THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume X, Number X, 2016, pp. 1–10

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2016.0023

ORIGINAL ARTICLE

Probiotics and Subclinical Psychological

Symptoms in Healthy Participants:
A Systematic Review and Meta-Analysis
Jennifer McKean, BHSc,1 Helen Naug, PhD,1,2 Elham Nikbakht, M NutSc,1,2
Bianca Amiet, M MedRes,1,2 and Natalie Colson, PhD1,2

Abstract
Introduction/Aim: Interest in the gut–brain axis and emerging evidence that the intestinal microbiota can
influence central nervous system function has led to the hypothesis that probiotic supplementation can have a
positive effect on mood and psychological symptoms such as depression and anxiety. Although several human
clinical trials have investigated this, results have been inconsistent. Therefore, a systematic review and meta-
analytic approach was chosen to examine if probiotic consumption has an effect on psychological symptoms.
Methods: The online databases PubMed, Scopus, and the Cochrane Library were searched for relevant
studies up to July 2016. Those that were randomized and placebo controlled and measured preclinical psy-
chological symptoms of depression, anxiety, and perceived stress in healthy volunteers pre and post supple-
mentation with a probiotic were included. To control for differences in scales of measurement, data were
converted to percentage change, and the standardized mean difference between the probiotic and control groups
was investigated using Revman software. A random effects model was used for analysis. Heterogeneity was
assessed using the I2 statistic. Quality assessment was undertaken using the Rosendal scale.
Results: Seven studies met the inclusion criteria and provided data for nine comparisons. All studies passed
the quality analysis. The meta-analysis showed that supplementation with probiotics resulted in a statistically
significant improvement in psychological symptoms (standardized mean difference 0.34; 95% confidence in-
terval 0.07–0.61, Z = 2.49) compared with placebo.
Conclusion: These results show that probiotic consumption may have a positive effect on psychological
symptoms of depression, anxiety, and perceived stress in healthy human volunteers.

Keywords: meta-analysis, neuropsychology, nutrition, probiotics

Introduction the microbiota and host is changing rapidly and is considered

to be mutualistic in that both microbe and host benefit.2 Re-

T he impact of the gastrointestinal (GI) tract on brain

function, cognition, and behavior has been of great in-
terest, with recent experimental work investigating the ther-
apeutic treatment of neuropsychiatric disorders by the
ingestion of live probiotic bacteria. The gut is colonized by
between 1013 and 1014 microorganisms. Comparatively, this
is 10 times the number of cells within a human body, with
>100 times the number of genes compared with the human
genome.1 Current understanding of the association between
cent studies have identified how changes within the gut mi-
crobiota can impact normal physiology and contribute to the
development of disease within the host. Of particular interest
is the interaction between the gut microbiota and the central
nervous system (CNS) via endocrine, neural, and immune
pathways, consequently having an effect on brain function,
cognition, and behavior.3
Given the cogent impact of gut bacteria on physiological
health, the conceptualization of the term microbiota–gut–brain

1
School of Medical Science, Griffith University, Gold Coast, Australia.
2
Menzies Health Institute, Gold Coast, Australia.

