The report released Thursday by the department's inspector general is the first comprehensive look at VA mental health care, particularly suicide prevention.
It found that nearly three years into the VA's broad strategy for mental health care, services were inconsistent throughout the agency's 1,400 clinics.
Several facilities lacked 24-hour staff, adequate screening for mental problems or properly trained workers.
With about one-third of veterans reporting symptoms of post-traumatic stress disorder, it is "incumbent upon VHA (the Veterans Health Administration) to continue moving forward toward full deployment of suicide prevention strategies for our nation's veterans," the report stated.
In a written response, the VA's acting undersecretary for health agreed with many of the recommendations. Michael Kussman noted that the VA recently has placed suicide prevention coordinators in each medical center.
The report comes as already-strained troops and veterans say they are suffering more psychological problems due to repeated and extended deployments to Iraq and Afghanistan. In a study this month, a Pentagon task force issued an urgent warning for improved care.
In the inspector general report, investigators echoed some of those concerns in calling for additional staffing and better training in VA facilities. It said about 1,000 veterans who receive VA care commit suicide every year and as many as 5,000 a year among all living veterans.
The report, which was requested last year by Rep. Michael Michaud, D-Maine, said clinics should work harder so veterans can seek treatment with feeling stigmatized. It recommended additional screening for patients with traumatic brain injury.
Among the other recommendations:
The report follows high-profile suicide incidents in which families of veterans say the VA did not do enough to provide care. In one case, the family of Marine Jonathan Schulze said he told staff at a VA Medical Center in Minnesota twice that he was suicidal in the days before he hanged himself Jan. 16, but that he was turned away. The VA has said that was not the case.
Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America, said he hoped the VA would place a high priority on suicide prevention given the thousands of veterans suffering from psychological wounds.
"We can not afford to nickel and dime our nations heroes," he said. "If we do, we'll be paying for it for a generation."
Sen. Patty Murray, a member of the Senate Veterans' Affairs Committee, said the report pointed to a lack of planning by the department.
"It is far past time for the administration to get its act together and treat invisible wounds with the same vigilance that is given to physical injuries," said Murray, D-Wash.
Hawaii Sen. Daniel Akaka, who chairs the Senate commitee, said the review showed a greater need for accountability in VA care. "I will continue oversight and work to ensure that VAs mental health professionals have the resources they need," he said.