Mindfulness-based interventions (MBIs) aim to develop a nonjudgmental awareness and experiential acceptance of present experiences (Ludwig & Kabat-Zinn, 2008). MBIs have developed over the last 30 years as a lifestyle approach to manage chronic health conditions and avert the negative psychological impacts from a range of medical and psychological disorders (Duarte et al., 2019). Mindfulness-based stress reduction (MBSR; Irving et al., 2009; Kabat-Zinn, 2009) and mindfulness-based cognitive therapy (MBCT; Teasdale et al., 2000) are commonly used MBIs found to significantly improve outcomes such as depressive symptoms, anxiety, stress, and physical functioning for patients with cancer, chronic pain, cardiovascular disease, somatic diseases, and depression (Duarte et al., 2019). There are other variations of MBIs that have also shown a positive impact on health, such as mindfulness-based positive behavior support training (MBPBS; Singh et al., 2015), meditation on the soles of the feet (a component of MBPBS; Felver & Singh, 2020; Singh et al., 2003), and mindfulness-based art therapy (MBAT; Prioli et al., 2017). With respect to the mental health challenges resulting from the COVID-19 global pandemic (Yao et al., 2020), meditation can serve as a protective factor against psychological distress (Conversano et al., 2020) and has been associated with more engagement in COVID-19 preventive health behavior (Haliwa et al., 2020). In response to social distancing and shelter-in-place pandemic protocols, MBIs have been successfully adapted to a telehealth delivery model (Chadi et al., 2020; Niles et al., 2012).

Most, if not all, health behavior interventions result in costs that must be considered when planning and allocating resources. Therefore, economic evaluations should be performed to understand the cost-effectiveness of alternative therapies such as MBIs (Reeves et al., 2019) to inform health policy, programming, and budget decisions. Such evaluations would help to objectively assess the costs and consequences of an MBI relative to an alternative course of action (Drummond et al., 2015; Duarte et al., 2019). Though several systematic reviews and meta-analyses have demonstrated the overall effectiveness of mindfulness-based training programs (Burton et al., 2017; Li et al., 2017; Xunlin et al., 2020) in improving health-related outcomes, there is a need for a systematic review to summarize and evaluate the evidence on the cost-effectiveness and cost-saving properties for MBIs. Such evidence is important for ensuring that scarce resources are allocated to health interventions that return value for money (Duarte et al., 2019). The aim of this study was to synthesize the existing evidence on the economic evaluations of MBIs by providing a systematic review of cost-effectiveness analyses (CEAs) and cost–benefit analyses (CBAs) of MBIs. The results from this study can help insurers, administrators, providers, employers, and patients to make more strategic and informed decisions related to using or enrolling in any specific types of MBIs with respect to patient conditions and needs, as well as assisting providers in anticipating and planning for costs for training and certification of MBIs.

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2010). Four databases (PubMed, Web of Science, JSTOR, and CINAHL) were systematically searched for studies between January 1985 and September 2021 that matched English search terms in both cost analysis (i.e., cost-effectiveness, cost–benefit, cost-reduction, cost-utility, economic evaluation) and MBIs (i.e., meditation, mindfulness). A manual search of the references of the reviewed studies was also conducted.

Studies with standard economic evaluation designs were searched for, including CEA and CBA (Atusingwize et al., 2015). The included studies were conducted from a variety of perspectives, such as societal (Jönsson, 2009), healthcare (Kunz et al., 2016), payer (Sorensen et al., 2011), provider (Navas et al., 2007), government (Einarson et al., 1994), and employer (Grimani et al., 2018) perspectives. In the review, CEA refers to the evaluation of the effectiveness of two or more interventions relative to their cost, where benefits are measured in non-monetary units (e.g., life years gained) to obtain an incremental cost-effectiveness ratios (ICERs: defined as the ratio of the additional costs per unit of incremental benefit of an intervention; York Health Economics Consortium, 2016). A CEA enables comparison between interventions by estimating the cost for achieving a unit gain of a health outcome, for example, a life year gained (Centers for Disease Control & Prevention, 2021). When quality-adjusted life years (QALYs) are used as a CEA outcome measure, a cost per QALY is calculated (Raisch, 2000). CBA refers to the studies about the cost outcome for the healthcare system and/or the society (through reducing productivity loss, employee turnover, etc.) following the “human capital” approach of defining cost–benefit analyses (Colombo et al., 2006; Robinson, 1993).

Studies were included in this review if they (1) reported original cost-related analysis, and (2) included an evaluation of an MBI. Conference proceedings, letters to the editor, commentaries, other review studies, studies where the meditation component was mixed with other types of interventions, cost analysis studies without outcomes, and studies where the effectiveness outcome was not health related were excluded.

