Family nurse practitioner's scope of practice in treating mental illness in primary care in indiana

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Hi there,

I only know Indiana is a reduced practice state, and the FNP in IN can treat GAD, depression. Are there any specific mental diseases that the FNP cannot diagnose and/or treat (any specific therapies that we need PA or MD's signature?) I think we cannot diagnose ADD, ADHD, Bipolar.

 

Thank you very much!

Specializes in Former NP now Internal medicine PGY-3.
3 hours ago, AM MSN said:

Again, why does a physician’s opinion have anything to do with this question? It is 100% outside of the FNP’s scope to diagnose and treat beyond STABLE anxiety and depression. I was speaking to the FNP’s scope as I’m aware of what a physician’s is. Adding a general medicine physician’s opinion, experience, or training is a moot point here which is why I brought up derm. It really has nothing to do with this conversation.

I would disagree, mostly as even psychiatry groups want PCPs to have a better handle on psych disorders. Sometimes as numenor said something is better than nothing. 
 

But I agree lithium is too much of a headache to monitor  most of the other ones are not such as seroquil, lamictal, etc  

 

I gave my opinion as I was previously an FNP and the forum is open to everyone  

even PCP needs to be able to have an understanding of basic psych. Patients cannot always connect an ADR to a specific med. In the hospital we often deal w AE from psych meds. So even if psych is on board PCPs should not ignore psych medication since it’s probably the most rxed group of meds.

it’s probably worse that they have FNP in the hospital managing cardiac drips versus outpatient FNP managing psych issues occasionally.

 

but back to the original question it is reasonable to be comfortably initiating therapy in several psych dx. More importantly though is making sure the diagnosis is correct. Unless you can get them in with psych quickly then I would just punt to them. See below.

 

unstable patients obviously just get sent to inpatient

https://www.psychiatrist.com/pcc/bipolar/diagnosis-treatment-bipolar-disorder-decision-making/

 

The real answer in a reduced practice state is what you’re attending allows you to do. If you have a well trained physician as you’re attending then yes you should with help be able to initiate treatment for bipolar disorder. Anything less is not doing your patient good service. 

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2 hours ago, Tegridy said:

I would disagree, mostly as even psychiatry groups want PCPs to have a better handle on psych disorders. Sometimes as numenor said something is better than nothing. 
 

But I agree lithium is too much of a headache to monitor  most of the other ones are not such as seroquil, lamictal, etc  

 

I gave my opinion as I was previously an FNP and the forum is open to everyone  

even PCP needs to be able to have an understanding of basic psych. Patients cannot always connect an ADR to a specific med. In the hospital we often deal w AE from psych meds. So even if psych is on board PCPs should not ignore psych medication since it’s probably the most rxed group of meds.

it’s probably worse that they have FNP in the hospital managing cardiac drips versus outpatient FNP managing psych issues occasionally.

 

but back to the original question it is reasonable to be comfortably initiating therapy in several psych dx. More importantly though is making sure the diagnosis is correct. Unless you can get them in with psych quickly then I would just punt to them. See below.

 

unstable patients obviously just get sent to inpatient

https://www.psychiatrist.com/pcc/bipolar/diagnosis-treatment-bipolar-disorder-decision-making/

 

The real answer in a reduced practice state is what you’re attending allows you to do. If you have a well trained physician as you’re attending then yes you should with help be able to initiate treatment for bipolar disorder. Anything less is not doing your patient good service. 

I’m going to disagree. It is outside of an FNP’s scope to treat psychiatric disorders outside of stable anxiety and depression. Period. Please refer to the Ohio.gov article I shared. There is also an ongoing APNA thread currently discussing this as many PMHNPs are being asked to testify through the BON as to what their training and scope is against FNP colleagues who diagnosed and treated psychiatric disorders. If you do not have the training in school, which FNPs do not, you should not be providing this care. 

Please refer to your state BON for further clarification, but with all due respect, a general physician should not be giving their opinion on the matter or on this thread. As you said, you don’t even have a scope. 

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Specializes in Former NP now Internal medicine PGY-3.
2 hours ago, AM MSN said:

I’m going to disagree. It is outside of an FNP’s scope to treat psychiatric disorders outside of stable anxiety and depression. Period. Please refer to the Ohio.gov article I shared. There is also an ongoing APNA thread currently discussing this as many PMHNPs are being asked to testify through the BON as to what their training and scope is against FNP colleagues who diagnosed and treated psychiatric disorders. If you do not have the training in school, which FNPs do not, you should not be providing this care. 

