Psychiatric Symptoms in Employees Experiencing High Levels of Stress Before and After the Intake of Probiotics
Psychiatric Symptoms in Employees Experiencing High Levels of Stress Before and After the Intake of Probiotics
Sub-project 1 Background:With the increasing number of shift workers required for social and
 economic activities, increasing prevalence of metabolic diseases has been found in this group
 of people. Although reasons for this include reduced physical activity owing to unfixed
 working hours, lack of sleep or disturbances in the circadian rhythm may also be related to
 the occurrences of type 2 diabetes or metabolic syndrome. The mechanism may be due to sleep
 deprivation induced activation of the hypothalamic- pituitary- adrenal axis (HPA axis) that
 affects blood glucose metabolism. The gut brain axis might adjust the HPA axis via the
 bottom-up pathway through vagus nerve, the neuroendocrine system, or the immune system. It is
 also possible that physiological or psychological stressors might influence intestinal
 function through the top-down pathways. Associations between microbiota and many chronic
 diseases, including metabolic syndrome, diabetes, obesity, neurodegenerative diseases, or
 mental diseases have been investigated in recent years. However, the application of using
 probiotics in treating sleep disorders is still lacking. The main research hypothesis: Is it
 possible to develop the relevant probiotic treatment model?

 Sub-project 2 Information technology (IT) is an industry related to productions of computers,
 information processing, or telecommunications. Such industry highly relies on the knowledge
 and solutions provided by professional IT specialists. Literature has described that the
 subjective stress scores were higher in IT specialists that developed diabetes, hypertension,
 and depression. Specific probiotics, also known as psychobiotics, may have the effects of
 alleviating levels of stress and mood symptoms. Therefore this open-label designed, single
 arm, baseline-controlled trial aiming to examine whether an 8-week intervention of a novel
 psychobiotic Lactobacillus plantarum PS128TM (PS128TM), may improve self-perceived stress and
 mood symptoms among high-stress IT specialists.
Sub-project 1 Materials

 1. Probiotics The probiotics used in this proposal are selected to be more related to mental
 conditions. The PS128, which belongs to Lactobacillus plantarum subsp. plantarum.
 Administration of probiotics for 4 weeks in animal experiments showed significant
 improvements in depression and anxiety behaviors, and increased mobility in mice (Liu et al.,
 2016). The concentration of dopamine in the prefrontal cortex, which was reduced due to
 depression, was also restored by feeding PS128 (Liu et al., 2016). PS23 belongs to
 Lactobacillus paracasei group. In animal experiments, both live and heat-treated bacteria
 have the effect of improving depression and anxiety behaviors. The strains used in this study
 are food usable bacteria listed on the front of the Food and Drug Administration in Taiwan.
 The products have been sold in Taiwan in 2015 and there have been no serious adverse
 reactions. Relevant clinical studies have been reviewed by Institutional Review Boards in
 multiple hospitals (including the National Taiwan University Children's Hospital, Kaohsiung
 Kai-Syuan Psychiatric Hospital, Wanfang Hospital, Antai Hospital, and National Yangming
 University). These probiotics and placebo will be provided by the Yifu Biomedical Company
 Ltd. The probiotic powder contains no lactose and can be eaten by people with lactose
 intolerance. The placebo capsule contains microcrystalline cellulose. Both PS128 and PS23
 probiotic capsules contain 10 billion CFU (colony forming units) of PS128 or PS23. The PS23
 heat-treated probiotic capsule contain 10 billion PS23 cells. These products should be stored
 in the refrigerator and be protected from light. The probiotics and placebo used in the study
 are all edible fungi or food supplements approved by the Food and Drug Administration. There
 are no data on serious potential risks or side effects. Only a few gastric discomfort such as
 bloating or diarrhea have been reported.

 Monitoring of adverse events and adverse reactions includes soft stools, flatulence, or
 diarrhea will be used for safety and tolerability assessment.

