Inside VA's mental health treatment decision-making process
Military Times recently examined how the Department of Veterans Affairs decides which mental health treatments become available to veterans, revealing a complex process that extends far beyond simple FDA approval. While many veterans assume that once the Food and Drug Administration approves a treatment it should immediately become available at VA facilities, the reality involves multiple layers of review, testing, and implementation planning that can take years to complete.
The VA's decision-making process involves numerous offices and considerations before any new mental health treatment becomes routine care. According to Dr. Ilse Wiechers, a VA mental health official, the department moves new treatments into practice through a step-by-step process that includes research evaluation, clinical guidelines development, medication reviews, patient-safety systems, ethics reviews, and practical assessments of whether VA has the staff, space, and equipment needed. Only after a treatment is shown to be safe and effective does VA roll it out more broadly, and the department specifically considers how evidence applies to the veteran population it serves.
This affects all veterans seeking mental health care through VA, particularly those dealing with conditions like PTSD and depression where new treatment options continue to emerge. The process is especially relevant for veterans who see promising treatments approved by FDA or available in civilian medicine but find those same options unavailable or restricted within the VA system. Veterans with service-connected mental health conditions may encounter situations where their civilian counterparts have access to treatments that VA has not yet fully implemented or has determined inappropriate based on veteran-specific evidence.
The case of repetitive transcranial magnetic stimulation for depression illustrates how this process works in practice. FDA approved rTMS in 2008, but VA then conducted its own large study involving veterans, tested the treatment in a pilot program at 35 VA sites, and only expanded access after the pilot proved successful. More than 60 VA facilities now offer rTMS, with some operating specialized clinics that combine it with other advanced depression treatments. The 2023 VA/DoD Clinical Practice Guideline for PTSD uses the GRADE methodology to evaluate treatment quality and strength of evidence, applying it more rigorously than the 2017 version, which resulted in some recommendations being downgraded as evidence was reevaluated.
For disabled veterans, this multi-layered approach has significant practical implications. The VA/DoD PTSD guideline currently recommends against benzodiazepines for PTSD, citing lack of evidence of benefit and known harms including drug dependence and addiction. It also recommends against cannabis and cannabis-derived products for PTSD, citing a lack of well-designed randomized controlled trials and potentially serious side effects. This means veterans like retired Army veteran George Canfield, who holds a medical cannabis license, must pay out of pocket for treatments they believe help them, even though VA covers almost any other medication.
Understanding this process helps explain why gaps exist between what veterans hear about in medical news and what their VA providers can offer. The department's formulary system, which establishes preferred medication lists and criteria for use documents, can result in FDA-approved medications being available in civilian medicine while having different prescribing conditions inside VA. This distinction becomes particularly important for treatments carrying significant risks or requiring specialized monitoring.
Veterans seeking specific mental health treatments should discuss all available options with their VA mental health providers and ask about the evidence base for recommendations. If a treatment is not currently available through VA, veterans can inquire whether clinical trials are underway or pilot programs are planned. Working with a Veterans Service Organization can also help veterans understand their options and navigate situations where desired treatments fall outside current VA guidelines or availability.