1
2 MCKEAN ET AL.
axis has emerged.4–6 The microbiota–gut–brain axis refers to
the two-way communication network between the GI and the
CNS.7 This term has been used to explain the relationship
between gut microbes, their metabolites, and the sympathetic
and parasympathetic branches of the autonomic nervous sys-
tem.8 There is a clear element of communication between the
gut microbiota and the CNS, with the GI tract acting as a
platform. Together they form what can be described as a
complex reflex network, which consists of afferents that extend
the centripetal cortical structures of the CNS and efferents that
innervate smooth muscle in the GI tract wall.3 Evidence sug-
gests that the composition of the microbiota within the gut
plays a role in mental illnesses involving the CNS.4 It is
postulated that these effects manifest via the microbiota–gut–
brain axis. It has been demonstrated that bacteria have the
capacity to generate both neuromodulators as well as neuro-
transmitters, including GABA, serotonin and noradrenalin,
dopamine, and acetylcholine.9–11
Probiotics can be described as living organisms that
benefit the health of the host, when ingested at adequate
levels.12,13 These living microorganisms are capable of
balancing microbial communities and suppressing the
growth of pathogens. Probiotics act as immunomodulators
by mediating cytokine secretion through signaling pathways
such as nuclear factor kappa-light-chain-enhancer of acti-
vated B cells (NFkB), which results in proliferation and
differentiation of immune cells and epithelial cells. Their
impact on epithelial cells may help protect the intestinal
barrier.14 Probiotics also produce neuroactive and neuroen-
docrine molecules, which can act on the CNS to alter be-
havior.4 Recent experimental studies have also shown
probiotics to reduce anxiety-like behavior in animals, re-
verse behavioral effects related to depression in rats post-
myocardial infarction,15 and have beneficial psychological
effects in humans.16 Although the mechanism by which
probiotics exert these effects is yet to be completely eluci-
dated, it has been suggested that their metabolic products
may affect the host metabolism, impacting brain function,
and also through immunological mechanisms by lessening
the effects of oxidative stress and inflammatory cytokines.4
While a number of animal trials have investigated the
impact of probiotic consumption on behavior and mood,
fewer clinical trials have specifically investigated the impact
of probiotic supplementation on psychological symptomol-
ogy in the general population. This study aimed to pool data
from similar studies available to date and used a meta-
analytical approach to examine any effects of probiotic in-
tervention on anxiety, depression, and perceived stress.
Methods
Article search
Searches were conducted independently by two researchers
via PubMed (MEDLINE), Cochrane Library (Central), and
Scopus databases up to July 2016, using combinations of the
following search terms: ‘‘probiotic, gut, or microbio*,’’ along
with ‘‘mood, neuro*, or psych*,’’ and ‘‘gut-brain axis’’
without imposing time limitations. Results were filtered
where possible for human clinical trials. In addition, refer-
ence lists of selected studies were screened for additional
studies of relevance. Initial screening of studies was con-
ducted by two researchers based on the titles and abstracts.
The next phase involved a review of abstracts and an ex-
amination of the full text based on the eligibility criteria.
The decision regarding the inclusion or exclusion of articles
was made through agreement between the two researchers.
In case of any disagreement between the first two research-
ers, a third researcher was involved in decision making.
The Preferred Reporting Items for Systematic Reviews
and Meta-Analysis (PRISMA) Statement was followed as
a guideline for conducting and reporting this systematic
review and meta-analysis.17
Study eligibility and selection
Trials for consideration had to be randomized, double-
blind controlled trials that used probiotic as a supplement
and reported on key aspects of mood and mental state,
particularly preclinical psychological symptoms of anxiety,
depression, and perceived stress in adult healthy volunteers
(aged ‡ 18 years). Selected trials provided pre- and post-
intervention measurement data for calculation of overall
effect. Studies were excluded if they supplemented the
mixture of probiotic and other nutrients. Review articles and
conference abstracts with no accessible full text in English
were also not included in this systematic review and meta-
analysis. Issues such as pregnancy, smoking, food allergy,
lactose or gluten intolerance, cardiovascular, renal, hepatic
or lung disease, and other severe systemic diseases or in-
flammation were all factors for exclusion of participants
from the trials. Dietary intake such as vitamin or antioxidant
supplements, antibiotics, recreational drugs or some other
prescribed medications, or high amounts of caffeine also
precluded participation.
Figure 1 provides details of the selection process. Quality
assessment was undertaken by two reviewers using the
Rosendal scale,18 and disagreements were resolved by dis-
cussion. An overall Rosendal score of 60% was regarded as
an excellent methodology quality.19 A Rosendal score of
<50% was chosen as a cutoff point for the exclusion of
studies. The highest Rosendal score of 94% belonged
to Messaoudi et al. study,20 and Steenbergen et al.21 had the
lowest Rosendal score of 62%.
Data handling and statistical analyses
Key aspects of mood and cognitive functioning were
examined. Included studies measured multiple psychologi-
cal aspects, and to minimize heterogeneity of the studies, it
was decided to analyze perceived stress, anxiety, and de-
pression, as they were common measures in all studies.
RevMan (v5.3) software was used to perform meta-analysis
of the data. A random effects model was applied due to
expected heterogeneity between studies.22 Data were ex-
tracted using an Excel data extraction tool. To control for
differences in scales of measurement, effect was calculated
using a percentage change in means from baseline to end-of-
study in each of the probiotic and placebo groups. Two
studies directly reported results as percentage change in
mean (Diop et al.23) or mode (Messaoudi et al.20). Where
necessary, standard error data were used to calculate stan-
dard deviations. Standard deviations were expressed as a
percentage of the change. Due to the differences in scales
used to measure perceived stress, anxiety and depression,
the standardized mean difference (SMD) was used as the
EFFECTS OF PROBIOTICS ON PSYCHOLOGICAL SYMPTOMS
summary statistic to determine the effect size. Heterogeneity
was assessed using the I2 statistic, with >50% representing
substantial heterogeneity and >75% representing consider-
able heterogeneity.22 A sensitivity analysis was performed
by removing one study at a time to determine whether the
results could have been influenced by a single study.
Dimensions of psychological symptoms
The choice of particular dimensions of psychological
symptoms was based on their common measurement, and
they fell into three categories—anxiety, depression, and
stress—although researchers used a variety of scales for these
measurements. Stress was measured by two commonly used
validated self-report measures: the Perceived Stress Scale
(PSs)24–26 and the State–Trait Anxiety Inventory (STAI),27 as
well as a 10 centimeter Visual Analog Scale (10-cm VAS
scale), which has been used extensively to rate pain and other
symptoms,28,29 and a daily web-based stress-scale survey
(0 = ‘‘no stress’’; 10 = ‘‘extreme stress’’)30 based on cold/flu
3
FIG. 1. Procedure for se-
lection of relevant studies.
symptom intensity. Depression was measured using the Lei-
den Index of Depression Sensitivity—revised (LEIDS-r),31 a
self-reported questionnaire that measures vulnerability to
depression.32 Anxiety and depression were measured together
by the Hospital Anxiety and Depression Scale (HADs),33
which has been validated previously,34,35 and all three were
measured together by the widely used Depression Anxiety
and Stress Scale (DASS) screening tool.36,37 Details of
measurement scales are described in Table 1.
Information on supplement
Four trials studied multiple selected commensal bacteria
species and/or strains, mostly including lactobacilli and bifi-
dobacteria,20,23 but also Lactococcus,21 and one including
Streptococcus.38 Langkamp-Henken et al.30 investigated in-
dividual bacteria strain of Bifidobacterium bifidum R0071,
following positive results from an earlier study of these spe-
cies in a combined bacterial formulation.39 Both Takada
et al.40 and Kato-Kataoka et al.41 trialled Lactobacillus casei
4 MCKEAN ET AL.

