VA Health Care: Status of Key Recommendations Related to Mental Health and Medication Management

What GAO Found

The Department of Veterans Affairs (VA) provides health care services to over 9 million enrolled veterans, and thousands of military service members transition to its care each year. Mental health conditions are a persistent issue for veterans, and many veterans also live with chronic pain. These conditions are often treated with medications that must be managed carefully. For example, opioids can be prescribed for pain, but these carry the risk of addiction and overdose.

VA has implemented four key GAO recommendations to strengthen its oversight of mental health treatment plans and to help ensure its providers follow strategies for mitigating the risk of opioids.

• Mental health treatment plans. Veterans with mental health conditions may be offered various treatment options, including medication or therapy, or a combination of both. The Veterans Health Administration (VHA) requires specialty providers, such as psychiatrists, to document in mental health treatment plans that evidence-based treatment options were considered. In June 2019, GAO found VHA did not have guidance for these requirements nor monitor whether the providers followed them. VA concurred with GAO’s two recommendations to address these issues and, in 2020, implemented both. For example, VA initiated reviews of selected charts biannually to ensure providers meet mental health treatment planning expectations.
• Opioid safety risk mitigation strategies. In response to concerns about opioid use, VA launched its Opioid Safety Initiative in 2013 to help ensure veterans are prescribed and use opioids in a safe and effective manner. As part of this initiative, VHA developed risk mitigation strategies for providers to follow when prescribing opioids to veterans, such as conducting urine drug screening. In May 2018, GAO found VHA providers at selected medical facilities did not consistently follow some risk mitigation strategies. Further, not all facilities had access to trained providers to educate other providers in ensuring opioid safety. GAO made two recommendations to address these issues. VA concurred and, in 2019 and 2020, implemented each recommendation. For example, VA created a planning tool that gives providers information on risk mitigation strategies, such as the patient’s last urine screening.

VA has not addressed GAO’s recommendation to the Department of Defense-VA Joint Executive Committee to assess the effectiveness of mental health services for transitioning service members and veterans. This Committee oversees the two departments’ coordination for health care and benefits, including programs that may assist service members and veterans during the transition. In 2024, GAO found that the Committee had identified a number of mental health touchpoints for transitioning service members. However, the Committee had not assessed the effectiveness of the departments’ efforts in facilitating access to such mental health touchpoints and made a recommendation that it do so. VA concurred with this recommendation, but as of November 2025, this recommendation has not yet been implemented.

Why GAO Did This Study

Effective medication management is of the utmost importance to ensure U.S. veterans receive safe and comprehensive treatment as part of their health care. This is particularly important for the growing number of veterans receiving treatment for mental health conditions and for vulnerable populations, such as those transitioning out of the military.

Concerns have been raised about the adverse effects of polypharmacy among veterans, which is the use of more than one medication. For example, research suggests that prescribing both benzodiazepines—a type of medication used to treat anxiety or post-traumatic stress disorder—and opioids to treat chronic pain can increase veterans’ risk of death from suicide.

GAO has reported on opportunities for VA to enhance its oversight of various issues related to medication management for veterans, including those with mental health conditions and those transitioning out of the military. This statement describes a selection of this work, including recommendations GAO has made related to (1) mental health treatment plans, (2) opioid safety, and (3) access to mental health services for transitioning service members and veterans.

This statement is based primarily on three GAO reports issued between May 2018 and July 2024 (GAO-18-380, GAO-19-465, and GAO-24-106189). GAO also reviewed available research related to VA prescribing practices and steps the agency has taken to address five selected recommendations GAO made across these reports.

For more information, contact Alyssa M. Hundrup at hundrupa@gao.gov.