VA mental health treatment: Who decides what works?

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 health system serves millions of veterans with unique service-connected conditions, combat trauma, and complex medical histories that may not mirror the general population studied in civilian clinical trials. When evaluating new treatments, VA must consider how evidence applies specifically to the veterans it serves and how a treatment fits into the existing health system infrastructure. 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 while considering patient perspectives and feasibility. This rigorous approach actually resulted in some recommendations being downgraded from the 2017 version as evidence was reevaluated.

This deliberative process affects all veterans seeking mental health care through VA, particularly those with PTSD, depression, and other service-connected mental health conditions. The gap between what receives FDA approval and what VA offers can be especially frustrating for veterans who see promising treatments available in civilian medicine but not through their VA benefits. Retired Army veteran George Canfield expressed this frustration directly, noting that he holds a medical cannabis license but must pay out of pocket for that medication while almost any other medication would be covered by VA.

The timeline for adopting new treatments can span years, as illustrated by repetitive transcranial magnetic stimulation for depression. The 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. This sequence demonstrates that FDA approval marks the beginning, not the end, of VA's evaluation process.

For medications specifically, VA maintains a National Formulary that establishes the department's preferred list of medications, with some having Criteria for Use documents that set evidence-based conditions or restrictions for prescribing. The formulary process involves VA physicians, Pharmacy Benefits Management officials, and Veterans Integrated Service Network pharmacist executives who review documents and solicit feedback from health care teams. This means an FDA-approved medication can be widely available in civilian medicine while having different prescribing conditions inside VA or being recommended against entirely, as is the case with benzodiazepines and cannabis for PTSD due to lack of evidence of benefit and known harms.

For disabled veterans, understanding this process matters because it explains why certain treatments discussed in veteran communities or available to civilian friends may not be options through VA care. The decision-making involves multiple offices including the Office of Mental Health, 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. No single office makes these determinations, which can slow adoption but aims to ensure safety and effectiveness for the veteran population specifically.

Veterans seeking specific mental health treatments should discuss all options with their VA mental health provider and ask directly about the evidence basis for recommendations. If a treatment of interest is not available through VA, ask whether it is under review, whether veteran-specific studies are planned, or whether there are evidence-based alternatives that address the same symptoms. Working with a Veterans Service Organization can also help navigate appeals or requests for specific treatments when clinical need is documented.