disorder, eating disorder history, or in withdrawal from alcohol or sedatives. It lowers seizure threshold. Otherwise it is a useful agent for depression with weight or fatigue concerns and is also FDA-approved for smoking cessation.

Do not require abstinence before starting OUD treatment. Buprenorphine and methadone work best when started without a waiting period. The "treatment requires abstinence" mindset delays effective care and increases mortality risk. Naltrexone, by contrast, does require an opioid-free period (7 to 14 days) before initiation.

Do not assume a patient with new mood symptoms in older age has primary depression. Late-life depression should prompt evaluation for medical causes: hypothyroidism, B12 deficiency, sleep apnea, medication effects, vascular depression, and early dementia. Treat reversible causes alongside antidepressants.

Do not forget that ADHD persists into adulthood. About 60 percent of childhood ADHD continues into adulthood. Adults present with disorganization, time management difficulties, and emotional dysregulation rather than overt hyperactivity. Stimulants (methylphenidate, amphetamines) and atomoxetine are appropriate; screen carefully for substance use given diversion risk.

Frequently asked questions

What is the first-line treatment for depression in primary care?

SSRIs (sertraline, escitalopram, citalopram, fluoxetine) or SNRIs (venlafaxine, duloxetine) are first-line, paired with psychotherapy (CBT or interpersonal) when available. Sertraline is often the practical first choice due to its favorable side effect profile, low drug interaction risk, and broad evidence base. Allow 4 to 6 weeks for effect.

How is anxiety different from depression on the boards?

Both share many features and often coexist. Generalized anxiety disorder requires excessive worry more days than not for at least 6 months, with at least 3 associated symptoms (restlessness, fatigue, concentration, irritability, muscle tension, sleep disturbance). GAD-7 quantifies severity. SSRIs and SNRIs treat both; CBT is also first-line.

Are benzodiazepines ever appropriate for chronic anxiety?

Generally no. Benzodiazepines are useful for acute panic or short-term bridging while SSRIs take effect, but chronic use carries dependence, cognitive, and mortality risks. They are not first-line for chronic anxiety and are tested as a wrong-answer option in most chronic management vignettes.

How do I screen for alcohol use disorder?

AUDIT-C is the brief 3-item screen, with positive scores of 4 or higher in men and 3 or higher in women. The full AUDIT (10 items) provides severity grading. Beyond screening, ask about consequences (relationships, work, legal, health), tolerance, withdrawal, and unsuccessful attempts to cut down. DSM-5 criteria require 2 of 11 symptoms over 12 months.

What is the role of buprenorphine in primary care?

Buprenorphine is the most accessible medication for opioid use disorder in primary care. Since 2023, the X-waiver requirement was removed, so any DEA-registered prescriber can prescribe it. It reduces overdose mortality by 50 percent or more in OUD and is appropriate for outpatient initiation in stable patients. It is a high-yield ABFM topic.

How is ADHD diagnosed in adults?

DSM-5 criteria require 5 or more symptoms (vs 6 in children) of inattention or hyperactivity-impulsivity, present before age 12, in 2 or more settings, with functional impairment. Self-report measures (ASRS-v1.1) help screen. Rule out other causes (sleep deprivation, depression, anxiety, substance use, thyroid). Treat with stimulants, atomoxetine, or alpha-2 agonists.

When should I refer to psychiatry?

Suspected bipolar or psychotic disorders, treatment-resistant depression (failure of 2 adequate medication trials), severe suicidality, complex comorbidities, eating disorders requiring intensive treatment, and pediatric ADHD complicated by other diagnoses. Most uncomplicated unipolar depression and anxiety can be managed in primary care.