Invited Commentary
Aging and Health
The Potential of Music as a Nonpharmacologic Intervention for the ICU—Sound Medicine
Farah Acher Kaiksow, Eduard Eric Vasilevskis
JAMA Intern Med Published Online: October 13, 2025
doi: 10.1001/jamainternmed.2025.5260
The intensive care unit (ICU) offers lifesaving interventions, but it is also associated with considerable patient pain, anxiety, and high rates of delirium. Delirium in patients in the ICU is a highly prevalent condition associated with increased inpatient mortality and long-term cognitive impairment. Unfortunately, the medications used to treat pain and anxiety in the ICU may simultaneously trigger delirium. This conundrum has motivated researchers to investigate alternative, nonpharmacologic therapies for pain and anxiety that have the potential to be less delirium inducing.
Music is one such nonpharmacological therapy that holds promise. Based on prior data showing that slow-tempo music has positive neurobiological effects, a body of literature supports the potential value of music in improving outcomes for this high-risk population. The association of music with reductions in anxiety is the most well established,1,2 but studies have also shown positive impacts on agitation, pain, heart rate, dyspnea, and general distress.3 The relationship between music and delirium is less clear, with studies reporting results in both positive and negative directions.4,5
In this issue of JAMA Internal Medicine, Khan et al6 report on a multicenter randomized clinical trial of 158 patients in ICUs who received either slow-tempo music or a silent soundtrack through noise-canceling headphones. The intervention was designed to be performed twice daily for up to 7 days, or fewer if the patient died or was transferred out of the ICU. The primary outcome was the number of coma and/or delirium-free days, as assessed by the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale (RASS). Secondary outcomes included delirium severity, pain, and anxiety. The authors hypothesized that patients who received the music intervention would have more days free of delirium or coma, as well as lower delirium severity and less pain and anxiety. The results, however, did not support this hypothesis; there were no statistically significant differences in the primary or secondary outcomes.
The study design and implementation of this clinical trial were rigorous, and the authors present their data in a comprehensive and transparent fashion.6 And although there was no difference in measured outcomes, this study should not be the last to examine this potential nonpharmacological therapy. There are important lessons to be learned from the rich data provided by this study, which offers evidence of the circumstances under which music may not have benefits, while also providing valuable insights into the design of future music therapy trials.
One of the first questions this study raises and helps to answer regards the timing and delivery method of music therapy: at what time of day should music be delivered? In this study, the participants received music either between 9 and 11 am or between noon and 4 pm. The optimal timing of an intervention such as this is unknown, and researchers’ selection of morning and daytime hours was likely based on feasibility. However, when considering the development of future music-based (or other nonpharmacologic) studies, researchers should be careful to ensure that evidence-based methods to improve overall outcomes in critically ill patients, including reducing delirium, are not supplanted by the potential new therapy. Khan et al6 note that the ICU sites used in this study adhered to the ABCDEF bundle7 but do not report on how thoroughly this tool was implemented or if the music intervention was purposefully scheduled so as not to interfere with sedation holidays or early mobility, as examples. Regarding delivery methods, future studies may want to consider the use of ambient music, rather than headphones, as an intervention. Headphones carry with them the potential for physical pain and/or discomfort, and, although not technically a restraint, limit a patient’s movement in the bed.
A second question relates to the dose: how many individual and total hours of music should be delivered? The goal of this study intervention was to provide twice-daily music sessions of 1 hour each.6 Despite a median ICU length of stay of 7 days, the average duration of music was only 312 minutes, with only half of the patients receiving at least 7 listening sessions, as seen in eTable 6 in Supplement 2. The cause of missed sessions is unknown, and there is no information on whether the reasons for missed sessions differed in the intervention vs the control participants. Overall, the dose of therapy appears to be modest, and results of this study should not be extrapolated to longer durations or greater total doses of therapy.
A third question is relevant to sedative medications often given in the ICU: at what level of sedation should music be delivered? The authors report that the music, on average, was delivered over 3.6 days in the ICU, but it is unclear on which specific days the intervention was given.6 This is particularly relevant given eFigure 1 in Supplement 2, which shows the distribution of the patients’ RASS scores over the study duration. As the eFigure illustrates, most patients in both the intervention and control arms received RASS scores of −1 or below for at least the first 3 days of the study, with more than a quarter experiencing coma. One could expect the impact of a musical intervention to be more salient if it were to occur when a patient was more alert vs at greater levels of sedation.
In summary, Khan et al6 report the results of a well-designed and well-executed study that failed to show any impact of the intervention (low doses of music delivered via headphones during daytime hours) on their chosen outcomes (delirium, pain, and anxiety) among critically ill patients in the ICU. Given opposing findings of similar studies, the intervention delivery considerations of the current work, and the serious negative consequences and complications of ICU stays, researchers should continue to explore the possibility of music—delivered regularly and after patients have been weaned from sedation—as an intervention. Recognizing that music alone is unlikely to be effective at improving patient outcomes given the complexity of ICU-level care, future studies should incorporate music into evidence-based multicomponent practices centered around the ABCDEF bundle and other effective multifaceted strategies outside of the ICU. These efforts can build on the strong foundational study design presented by Khan et al and, hopefully, contribute to the development of nonpharmacologic tools for the management of pain, anxiety, and delirium in the ICU.