Table 1. Double-Blind, Placebo-Controlled Trials on the Effects of Probiotic Supplementation

on Psychological Symptoms That Met Inclusion Criteria
Study, year, Participants, Supplementation Duration Psychological
location treated/total type, daily dosage (days) measures
Diop et al., Healthy volunteers with daily 2 species Probio-Stick 21 10-cm Visual Analog Scale,
2008,23 symptoms of stress during (Lactococcus acidophilus 62 items to assess eight
France past month, (n = 31/64) Rosell 52, Bifidobacterium stress-induced physical and
longum Rosell 175): psychological symptoms
1 sachet (3 · 109 CFU)
Kato-Kataoka Healthy medical students <30 100 mL of milk fermented 56 STAI scores of 2 · 20 item
et al., years old undertaking an with L. casei strain Shirota self-report scales on current
2015,41 examination; without (>1 · 109 CFU/mg) anxiety and anxiety
Japan mental disease, milk or proneness
other allergies (n = 4/47)
Langkamp- Healthy academically stressed One of three separate species: 42 Daily web-based stress-scale
Henken university students who L. helveticus R0052, or survey: cold SI self-report
et al., reported at least one cold in B. longum ssp. Infantis scores
2015,30 past year; groups stratified R0033, or B. bifidum
United by BMI (n = 147/294) R0071, each at 3 · 109 CFU
States
Messaoudi Healthy Caucasian men and 2 species Probio-Stick 30 HADs, 14 item self-
et al.,a women, scoring £12 in (L. helveticus R0052, assessment
2011,20 HADs-A and HADs-D, and B. longum R0175): 1 stick
France £20 HADs total score of 1.5 g (3 · 109 CFU)
(n = 26/55)
Messaoudi Healthy Caucasian men and 2 species Probio-Stick 30 PSs, 14 item self-reported
et al.,b women, scoring £12 in (L. helveticus R0052, questionnaire of recent life
2011,20 HADs-A and HADs-D, and B. longum R0175): 1 stick stress
France £20 HADs total score of 1.5 g (3 · 109 CFU)
(n = 26/55)
Mohammadi Stressed petrochemical 2 species probiotic yoghurt 42 DASS scores: 3 · 14 item
et al.,a workers, 20–60 years old; (L. acidophilus LA5, B. self-report scales as below
2015,38 Iran groups stratified by BMI lactis BB12): minimum of
(n = 25/70) 1 (average 4.03 · 107 CFU)
Mohammadi Stressed petrochemical 7 species probiotic capsule: 42 DASS scores: 3 · 14 item
et al.,b workers, 20–60 years old; L. casei (3 · 103), self-report scales measuring
2015,38 Iran groups stratified by BMI L. acidophilus (3 · 107), depression, anxiety, and
(n = 25/70) L. rhamnosus (7 · 109), stress
L. bulgaricus (5 · 108),
B. breve (2 · 1010), B.
longum (1 · 109), and
S. thermophilus
(3 · 108 CFU/g)
Steenbergen Healthy young adults with no Ecologic Barrier containing 28 LEIDS-r scores of 34
et al., current mood disorder 8 species/subspecies: questions; 6 subscales:
2015,21 (n = 20/40) B. bifidum W23, B. lactis aggression, hopelessness/
Netherlands W52, L. acidophilus W37, suicidality, acceptance/
L. brevis W63, L. casei coping, control/
W56, L. salivarius W24, perfectionism, risk
Lactococcus lactis W19 aversion, and rumination
and W58: 2 g
(2.5 · 109 CFU/g)
Takada et al., Healthy medical students <30 100 mL of milk fermented 56 STAI scores of 2 · 20 item
2016,40 years old undertaking an with L. casei Shirota YIT self-report scales on current
Japan examination; without 9029 (1.0 · 109 CFU/mL) anxiety and anxiety
diagnosis of mental proneness
disorder and a score of £60
on the SDS (n = 70/140)
a
Messaoudi subjects assessed using HADs.
b
Messaoudi subjects assessed using PSs.
BMI, body mass index; DASS, Depression Anxiety and Stress Scale; HADs, Hospital Anxiety and Depression Scale; LEIDS-r, Leiden
Index of Depression Sensitivity—revised; PSs, Perceived Stress Scale; SDS, Self-Rating Depression Scale; SI, symptom intensity; STAI,
State–Trait Anxiety Inventory.
EFFECTS OF PROBIOTICS ON PSYCHOLOGICAL SYMPTOMS
Shirota strain YIT 9029. Viability of probiotic formulations
was checked by the producer and in one study by an inde-
pendent laboratory.21 All formulations displayed a good
safety profile, with no adverse side effects during the treat-
ment period. Please see Table 1 for formulae and dosages.
Results
