VA's Only Depression Drug Needs 50 Visits a Year

VA Veterans Face Up to 50 Clinic Visits a Year for Depression Treatment

According to a report from Military.com published August 24, 2026, the only drug the Department of Veterans Affairs (VA) offers for treatment-resistant depression can require veterans to attend up to 50 in-clinic visits per year. Treatment-resistant depression is a diagnosis given when a patient's depression has not responded to at least two adequate trials of standard antidepressant medication. The report's description does not name the drug directly, but the only FDA-approved medication in this category is esketamine, sold under the brand name Spravato, a nasal-spray derivative of ketamine approved by the FDA in 2019 specifically for treatment-resistant depression when used alongside an oral antidepressant.

Esketamine carries a federal Risk Evaluation and Mitigation Strategy (REMS), a set of FDA-mandated safety controls that require patients to self-administer the drug in a certified healthcare setting and remain under clinical observation for at least two hours afterward because of sedation and dissociation risks. That structure is almost certainly the source of the visit count the report describes: dosing typically starts twice weekly for the first month, then tapers to weekly and eventually biweekly or monthly maintenance sessions, a schedule that can plausibly add up to dozens of appointments annually. Military.com's report frames this as a significant access burden for veterans, though the original article was not reviewed in full for this analysis, and further details on cost, geographic distribution of VA prescribing sites, or veteran testimony were not available in the material provided.

Why Ketamine Troches Look Different From the VA's REMS Model

A ketamine troche is a compounded lozenge, dissolved between the cheek and gum or under the tongue, that delivers a controlled dose of ketamine through the oral mucosa rather than by nasal spray or IV infusion. Troches are prepared by licensed compounding pharmacies under a prescription, typically through telehealth or in-person ketamine clinics that operate outside the VA system and outside the FDA-approved esketamine REMS framework, since compounded ketamine is not itself an FDA-approved drug product for depression.

That regulatory distinction matters for the visit-burden comparison the Military.com report raises. Esketamine's two-hour, in-office observation requirement exists because the FDA REMS specifically mandates it for that approved drug. Troches, by contrast, are most often dispensed for at-home use after an initial in-person or telehealth evaluation, with follow-up visits scheduled around clinical need rather than a fixed federal monitoring schedule. In practice, many troche-based ketamine programs see patients far less frequently in a clinical setting than the weekly-to-biweekly cadence esketamine's REMS can require, particularly once a stable maintenance dose is established. That said, lower visit frequency is not automatically safer; it shifts more of the monitoring responsibility onto the patient, their prescribing provider, and any support person present during dosing, which is why reputable troche programs still build in scheduled telehealth check-ins, dose titration protocols, and clear guidance on what side effects warrant contacting the clinic immediately.

What Veterans and Patients Should Weigh

For veterans currently navigating VA mental health care, the practical question raised by this report is not whether esketamine works, since it is FDA-approved specifically because clinical trials supported its use in treatment-resistant depression, but whether the visit schedule is realistic given work, transportation, and travel-distance constraints. Veterans who find the REMS visit cadence unworkable have three general paths worth discussing with a VA provider or an outside mental health team: continuing esketamine treatment through the VA as prescribed, seeking a private or telehealth ketamine program that offers troches or other at-home-compatible formulations, or pursuing VA Community Care referrals if local access to esketamine sites is limited. None of these paths is automatically the right answer for every patient, and switching between ketamine formulations should always be a decision made with a prescribing clinician who can evaluate dosing equivalence, safety monitoring needs, and how a patient's specific depression history responds to each delivery method.

Practical Next Steps for Readers Considering Troche Therapy

Anyone comparing VA esketamine access to a troche-based program should ask a prospective clinic three things: who compounds the troches and under what pharmacy licensing, what the required check-in schedule looks like before and after dose stabilization, and how the clinic handles emergency contact if a patient experiences an adverse reaction while dosing at home. Troches offer a meaningfully different visit-frequency profile than the VA's esketamine REMS pathway described in this report, but that flexibility depends on choosing a program with real clinical oversight, not simply the lowest number of required appointments. Readers should treat the 50-visit figure reported by Military.com as a signal of the structural access challenge facing treatment-resistant depression care generally, not as a verdict on any single drug, clinic, or treatment format, and should confirm current VA scheduling policy directly with their care team since visit requirements can change as REMS guidance or VA protocols are updated.

Source: Military.com, "VA's Only Drug for Treatment-Resistant Depression Requires Up to 50 Visits a Year", published August 24, 2026.