 A total of 2 assessments and blood draws (week 0 and 8+1 weeks) will be required during the
 study period. Subjects will be invited to participate in the study (V0) and a questionnaire
 will be assessed. Those who meet the inclusion criteria will be assessed for baseline (V1),
 and the app for working hours recording and Rhythm (mobile phone schedule) must be installed
 to participants' mobile phones to record the working hours in the hospital. The once daily
 test capsules will be consumed the next day after the evaluation for 8 weeks until week 8 +1
 (V2). At V2, a second assessment will be performed. The time of the second assessment needs
 to be the same as the first assessment. For example, the first assessment is for the day
 shift, and the second assessment must be for the day shift. The number of days consumed by
 each subject may be inconsistent, at least 28 days, and up to 35 days. Subjects are required
 to provide a working schedule for the study period for the second assessment to allow the
 investigator to match the assessment results for the analysis.

 Research methods:

 1. Investigators will enroll 240 nursing, psychologists and social workers who are working
 in the chronic and acute wards to participate. Participants will be evaluated in overall
 physical and mental health, sleep disturbances. 60 electronic employees will also be
 enrolled, participants will be evaluated in overall physical and mental health, sleep
 disturbances.

 2. Blood TAC, Cortisol and DHEAS will be examined before and after administration of
 probiotics and placebo.

 3. Subjects will need to complete several self-test scales, including the Questionnaire
 (PHQ-9), State-trait Active Inventory (form YA), Insomnia Severity Index (ISI), Buss
 Perry Offensive Scale, Quality of Life and Satisfaction Survey, 10 cm Visual Analogue
 Scale for Gastrointestinal Symptom and stress, Profile of Mood States (POMS) and
 Computerized Selective Attention Test.

 4. In this study, double blind design will be adopted for subproject one and open label
 design will be adopted for subproject two. After consenting, participants will complete
 the above baseline assessment. All participants will then be randomly assigned to
 probiotic or placebo groups according to a computer-generated random number table. These
 two groups will be administered with probiotics or placebo for 8 weeks.

 For the sub-project 2, all the participants will complete the baseline assessment and
 administered with probiotics for 8 weeks.

 Statistics

 1. General Considerations Data will be entered and error-checked by the Project Coordinator
 on IBM-compatible/Macintosh computers present both in the Psychological & Behavioral
 Science Research Laboratory in Mackay Memorial Hospital. The process of data entry,
 including preparation of data harvesting forms, database fields, data entry, and
 checking by editors will be supervised by the staff of the Psychological & Behavioral
 Science Research Laboratory, with extensive experience in both clinical trials and
 longitudinal studies with large data sets. Once the data set is entered and checked,
 analyses will be conducted using SPSS software. An "intent to treat" analysis examining
 all patients randomized to the trial will be performed to preserve the effect of
 randomization.

 2. Power determination for the test of null hypothesis The power analysis will be conducted
 using the effect size from previous publications and the relevant studies of probiotics
 intervention. A minimally significant difference in PSS or ISI changes between
 treatments would be defined as a reduction of 20% or more in the score levels. Based on
 a power of 80% and assuming a 30% dropout rate and an alpha level of 0.05, a sample of
 500 participants (120 per group) will be required. All results will be analyzed using an
 intent-to-treat analysisbased on treatment assignment, whether they complete treatment
 or not. It will also conduct a per-protocol analysis based on 'treated' participants,
 defined as those who received treatment and completed assessments at 0 and 8+1 weeks
 after allocation. To test the adequacy of randomization, it will conduct between group
 comparisons of baseline characteristics on all measures, using t tests for continuous
 variables and chi-square tests for dichotomous variables. Two tailed P-values<0.05 is
 considered significant. All analyses will be performed with SPSS version 12.0. To define
 better the link between changes in questionnaires and treatment response, changes in
 assessment scores will be assessed within the following categories according to
 treatment response as stated in previous literature: for PSS, ISI, STAI: 0% improvement;
 >0 to <=10% improvement; >10 to <=20% improvement and >20% improvement. Finally, to
 ensure that the observed effect will not better explained by changes in medication
 during follow-up or by antidepressant treatment, these two variables (changes in
 medication yes/no and taking antidepressant yes/no) will also be added into the models
 as covariates. The results of regression models will be presented as standardized
 regression coefficients (b) with 95% confidence intervals that can be interpreted as
 effect size. The threshold of significance was P=0.05.