Please refer to your state BON for further clarification, but with all due respect, a general physician should not be giving their opinion on the matter or on this thread. As you said, you don’t even have a scope. 

The terminology is vague on the article you quoted. “Such as” was only giving examples. “Complicated and severe” honestly does not include most mental illness, even several that would not fall under “anxiety or depression”. I would agree that complex and severe should be managed by mental health, but most cases are not either of those. 
 

it sounds like a turf war, some of which has merit (FNP shouldn’t work IN psychiatry but to say ONLY to allow anxiety and depression? Nonsense) but honestly with all this vague terminology I’d rather just hire PAs where the rules are cut and dry (since the medical board oversees them). 

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47 minutes ago, Tegridy said:

The terminology is vague on the article you quoted. “Such as” was only giving examples. “Complicated and severe” honestly does not include most mental illness, even several that would not fall under “anxiety or depression”. I would agree that complex and severe should be managed by mental health, but most cases are not either of those. 
 

it sounds like a turf war, some of which has merit (FNP shouldn’t work IN psychiatry but to say ONLY to allow anxiety and depression? Nonsense) but honestly with all this vague terminology I’d rather just hire PAs where the rules are cut and dry (since the medical board oversees them). 

You are arguing with the state BON SOP. Write a letter with your disagreements. However, you’re giving bad advice telling a FNP to put herself in a position where their license is at stake. Turf has zero to do with it. 

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Again, not sure why a physician is on a nursing board arguing about what an APRN’s SOP is, but here’s more information on the subject. 
 

https://www.npjournal.org/article/S1555-4155(18)31013-4/fulltext?fbclid=IwAR1lpvIShUmGJmqt9KNl8ZE2fH5K4-x7PsyjqhyN6JmAueH8YASRXq4wdSs

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On 12/9/2022 at 2:37 PM, AM MSN said:

Again, not sure why a physician is on a nursing board arguing about what an APRN’s SOP is, but here’s more information on the subject. 
 

https://www.npjournal.org/article/S1555-4155(18)31013-4/fulltext?fbclid=IwAR1lpvIShUmGJmqt9KNl8ZE2fH5K4-x7PsyjqhyN6JmAueH8YASRXq4wdSs

Weird hill to die on. Forums are open to anyone and he was a FNP. 

Starting someone on a medication that eventually requires specialty assistance and having them follow up is not out of scope. Especially if the patient has a hx of mood disorders and was lost to follow up to follow up or something

If I prescribed Entresto or Meropenem is that out my scope? 

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This should be something we all know and defend - patient safety and your license should be paramount and going off of the “opinion” of some rando poster who claims to be a physician and an FNP is completely ridiculous. 
Diagnosing and treating anything other than anxiety and depression IS against a FNP’s scope - how is anyone even arguing this? Makes sense why so many are being sued right now because this is awful advice.
Refer to attached screenshot - scope is left to the certifying bodies and this is what your BON will send you. Your insurance will not defend an FNP if you diagnose and treat beyond stable anxiety and depression (meaning you’re only carrying over medications they’re already stable on) and some states, ADHD. It’s your license and if you want to treat patients and risk your future based on what someone online says with zero proof, cool.

And why in the world would a physician still be licensed as an FNP and then argue about what their physician “scope” is? That’s not the question here. 
If you scroll down and see what the FNP vs PMHNP scope is, it’ll be very clear.

https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

6FE2677E-7D55-4D35-A8DD-2A6338EA090F.jpeg

6FE2677E-7D55-4D35-A8DD-2A6338EA090F.jpeg
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Again - don’t get advice about your license and scope from someone online. Go to your state BON. When they sent this to me a gazillion years ago, it was the same as it is now. If your competencies only show you can screen for something, you will not be defended in court when you treat beyond it. This isn’t some turf war or whatever was mentioned before, this is your license so be smart about it. Good luck. 

