In this issue of JAMA Internal Medicine, Burgess and colleagues¹ provide encouraging evidence in their randomized clinical trial (RCT) that implementing low-cost online mindfulness-based interventions (MBIs) for chronic pain in a health care system can improve patient outcomes. Their RCT, conducted in Veterans Affairs (VA) health care systems, compared the effects of implementing 2 different types of 8-week telehealth MBI programs with usual care. The first was a group intervention with prerecorded mindfulness education and skill training videos led by an experienced instructor, and the second was a self-paced asynchronous intervention using the same videos supplemented with 3 phone calls with a facilitator. The effects of the 2 MBIs on pain outcomes (pain-related function and pain intensity) and psychosocial outcomes (anxiety, depression, posttraumatic stress disorder, sleep disturbance, and participation in social roles/activities) were measured at 12 weeks, 6 months, and 1 year. Strengths of this trial were a large sample size (N鈥�=鈥�811), follow-up rates between 83% and 91% for the 3 study arms at 12 months, and satisfactory adherence to the assigned treatment: 69% of participants in the group MBI attended at least 6 of 9 sessions, and 76% of participants in the self-paced arm attended at least 2 of 3 facilitator calls.

Compared with participants receiving usual care, those in both intervention groups reported more favorable outcomes on almost all outcome measures and follow-up intervals.¹ The 2 MBIs did not significantly differ from each other except on 1 secondary measure, the percentage of participants achieving at least a 30% reduction in pain interference at 12 months: 42% in self-paced MBI, 30% in the group MBI, and 24% in the usual care group. The authors correctly note that although the effect sizes found in this trial were small to moderate and diminished over time, they were 鈥渟imilar to other guideline-recommended chronic pain treatments including MBSR [mindfulness-based stress reduction].鈥�¹ Given the high level of psychiatric comorbidities in the study population (62% had mental health diagnoses, including 25% with posttraumatic stress disorder), larger effects would have been surprising. While the results for the group MBI confirmed the results of previous RCTs for chronic pain, a novel finding was that participants in the self-paced MBI did as well as those in the group MBI. Having a self-paced option could expand the appeal of MBIs to individuals who are uncomfortable in groups or whose availability to attend classes is irregular. Finally, the MBI groups had half the number of adverse events as the usual care group.

A major question arising from this study¹ is whether MBIs implemented in the VA could be successfully implemented in other settings. Because the VA has an integrated health care system that has embraced a whole person health approach to patient care, implementing and evaluating new evidence-based strategies for improving care for patients with the most challenging cases is consistent with its mission, values, and culture. The VA also has a fixed budget and is incentivized to provide services that have the greatest value to patients. Overcoming barriers to implementing MBIs in health care organizations with different values, funding schemes, and incentives will likely be more difficult.

Current research supports health care systems incorporating MBIs as a standard treatment option for chronic pain and other chronic conditions caused or exacerbated by stress. In the past 15 years, substantial numbers of scientifically rigorous RCTs evaluating MBIs have been published. Remarkably, almost all of these trials found MBI interventions effective, regardless of the specific type of intervention (eg, MBSR, mindfulness-based cognitive therapy, or cognitive behavioral therapy), mode of implementation (in person or online), specific condition being treated (eg, chronic pain, depression, stress, insomnia, or hypertension), or setting (eg, health care, schools, or workplaces).² MBIs also have a low risk of adverse effects.³ Finally, a study of MBSR for chronic low back pain found the benefits persisted for at least 2 years.⁴ It is difficult to identify other clinical interventions that have achieved this widespread success. Why might this be?

In contrast to most medical interventions that treat a specific condition with specific treatments believed to be helpful for that condition, MBIs do not directly target the patient鈥檚 condition. Rather, they target the counterproductive ways in which patients think about and react to their problems. MBI programs provide patients with strategies and tools to help them create the time and space to become more fully aware of what is going on in their minds and hearts that is negatively impacting their lives. It is, therefore, not surprising that MBIs have been found effective for a broad range of conditions and that they lead to improvements not only in patients鈥� primary problem but also in other important outcomes that affect quality of life.² Basic science research is beginning to elucidate how MBIs affect brain activity and physiological markers such as cortisol, C-reactive protein, systolic blood pressure, and triglyceride levels.²

Another valuable feature of MBIs is that, unlike medications and surgery that may effectively manage a specific condition, MBIs teach patients techniques helpful for more effectively managing all of life stresses. As a result, many MBI participants retain the new awareness and skills they learn in the programs and are better equipped to effectively deal with subsequent stressful life events. This could reduce the occurrence of stress-related conditions (eg, pain, sleep loss, depression), increase adoption of healthier behaviors, increase the ability to manage symptoms without seeking medical care, and possibly decrease health care utilization and costs. MBIs have been found to be cost-effective compared with usual care or other non-MBI treatments for a variety of conditions⁵ and possibly cost-saving for chronic low back pain.⁶

Given the effectiveness, low cost, lasting benefits, and safety of MBIs for various challenging conditions, one might wonder why they have not been widely embraced as an important component of high-quality and high-value medical care. The greatest barrier may be that the fee-for-service business model operating in many health care settings sees no economic benefit in implementing a low-cost mindfulness program. Another obstacle may be that treatments such as MBIs do not emanate from conventional medicine and do not fit well into the classic biomedical perspective. Other hypothesized barriers include lack of insurance coverage, unavailability of trained instructors, and lack of knowledge among clinicians and health care systems.⁷

It is heartening to learn that veterans have access to care from a system that is dedicated to addressing their most fundamental needs through research like this RCT by Burgess and colleagues.¹ Learning how much health care can be improved when health care systems are structured and incentivized to meet the needs of the patients they serve is truly remarkable.

Corresponding Author: Dan Cherkin, PhD, Osher Center for Integrative Health, Department of Family Medicine, University of Washington, 3823 NE 153rd St, Lake Forest Park, WA 98155 (dcherkin@uw.edu).

Published Online: August 19, 2024. doi:10.1001/jamainternmed.2024.3952

Conflict of Interest Disclosures: None reported.