Data extraction, quality assessment, and evaluation of indirectness (Schünemann et al., 2020) in outcome measures were performed by the lead reviewer and validated by a second reviewer. Any disagreement was resolved through a discussion between the two reviewers to achieve a consensus or by consulting a third reviewer. Data extraction included the following characteristics of each study: study population, type of intervention, comparator, effectiveness data (CEA studies), measure of benefit (CBA studies), cost data, discounting, time horizon, study perspective, sensitivity analyses, and results. All monetary values reported were converted to 2020 US dollars to allow the comparison of results across studies. Quality assessment was conducted using the Drummond 10-point checklist (Drummond et al., 2015), a concise tool for assessing the quality and possible biases of empirical studies (Atusingwize et al., 2015). The studies were evaluated to check whether they used proxy or surrogate measures when reporting their intervention outcomes (Schünemann et al., 2020). This systematic review was not prospectively registered.

Results

The database search yielded 1329 relevant articles. One additional study was identified through manual search of the references of the included studies. After screening titles and abstracts, 1273 articles were excluded, leaving 58 articles for full-text reviews. Sixteen articles were excluded after the initial full-text review, including one conference proceeding, one correspondence article, and 14 articles without cost analyses of MBIs. Two articles (van Ravesteijn, 2016; van Ravesteijn et al., 2013) were considered a duplication since they were based on the same study. Thus, there were 41 studies included at this stage. At the final level of review for inclusion, 13 additional studies were excluded because the meditation component was mixed with other types of interventions (D’Amico et al., 2020; Doyle et al., 2019; Gaupp et al., 2020; Ljótsson et al., 2011, 2014; Mercer et al., 2016; Orme-Johnson & Herron, 1997; Stahl et al., 2015; Sun et al., 2021), they were feasibility studies with only intervention costs (Hennelly et al., 2020; Tulloh et al., 2018), the effectiveness outcome included for cost-effectiveness calculation was not a health-related outcome (e.g., teaching competency as the effectiveness outcome; Crane et al., 2020), or the meditation intervention was not an MBI (Herron, 2011), leaving 28 studies meeting the criteria to be included in this study (Fig. 1).

Fig. 1
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Search and selection process of studies

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About the specific types of MBIs included in the study, MBSR (Irving et al., 2009; Kabat-Zinn, 2009), MBCT (Teasdale et al., 2000), MBPBS (Singh et al., 2015), meditation on the soles of the feet (Singh et al., 2003), MBAT (Prioli et al., 2017), and non-standarded formats of MBIs (Müller et al., 2019; Saha et al., 2020; van Dongen et al., 2016) were presented in the analyses.

Characteristics of the Studies

Tables 1 and 3 report the key characteristics of the included studies. The 28 articles were divided into two categories: (1) CEAs (n = 18) that addressed both cost (direct costs and/or indirect costs) and treatment effectiveness outcomes (Table 1); and (2) CBAs (n = 10) that focused on cost outcomes (direct costs and/or indirect costs) (Table 3). The studies included were based in nine countries: USA (n = 11), Netherlands (n = 5), UK (n = 4), Canada (n = 2), Denmark (n = 2), Sweden (n = 1), Spain (n = 1), Australia (n = 1), and Germany (n = 1). The types of interventions in the reviewed studies included MBCT (n = 10), MBSR (n = 5), MBPBS (n = 4), meditation on the soles of the feet (n = 1), MBAT (n = 1), and other MBIs (n = 7). The study design included randomized controlled trials (RCTs) (n = 17), quasi-experimental studies (n = 4), multiple baseline design studies (n = 2), observational studies (n = 2), and simulation studies (n = 3).

Table 1 Cost-effectiveness analyses
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Cost-effectiveness Analyses (CEAs)

Table 1 reports the findings on interventions that were both clinically effective and cost saving. To summarize, MBCT for the following types of patients had the cost-saving property in addition to effectiveness: (1) individuals with a history of major depressive disorder episodes (Pahlevan et al., 2020; Shawyer et al., 2016); (2) women with breast cancer and persistent pain (Johannsen et al., 2017); (3) multiple sclerosis patients (Bogosian et al., 2015); and (4) Parkinson’s disease patients (Bogosian et al., 2021). In addition, for patients with chronic lower back pain, the standardized protocol of MBSR also had the property of cost saving plus its effectiveness advantage as compared with the usual care of cognitive behavioral therapy (Herman et al., 2017).

