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Inflammatory bowel disease (IBD) is a chronic illness that is comprised of two major disorders: Crohn's disease and ulcerative colitis. Adults with IBD have adopted telehealth and mobile health (mHealth) interventions to improve their selfmanagement skills and symptom-monitoring. This systematic review aimed to evaluate the efficacy of telehealth and mHealth interventions and explore the benefits and challenges of these interventions in patients with IBD. This review used a convergent segregated approach to synthesize and integrate research findings, a methodology recommended by the Joanna Briggs Institute for mixed-methods systematic reviews. Databases searched included PubMed, CINAHL, Embase, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. The search followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which yielded sixteen quantitative and two qualitative articles. A narrative synthesis was performed to present the findings of quantitative and qualitative studies. Evidence from quantitative and qualitative studies was then integrated for a combined presentation. The results of quantitative analysis supported the efficacy of telehealth and mHealth interventions to improve patients' quality of life, medication adherence, disease activity, medication monitoring, disease-related knowledge and cost savings. While some participants in qualitative studies reported certain challenges of telehealth and mHealth interventions, most of the participants conferred the benefits of the interventions, including improved disease-related knowledge, communication between patients and providers, sense of reassurance, and appointment options. The evidence from quantitative and qualitative synthesis partially supported each other. 1 | INTRODUCTION Inflammatory bowel disease (IBD) is a chronic illness of the gastrointestinal (GI) tract that mainly encompasses two major disorders: Crohn's disease (CD) and ulcerative colitis (UC; Lee, Kwon, & Cho, 2018). Active inflammation of the GI tract is the key factor behind IBD (Stein & Shaker, 2015). The clinical presentation of IBD includes abdominal pain, diarrhea, bowel urgency, rectal bleeding, weight loss, nutritional deficiencies, and many other extraintestinal manifestations (Stein & Shaker, 2015). Additionally, other symptoms, such as anxiety, depression, sleep disturbances, and fatigue, are highly prevalent in adults with IBD (Conley et al., 2017). This symptom burden, coupled with the remitting-relapsing nature of the disease and many other factors, including low social and family support, female gender,

systemic symptoms, such as anxiety, depression, fatigue, sleep disturbances, and pain, are also common in adults with IBD. 4 The quality of life (QOL) of those with IBD is lowered due to the GI and systemic symptoms, as well as due to the extraintestinal manifestations. 5,6 Although, many advanced medical and surgical therapies are available to manage IBD, adults with IBD may look for other adjuvant options to manage their symptoms and improve their QOL. Physical activity (PA) is one such alternative intervention. 7 Exercise is an equivalent term used in the literature for PA, however it refers to more structured and repetitive activities. 8 Alterations in the intestinal immune system act as a trigger for IBD inflammation. 9 The anti-inflammatory benefits of exercise are well documented and are related to the control of pro-inflammatory cytokines in the intestinal system. In healthy individuals, the immune system of the intestine is in a state of

Objectives: To assess the published randomized controlled trials (RCT) of non-pharmacological interventions systematically and to synthesize the evidence of these interventions for the management of anxiety and depression in adults with inflammatory bowel disease (IBD). Background: Anxiety and depression are common symptoms in adults with IBD and can have many negative outcomes on their quality of life (QOL). Non-pharmacological interventions for anxiety and depression are important to improve the adaptive strategies of adults with IBD. Previously published reviews of non-pharmacological interventions to mitigate anxiety and depression in those with IBD have resulted in inconclusive evidence. This review is aimed to fill that gap. Design: Systematic review and meta-analysis. Method: Using a PRISMA diagram, English-language RCT published were searched using combined keywords of inflammatory bowel disease, Crohn's disease, ulcerative colitis, randomized controlled trial, anxiety, and depression. The Cochrane risk of bias tool is utilized to assess the methodological quality of each study. A meta-analysis of RCTs was conducted using Comprehensive Meta-Analysis (CMA) software. Results: The final review included 10 studies. The overall risk of bias of the selected studies varied from low risk in three studies, some concerns in four of the studies, and high risk of bias in three of the studies. Interventions included cognitive-behavioral therapy, mindfulness-based therapy, breath-body-mind-workshop, guided imagery with relaxation, solution-focused therapy, yoga, and multicomponent interventions. The pooled evidence from all non-pharmacological interventions showed that these interventions significantly helped to reduce anxiety, depression, and disease specific quality of life (QOL) in adults with IBD compared to control groups. However, the effect sizes are small. The pooled standardized mean difference (SMD) was −0.28 (95% CI [−0.47, −0.09], p = 0.004) for anxiety, −0.22 (95% CI [−0.41, −0.03], p = 0.025) for depression and 0.20 (95% CI [0.004, 0.39], p = 0.046) for disease specific QOL. Davis et al. Non-pharmacological Interventions for Anxiety and Depression in IBD Conclusion: The addressed non-pharmacological interventions were multifaceted and demonstrated positive effects on anxiety and depression, and QOL in those with IBD. Healthcare providers can facilitate a discussion with adults with IBD about the availability of these interventions to mitigate their anxiety and depression and to improve their QOL.

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