Inside VA's mental health treatment playbook

The Department of Veterans Affairs uses a complex, multi-layered process to decide which mental health treatments become available to veterans, and that process extends far beyond simple FDA approval. 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, clinical guidelines, medication reviews, patient-safety systems, ethics reviews, and practical questions about staffing, space, and equipment. Only after a treatment is shown to be safe and effective does VA roll it out more broadly.

The VA's approach involves multiple offices working together to evaluate new treatments. These include the Office of Mental Health and its programs such as the National Center for PTSD, the Office of Suicide Prevention, Pharmacy Services, the National Center for Ethics in Health Care, Nursing Services, and Care Management & Social Work Services. For medications specifically, VA's National Formulary establishes the department's preferred list of drugs, and some medications have Criteria for Use documents that set evidence-based conditions or restrictions for prescribing. This means an FDA-approved medication can be available in civilian medicine while having different prescribing conditions inside VA.

This process affects all veterans seeking mental health care through VA, particularly those with conditions like PTSD and depression. The 2023 VA/DoD Clinical Practice Guideline for PTSD uses the GRADE methodology to evaluate the quality and strength of evidence, weighing benefits and harms of treatment options while considering patient perspectives and feasibility. That guideline applied GRADE more rigorously than the 2017 version, which resulted in some recommendations being downgraded as evidence was reevaluated, demonstrating that recommendations can change as research develops.

The case of repetitive transcranial magnetic stimulation, or rTMS, illustrates how this process works in practice. The FDA approved rTMS for depression 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 distinction between FDA approval and VA implementation becomes particularly important when treatments carry significant risks or lack sufficient evidence. The VA/DoD PTSD guideline recommends against benzodiazepines for PTSD, citing a lack of evidence of benefit and known harms such as 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 creates frustration for veterans like retired Army veteran George Canfield, who has a medical cannabis license and must pay for his medication out of pocket while almost any other medication is covered by VA.

For disabled veterans, understanding this process matters because it explains why certain treatments available in civilian healthcare may not be immediately accessible through VA, and why some treatments you hear about in the news may take years to reach VA facilities. The department's emphasis on veteran-specific evidence and practical implementation considerations means that promising treatments must clear multiple hurdles beyond initial FDA approval. This approach aims to protect veterans from ineffective or harmful treatments, but it can also create delays in accessing newer therapies.

Veterans seeking specific mental health treatments should discuss all available options with their VA mental health provider and ask about the evidence base for treatments they're interested in. If a treatment isn't currently available at your facility, ask whether it's being studied or piloted at other VA locations, and whether you might be eligible for participation in research studies or pilot programs. Working with a Veterans Service Organization can also help you understand your options and advocate for access to evidence-based treatments that fit your specific needs.