Cost-effectiveness thresholds vary among countries and other entities, as these variations reflect the highest financial amount that a payer entity is willing to pay for an additional QALY. MBSR among women with breast cancer versus usual care was an illustration of interventions that improved effectiveness, but increased cost, which resulted in the cost per QALY gained of $19,733 (equivalent to $23,058 in 2020) for patients and $22,200 (equivalent to $25,941 in 2020) for providers at the 12-week time point (Lengacher et al., 2015). These values fall well below the cost-effectiveness threshold of $100 K/QALY gained (Neumann et al., 2014). For patients with medically unexplained symptoms, MBCT’s ICER as compared with enhanced usual care was 56,637 Euro, equivalent to $99,818 in 2020 per QALY gained (van Ravesteijn, 2016; van Ravesteijn et al., 2013) which fell just slightly below the threshold (Neumann et al., 2014), and £27,107 (equivalent to $40,872 in 2020) as compared to usual care (Bogosian et al., 2021).

No effectiveness advantage was documented for mindfulness group therapy using a non-standardized protocol (Bogosian et al., 2015). Saha et al. (2020) showed that mindfulness group therapy had a considerable probability of being cost-effective (67% from the societal perspective and 70% from the healthcare perspective) among adult patients with depression, anxiety or stress, and adjustment disorder as compared with usual care. Economic evaluations of less common mindfulness intervention protocols did not find the programs to be more effective or cost-effective than controls, for example, MBAT among breast cancer patients (Prioli et al., 2017) and worksite MBIs among government employees (van Dongen et al., 2016).

When costs are measured from a healthcare perspective in terms of adverse episodes averted among patients with recurrent depression, MBCT with support to taper off/stop antidepressant medication (MBCT-TS) saved $439 (equivalent to $673 in 2020) per relapse averted and $23 (equivalent to $35 in 2020) per disease-free day gained, as compared with maintenance-antidepressant medication treatment (m-ADM; Kuyken et al., 2008). This result compared favorably with the ICER of popular adjunctive therapies such as cognitive therapy (Scott et al., 2003) in depression care. However, when Kuyken et al. (2015) further tested the effectiveness and cost-effectiveness of MBCT-TS among patients with three or more major depressive disorder episodes and on prescribed medication, they found that MBCT-TS was neither more effective nor more cost-effective compared with m-ADM, though both MBCT-TS and m-ADM had enduring effectiveness.

The CEA studies included a broad variety of interventions and used different measures of costs and effectiveness. Therefore, it was not possible to statistically compare the results across studies. Instead, to categorically assess the studies, a matrix was created where individual studies were classified based on their findings as follows: (1) cost-effective, results under the threshold of $100 K/QALY or with a higher probability of increased willingness to pay (n = 9); (2) cost saving, i.e., an intervention with less costs than the comparison group with greater or equal effectiveness (n = 6); and (3) neither, interventions that reported non-statistically significant results or results with higher cost and lower benefit (n = 3). The reviewed studies are classified accordingly in Table 2.

Table 2 Matrix of cost-effectiveness analyses’ findings (results were not limited by the threshold of 100 K per QALY but with other denominators): intervention vs. comparator
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Cost–Benefit Analyses (CBAs)

The reviewed cost analyses included studies on caregivers (n = 4), patients (n = 3), professional caregivers of adult patients with mild intellectual disabilities (n = 1), high-cost insurance enrollees (n = 1), and employees of a large university (n = 1) (Table 3). The cost-saving property of mindfulness training was most salient when applied to societal outcomes. In particular, MBIs for aggressive behavior among individuals with intellectual/developmental disabilities in mental healthcare facilities resulted in reduced caregiver stress, injuries, and turnover (Singh et al., 2015, 2016a, b). Net savings between $12,051 and $14,820 per caregiver were achieved (Singh et al., 2015, 2016a, b). In considering additional cost benefits from the societal perspective, MBIs have demonstrated reductions in disability pensions in a Danish sample (Fjorback et al., 2013) and reduction in missed days of work in a sample of older adults with multiple respiratory infections (Rakel et al., 2013). From the healthcare perspective, findings were mixed. A Canadian study showed that MBSR among patients with multiple physical and/or mental health conditions (Knight et al., 2015) led to reductions in healthcare costs when compared to no intervention. In contrast, a study of US university employees found no relative cost differences between MBI participants and matched controls, a result attributed to fewer primary care visits but higher prescription drug costs (Klatt et al., 2016).