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18 hours ago, AM MSN said:

This should be something we all know and defend - patient safety and your license should be paramount and going off of the “opinion” of some rando poster who claims to be a physician and an FNP is completely ridiculous. 
Diagnosing and treating anything other than anxiety and depression IS against a FNP’s scope - how is anyone even arguing this? Makes sense why so many are being sued right now because this is awful advice.
Refer to attached screenshot - scope is left to the certifying bodies and this is what your BON will send you. Your insurance will not defend an FNP if you diagnose and treat beyond stable anxiety and depression (meaning you’re only carrying over medications they’re already stable on) and some states, ADHD. It’s your license and if you want to treat patients and risk your future based on what someone online says with zero proof, cool.

And why in the world would a physician still be licensed as an FNP and then argue about what their physician “scope” is? That’s not the question here. 
If you scroll down and see what the FNP vs PMHNP scope is, it’ll be very clear.

https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

6FE2677E-7D55-4D35-A8DD-2A6338EA090F.jpeg

6FE2677E-7D55-4D35-A8DD-2A6338EA090F.jpeg

LOL and yet FNPs get 150 hours seeing kids in clinical and all of a sudden can treat them head to toe. But yeah mood disorders are just too much for the scope. Makes sense.

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1 hour ago, Numenor said:

LOL and yet FNPs get 150 hours seeing kids in clinical and all of a sudden can treat them head to toe. But yeah mood disorders are just too much for the scope. Makes sense.

I agree. It’s frustrating to hear that an FNP *has* to do something because of rural setting or lack of providers or appointments or whatever. Telepsych makes accessing a psych provider so much easier. There is a reason your will drop you if they get wind an FNP is treating beyond their scope, and this is a great example of that as well as why the AMA is going after NPs for scope creep. Don’t get your scope from an MD who will drop you for a PA (much like the physician in this thread said they would). They don’t know the scope difference between a PA and NP and don’t realize we’re working with our license and certification and NOT theirs. Protect your license. Protect your patients. Get your scope from your state board. 

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On 12/12/2022 at 3:03 AM, AM MSN said:

I agree. It’s frustrating to hear that an FNP *has* to do something because of rural setting or lack of providers or appointments or whatever. Telepsych makes accessing a psych provider so much easier. There is a reason your malpractice insurance will drop you if they get wind an FNP is treating beyond their scope, and this is a great example of that as well as why the AMA is going after NPs for scope creep. Don’t get your scope from an MD who will drop you for a PA (much like the physician in this thread said they would). They don’t know the scope difference between a PA and NP and don’t realize we’re working with our license and certification and NOT theirs. Protect your license. Protect your patients. Get your scope from your state board. 

Telepsych can be and often is next to useless and still hard to get/use. Trust me we use them for consults.

I am independent. In my role, my scope is the exact same as a MD per our hospital bylaws and state practice act...

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FYI from my state board:

”APRN scope is not determined by the setting in which the APRN practices.  The focus is on what it is the APRN is doing – what care are they providing and what care are they managing, and, for what population including level of acuity.  In short, an APRN-CNP may engage in mental health care consistent with the competencies validated by the national certification they obtained and maintain.  The national certifying examination is the determining factor as to the APRN’s role and the population focus for whom APRNs are formally educated to provide care/medical management. APRN licensure by the Board is based on the applicant having passed a national certification examination by an approved national certifying body, in a particular role  (certified nurse practitioner/CNP; certified nurse specialist/CNS; certified nurse midwife/CNM; or certified registered nurse anesthetist/CRNA) and in one of several different population foci (Family,  Adult-Gerontology Acute Care, Adult-Gerontology Primary Care, Pediatric Acute Care, Pediatric Primary Care, Women’s Health, Psychiatric/Mental Health, etc.).  An APRN may manage the care of those patients and conditions for which their formal education has prepared them, as evidenced by their national certification.  It can be helpful to look at the test plan for the APRN’s national certification as the APRN’s practice should align with the competencies validated by the national certification.”

They go on to state, “Managing more complex or severe mental health issues such as psychosis would require PMH certification, for example. Again, the APRN would look to the national certification they obtained and maintain, as certification validates their training, education and competencies regarding the types of conditions they can manage.”

That would be the last document I uploaded here. So to answer the OP’s question, it doesn’t matter the practice setting or what someone’s “opinion” is that FNPs should be treating, it’s what you’re trained and ultimately certified to do - and anything outside of stable anxiety, depression, and some states ADHD is outside of scope for anyone other than a psychiatric nurse practitioner. 

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