 Potential Benefits:

 To the patients:

 It may be possible to improve the stress, sleep or gastrointestinal symptoms of high-pressure
 nurses by supplementing probiotics.

 To the participating researchers:

 All participating assessors will be able to master the interview skills after the intensive
 interviewer training, in particular, familiar with semi-structured psychiatric interview and
 a package of self-report questionnaires. The laboratory researcher will be able to master the
 laboratory skills of performing epigenetic analysis, which can also be helpful in extending
 his research experience.

 Scientific expectations:

 The study will fill the research gap of shift work, metabolism, and probiotics in generally
 healthy high stress nursing staff. The results will provide empirical evidence for Asian
 scientists where there is still a lack of studies linked to changes before and after
 protiotics intervention. The knowledge for probiotics towards health promotion is expected to
 be increase and hope to lead to more personalized stratification for disease-risk models and
 for targeting effective interventions.

 Sub-project 2 Materials: Probiotics The probiotics used in this proposal are selected to be
 more related to mental conditions. The PS128, which belongs to Lactobacillus plantarum subsp.
 plantarum.

 Method:

 IT specialists from a large IT company in Northern Taiwan were invited and first screened by
 the Perceived Stress Scale (PSS) 10 items version. Participants with a PSS-10 items score of
 27 or higher were included in our study. Those currently under antibiotic or psychotropic
 treatments, have cancer, or other chronic physical or mental diseases were excluded. Two
 capsule that contained 300 mg of PS128TM powder, equivalent to 10 billion colony forming
 units, were suggested to be taken daily by the included participants. Other self-report
 measures included the Job Stress Scale, Visual Analogue Scale of Stress, the Insomnia
 Severity Index, the State and Trait Anxiety Index, The Questionnaire for Emotional Trait and
 State, the Patient Health Questionnaire, the Quality of Life Enjoyment and Satisfaction
 Questionnaire, and the Gastrointestinal Severity Index. Objective measures included Saliva
 levels of stress biomarkers include cortisol, α-amylase, Immunoglobulin A (IgA), lactoferrin,
 and lysozymes, and Tests on Attentional Performance.
Sub-project 1

 Inclusion Criteria:

 -  Full-time nursing staff from Mackay Memorial Hospital, including wards and special
 units.

 -  Age 20 to 60 years old.

 -  Perceived Stress Scale (PSS) 10- questions version, with a cutoff point of 27 points
 or more.

 Exclusion Criteria:

 -  Have taken or are receiving antibiotics within one month.

 -  Probiotics used in powder, capsule or tablet in two weeks (except for Yogurt, Yogurt,
 Yakult and other related foods)

 -  Patients with hepatobiliary gastrointestinal tract who have undergone surgery

 -  Patients with past or present inflammatory bowel disease

 -  Those with a history of cancer

 -  Those who are allergic to lactic acid bacteria

 -  Currently taking medication to treat acute or chronic diseases or sleep disorders

 Sub-project 2

 Inclusion Criteria:

 -  Age 20 to 60 years old.

 -  Perceived Stress Scale (PSS) 10- questions version, with a cutoff point of 27 points
 or more

 -  Full time employee

 Exclusion Criteria:

 -  Have taken or are receiving antibiotics within one month.

 -  Probiotics used in powder, capsule or tablet in two weeks (except for Yogurt, Yogurt,
 Yakult and other related foods)

 -  Patients with hepatobiliary gastrointestinal tract who have undergone surgery

 -  Patients with past or present inflammatory bowel disease

 -  Those with a history of cancer

 -  Those who are allergic to lactic acid bacteria

 -  Currently taking medication to treat acute or chronic diseases or sleep disorders