Table 3 Cost–benefit analyses
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Quality Assessment and Evaluation of Indirectness of Outcome Measures

Results of the quality assessment of studies are presented in Table 4. Studies were rated as follows: having defined their research questions appropriately (n = 24); having clear and comprehensive description of competing alternatives (n = 22); and having identified important and relevant costs and (for CEA studies only) consequences for each alternative (n = 23). While most of the reviewed studies provided either the societal or healthcare viewpoint and all had operating costs, few included capital and operating costs (n = 2) (Kuyken et al., 2008; van Dongen et al., 2016). Most studies included appropriate and accurate measurements for outcomes (n = 21) and credible valuation of costs (for CEA studies only) and consequences (n = 21), as well as covered issues of concern to user satisfaction in their presentation and discussion of results (n = 19).

Table 4 Quality assessment
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Among studies with a time horizon of at least 1 year for costs, three adjusted for differential timing and provided information on, and justification for, the discount rate used. The quality assessment of the CEA studies indicated that most studies established effectiveness of MBI at improving health outcomes (n = 16), calculated ICERs taking into account both costs and consequences to compare between the alternative treatments (n = 17), and adequately characterized uncertainty in the estimates of costs (for CEA studies only) and consequences (n = 23).

Discussion

This systematic review summarized the cost-effectiveness and cost-saving properties of 28 economic evaluations of MBIs, with a notable variety in study populations, types of MBIs, and measures and outcomes reported. Study participants included adult caregivers, specific insurance enrollees, and those with a broad range of physical, behavioral, or mental health conditions. The time horizon of MBIs varied from 8 weeks to 2 years. With few exceptions, the results of this review showed that MBIs were generally cost-effective and/or cost saving in comparison with other treatments (usual care or other non-MBI treatments), at least in the short term (< 5 years). The standardized protocols of MBSR and MBCT indicated robust empirical evidence for their cost-effective properties—a pattern consistent across different patient groups and countries. The most favorable outcomes, i.e., interventions that achieved both cost-effectiveness and cost savings, were noted for the following: (1) MBSR, for women with breast cancer (Lengacher et al., 2015), patients with chronic lower back pain (Herman et al., 2017, 2020), and patients with fibromyalgia (Pérez-Aranda et al., 2019); (2) MBCT, for patients with depression (Kuyken et al., 2008), patients with medically unexplained symptoms (van Ravesteijn, 2016; van Ravesteijn et al., 2013), patients with multiple sclerosis (Bogosian et al., 2015), women with primary breast cancer and persistent pain (Johannsen et al., 2017), non-depressed adults with a history of major depressive episodes (Pahlevan et al., 2020; Shawyer et al., 2016), adults diagnosed with ADHD (Janssen et al., 2019), and all types of cancer patients (Compen et al., 2020); and (3) other MBIs, for adults with national insurance (Müller et al., 2019).

Additionally, the cost-effectiveness advantages of MBIs were found to be most salient among participants with mental health challenges (Janssen et al., 2019; Kuyken et al., 2008; Pahlevan et al., 2020; Saha et al., 2020; Shawyer et al., 2016), breast cancer (Johannsen et al., 2017; Lengacher et al., 2015), lower back pain (Herman et al., 2017, 2020), fibromyalgia (Pérez-Aranda et al., 2019), and multiple sclerosis (Bogosian et al., 2015) with the comorbidity of pain. Among the CBAs reviewed, MBPBS for professional caregivers of persons with intellectual and developmental disabilities (Singh et al., 2008, 2015, 2016a, b, 2020) was found to have a net economic benefit, from both the healthcare and societal perspectives. When delivered to people with various physical/mental health conditions (Knight et al., 2015) or somatization disorder and functional somatic syndromes (Fjorback et al., 2013), MBIs were found to achieve cost savings from the healthcare perspective. For adults with acute infection episodes (Rakel et al., 2013) and non-clinical employees (Klatt et al., 2016), findings were inconclusive related to the cost/cost-effectiveness of MBIs reported. It is important to note that MBIs’ observed cost-effectiveness among patients with pain due to certain chronic diseases may not be generalizable for MBIs’ cost-effectiveness among all patients with chronic diseases since pain reduction is a specific outcome where MBIs have more evidential support compared with MBIs’ impact on chronic disease management in general (Hilton et al., 2017).

It is also worth noting the extent to which cost-effectiveness may vary depending on the “usual care” comparator programs’ cost volume. For example, in one study (Lengacher et al., 2015), the cost of the MBSR program to improve the QALY among breast cancer survivors comprised less than 1% of direct medical costs, whereas in another study (Fjorback et al., 2013), the MBI delivered to patients with somatization disorder and functional somatic syndromes was 5–6 times more expensive than the cost of usual care for these patients.

