Depression care in the US Department of Veterans Affairs health system appears to be moving in an unexpected direction. A large cohort study of 1,582,834 veterans diagnosed with major depressive disorder found that most patients received treatment considered recommended for the condition, but the proportion who did not receive such care increased over time, reaching 10.2% in 2025. The findings raise concerns about a growing gap between clinical need and treatment delivery in outpatient Veterans Health Administration settings, even within one of the largest integrated health care systems in the United States.
Major depressive disorder, commonly referred to as clinical depression, is more than a temporary period of sadness. It is a psychiatric condition characterized by persistent low mood or loss of interest, together with symptoms that can include sleep disruption, changes in appetite, fatigue, impaired concentration, feelings of worthlessness, and thoughts of death or suicide. Evidence-based treatment typically involves antidepressant medication, psychotherapy, or a combination of approaches, depending on the patient’s symptoms, preferences, medical history, and risk profile. When people with diagnosed depression receive none of the care recommended by clinical standards, symptoms may persist or worsen and the likelihood of functional impairment can increase.
The study examined treatment patterns across a vast veteran population, making it one of the largest investigations of depression care in the VHA system. Rather than focusing on a small clinical sample, the researchers analyzed a nationwide cohort of veterans with MDD who received care through the Veterans Health Administration. This type of population-level analysis can reveal changes that may be invisible in individual clinics, including shifts in prescribing, psychotherapy access, referral practices, and the availability of mental health professionals. It can also show whether care is being distributed consistently across a health system that serves patients with widely varying medical, psychiatric, geographic, and socioeconomic circumstances.
The central finding was not that depression treatment had broadly collapsed. Most veterans in the cohort received recommended treatment. The concern was the direction of the trend: over the study period, the share of patients who did not receive recommended treatment gradually increased, reaching 10.2% in 2025. In a population this large, even a percentage that appears relatively modest represents a substantial number of people. A rate of 10.2% among more than 1.5 million veterans would correspond to well over 150,000 individuals if applied to the entire cohort, although the precise number in any given year would depend on the annual patient distribution and the study’s analytic definitions.
The researchers emphasize that the results require further investigation rather than offering a single explanation for the increase. A patient may not receive documented treatment for many different reasons. Some veterans may decline medication or psychotherapy, prefer to monitor symptoms, seek care outside the VHA, or experience barriers that prevent them from completing a referral. Others may face long travel distances, limited appointment availability, transportation problems, work or caregiving responsibilities, financial pressures, stigma, or concerns about medication side effects. Treatment may also be delayed while clinicians evaluate whether depressive symptoms are caused or intensified by another medical condition, substance use, trauma-related illness, bipolar spectrum symptoms, or medication effects.
Mental health service availability is therefore a key issue raised by the findings. Recommended depression care depends not only on clinical guidelines but also on whether the health system has enough psychiatrists, psychologists, social workers, primary care clinicians, and other trained professionals to provide that care. A patient can be correctly diagnosed yet remain untreated if the next available psychotherapy appointment is months away or if medication management is difficult to access. Even when services exist, shortages may create bottlenecks, particularly in rural areas and regions with high demand. Telehealth can reduce some geographic barriers, but it does not eliminate problems involving broadband access, privacy, digital literacy, scheduling, or the need for in-person assessment.
The study also highlights the technical challenge of measuring treatment in large health databases. Administrative and electronic health record data can identify diagnoses, prescriptions, visits, and referrals, but they may not fully capture what happened outside the health system or whether a patient actually took a prescribed drug or participated meaningfully in therapy. A medication listed in a record does not prove adherence, just as the absence of a prescription does not prove that no treatment was received elsewhere. Observational cohort studies are valuable for identifying patterns and generating hypotheses, but they cannot by themselves establish that reduced treatment caused worse outcomes or determine why an individual veteran did not receive care.
The implications are significant because untreated or undertreated depression can affect nearly every dimension of health. Depression is associated with impaired work and social functioning, poorer management of chronic diseases, increased substance use, sleep problems, and elevated suicide risk. Veterans may also experience depression alongside posttraumatic stress disorder, traumatic brain injury, chronic pain, cardiovascular disease, or other conditions that complicate treatment decisions. The study’s findings should therefore prompt a closer examination of how MDD is diagnosed, how treatment recommendations are recorded, how quickly patients can access services, and whether clinicians have practical alternatives when standard pathways are unavailable.
The authors call for additional research into the factors that influence treatment selection and access among VHA outpatients with MDD. Future studies could examine whether the upward trend differs by age, sex, race and ethnicity, rural or urban residence, disability status, comorbid illness, military service characteristics, or facility location. Researchers may also need to distinguish between clinically appropriate non-treatment and treatment that was missed because of system-level barriers. Understanding that difference will be essential: some patients may reasonably choose not to begin therapy or medication, while others may want care but be unable to obtain it. The nationwide cohort provides an important warning signal, but the next step is determining where the gap is occurring and what interventions can close it without sacrificing individualized, patient-centered decision-making.
Subject of Research: Recommended depression treatment and potential undertreatment among veterans with major depressive disorder in Veterans Health Administration outpatient care.
Web References: https://doi.org/10.1001/jamanetworkopen.2026.28853
References: Aslan M et al. Cohort study of treatment patterns among 1,582,834 veterans with major depressive disorder. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.28853.
Keywords: major depressive disorder, depression, veterans, Veterans Health Administration, mental health care, antidepressant treatment, psychotherapy, undertreatment, health services research, cohort study, treatment access, clinical decision-making.
