Review articleA systematic review and meta-analysis of mindfulness based interventions and yoga in inflammatory bowel disease☆
Introduction
IBD is an immune-mediated disease associated with chronic inflammation of the gastrointestinal tract and frequent extra-intestinal manifestations [[1], [2], [3]]. Individuals with IBD experience high burden of disease and significant mental health comorbidities [4]. Rates of depression and anxiety in periods of remission are two to three times higher than in age matched individuals in the general population [4,5]. During active disease, rates of depression rise to over 60% with wide ranging implications in all areas of life [6]. Despite this, treatment of depression and anxiety is not routinely included in standard IBD care, although there are recommendations for screening and treatment of depression and anxiety to be embeded in integrated IBD care [7].
There has been increasing research evidence outlining the impact of stress [8], anxiety and depression on the course of IBD [5], with a recent systematic review showing that depression and anxiety were independently associated with clinical recurrence of IBD [9].Mindfulness based interventions have been of particular interest in IBD due to their effectiveness in attenuating stress and treating depression and anxiety [[10], [11], [12]],as well as their potential to improve the course of IBD related to emerging evidence of their salutogenic impact on the immune system [13].
Mindfulness is defined as an experiential practice of focussing one's attention with intention and without judgement [14]. While this definition of mindfulness is generally accepted, there is ongoing debate in the literature regarding the measuring and operationalization of mindfulness [15,16].
Mindfulness Interventions include manualised mindfulness-based programs such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), mindfulness-informed interventions such as Dialectical Behaviour Therapy (DBT) and Acceptance and Commitment Therapy (ACT), modified mindfulness interventions and yoga.
To our knowledge, there has been only one systematic review to date examining the efficacy and use of mindfulness interventions in IBD [17], published in 2015. The review included manualised and adapted mindfulness programs published in English and German and it was restricted to adults. It found that no study showed significant group differences regarding physical or psychological variables in the main analysis, and that only a subset of patients with additional irritable bowel syndrome (IBS) symptoms experienced significant improvements in quality of life. The review reported that the findings about the efficacy of mindfulness interventions in IBD were inconclusive, that these interventions might be useful in subgroup of IBD patients with IBS symptoms and that further research of higher methodological quality was needed.Two narrative reviews reported similar findings [18,19].
Since then, there have been several further RCTs of mindfulness interventions in IBD This systematic review therefore addresses the evidence gap by exploring a wide range of mindfulness interventions and including papers published in languages other than English and German and conducted in individuals of any age.
Section snippets
Objectives
The aim of this systematic review was to evaluate the effectiveness of mindfulness interventions in the management of psychosocial and physical symptoms associated with IBD. We aimed to answer the following questions:
- 1.
Can mindfulness interventions improve psychological symptoms in IBD including depression, anxiety, stress and coping?
- 2.
Can mindfulness interventions improve quality of life (QoL) in IBD?
- 3.
Are mindfulness interventions effective in improving biological markers in IBD and other measures
Results
We identified 202 records and removed 37 duplicates (Fig. 1). We excluded a further 154 after screening titles and abstracts of the remaining 165 records. We examined the remaining 11 articles for eligibility and excluded 3 of them, two because of being conference abstracts which were superseded by the full text articles and one because of not having the RCT design. The remaining 8 studies [[34], [35], [36], [37], [38], [39], [40], [41]] were included in qualitative and quantitative analysis.
Discussion
This review is the first systematic review to explore the efficacy of a broad range of mindfulness interventions in IBD while including all population ages and settings and posing no language or time and type of publication restrictions. It updates an earlier review of 2015 with more restrictive inclusion criteria and we were able to add six studies published since that meta-analysis. Broadening the definition of mindfulness interventions brought five additional studies, including 2 yoga
Strengths and limitations of the review
Strengths of this review are the inclusion of a broad range of mindfulness interventions and exploration the impact of mindfulness interventions on biological as well as psychological outcomes. Limitations of this review are that it has only eight included studies and with small sample sizes which resulted in limited sensitivity analysis and no assessment of publication bias. Furthermore, the quality of individual studies has been affected by poor blinding of the outcome assessors, incomplete
Contributions
Systematic review was conceived and designed by TE, SK and KR and critically revised by SK, MK, JB and KH. Drafting of the paper was completed by TE. All authors approved the final manuscript.
Funding statement
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declarations of interests
None.
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Registration details: International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42017080632.