Although the heterogeneity in MBIs’ delivery formats, as implemented to meet the needs of vastly different populations, presented a challenge for conducting a meta-analysis of these included studies, it highlighted the utility of MBIs as being adaptable, effective, and accessible to a variety of populations. Furthermore, the findings of this study underscored the potential positive impact of MBIs on population health, especially in systems with limited resources. This review confirmed prior findings that mindfulness training is a well-established, low-cost, and scalable intervention, and can serve as an effective therapeutic treatment with relatively few adverse effects reported (Greenlee et al., 2017).

Limitations and Future Research

More research is needed to understand the long-term effectiveness of MBIs (i.e., more than 5 years). More cost-effectiveness and cost–benefit analyses for other standardized MBIs, such as mindfulness-oriented recovery enhancement (MORE; Garland et al., 2014) and mindfulness-based relapse prevention (MBRP; Witkiewitz et al., 2013), are also needed.

The absence of studies from Asia, Africa, and Latin America may have been impacted by the search strategy used in this study (database searches only conducted with English keywords), or the fact that MBIs (and the resulting academic reporting) may not be widely implemented and/or evaluated yet in these regions. The studies that met the inclusion criteria in this study were conducted in middle- and high-income countries with generally higher per capita incomes. Given the cost-effectiveness and cost-saving properties of MBIs in the findings of this study, more interventions and research are needed to document the extent to which MBIs could be successfully implemented in communities or regions with lower economic resources. Indeed, given the encouraging findings related to the cost-effectiveness and cost savings of the studies reviewed, low-resource settings might need these MBIs more than high-resource countries. In addition to health and cost-effectiveness benefits, concerns regarding participant recruitment, retention, and adoption, all of which are impacted by social determinants that may result in disparity, should also be assessed when considering implementation, sustainability, and feasibility.

Due to the variations in the types of MBIs, populations included, health outcomes targeted, differences in study designs, and time frames for assessing outcomes, it was not possible to conduct a quantitative meta-analysis of the cost saving or cost-effectiveness of MBIs. Efforts to report data that could be more easily statistically compared would assist such efforts in the future. More studies could also be done to understand better the overall cost savings of MBIs from the societal perspective, as most of the articles reviewed in this study still were limited to the healthcare perspective of cost savings.

MBSR has been shown effective in reducing symptoms of anxiety and depression, perceived stress, blood pressure, and body mass index among patients with coronary heart disease (Parswani et al., 2013). Strong and consistent evidence indicates that MBIs can lower blood pressure (Parswani et al., 2013; Shi et al., 2017), and MBSR generally shows promise in addressing symptoms for people with hypertension (Conversano et al., 2021). MBIs have growing support as a promising treatment for obesity-related eating behaviors as well (O’Reilly et al., 2014). Cost-effectiveness or cost analyses on MBIs for people with cardiovascular conditions would be informative. In addition, arthritis ranks among the top five chronic diseases which contribute the most to national healthcare expenditures (Lee et al., 2017). Economic evaluations of MBIs with demonstrated effects among arthritis patients could also be worthwhile.

Similarly, with the ongoing and growing healthcare impacts resulting from opioid addiction and other substance misuse disorders (Haight et al., 2018), MBIs for those in recovery for substance misuse disorders, such as MBRP, have been developed and standardized to become a notable option to control addictive behaviors (Garland, 2016; Grant et al., 2017; Li et al., 2017). However, economic evaluations of MBIs targeting substance misuse/relapse prevention have not been conducted. Given the substantial healthcare burden of drug and alcohol misuse disorders (Barrio et al., 2017; Inocencio et al., 2013) and MBIs’ emerging role in reducing substance abuse, future research needs to address these research gaps with rigorous study designs.

Additional research could also be done to further the understanding of the potential role of MBIs beyond the individual level. MBIs have been associated with increased labor productivity (Bhargava et al., 2001), reduced tax burden (Bhargava et al., 2001), and reductions in care facility employee turnover and disability insurance (Singh et al., 2008, 2015, 2016a, b, 2020), which provide evidence that MBIs could create cost savings for society at large. More research regarding MBIs and productivity can in turn inform discussions on issues such as private sector human resources development (Dewa & McDaid, 2011) as well as public sector investment in the future labor force.

In summary, while MBIs are not yet commonly covered by health insurance, this review study synthesized evidence for decision-making about whether MBIs should be covered by health insurance. More economic evaluations of MBIs in areas such as physical health and substance use will broaden the understanding about their cost-effectiveness and cost-saving properties for both healthcare and society.