Of the total 882 studies initially identified, nine fulfilled
the inclusion criteria. All studies passed quality assessment
at >50% (see Appendix). Two were later excluded, as data
were insufficient for the combined analysis.42,43 Seven
studies were retained in the final analysis. One study, Mo-
hammadi et al.,38 trialed parallel supplementation of two
different probiotic preparations on separate subject groups,
and another, Messaoudi et al.,20 provided results from two
separate psychological measurement tools, providing a total
of nine available statistical results for meta-analysis.
Overall, the meta-analysis showed that supplementation
with probiotics resulted in significantly reduced preclinical
psychological symptoms of anxiety, depression, and stress
in healthy individuals (SMD = 0.34, 95% confidence interval
[CI] 0.07–0.61, p = 0.01). There was considerable hetero-
geneity at 67% (Fig. 2).
Sensitivity analysis
To evaluate the effect of individual studies on the overall
meta-analysis results, a one-by-one sensitivity analysis was
conducted. There was no marked change in the pooled SMD
or 95% CI, and results remained significant when each study
was individually excluded. Therefore, no individual study had
excess influence on the pooled results of the meta-analysis.
Discussion
The purpose of this systematic review and meta-analysis
was to examine the effect of probiotic consumption on psy-
chological symptoms. The results from this pooled analysis of
394 participants suggest that supplementation of healthy adult
subjects with combinations of particular probiotic species
may have advantageous effects on mental health by lessening
the psychological symptoms of perceived stress, depression,
and anxiety.
These results contrast with those of Romjin and Ricklidge,
who, after systematically reviewing 10 randomized controls
of the effect of probiotics on psychological outcomes and
psychiatric symptoms by narrative synthesis, concluded that
FIG. 2. Data and forest plot of probiotic supplementation and placebo for all included studies.
5
there was limited evidence for their effect.44 There are a
number of important differences between the present study
and that of Romjin and Rucklidge. The present study chose
studies examining anxiety, depression, and stress in healthy
adult non-smoking participants without systemic or inflam-
matory disease, while Romjin and Rucklidge chose all psy-
chiatric symptoms including schizophrenia in trials that
included smokers and those with chronic inflammatory and
other conditions such as irritable bowel syndrome (IBS) and
rheumatoid arthritis.44 The pooled results in the present study
were statistically analyzed, while Romjin and Rucklidge
produced a narrative synthesis.44 Only one of the studies in-
cluded in the present analysis was also included in Romjin
and Rucklidge.
There is good evidence from animal and human studies
that probiotics may have psychological health benefits in
humans (recently reviewed in Liu et al.45 and Grant and
Baker,46 who also examined the effect of exercise). How-
ever, it is possible that this effect may be reduced in indi-
viduals suffering from existing chronic conditions,
particularly those associated with altered gut microbiota,
termed dysbiosis, immune function changes, and psycho-
logical comorbidities such as IBS47,48 and rheumatoid ar-
thritis.49,50 In conditions with psychoneuroimmunological
disturbances, supplementation with probiotics may have
limited effect, and may help explain the difference between
the present results and those of Romjin and Rucklidge.
McFarland51 performed a systematic review of the use of
probiotics in certain disease states and reported that while
some species changed the composition of the microbiota in
chronic disease states, the disease state made it difficult to
determine a normal baseline microbiota, and thus any po-
tential positive effect of treatment. On the other hand, there
was significant evidence for the ability of probiotics to re-
store normal microbiota in situations of acute disruption
(e.g., antibiotic exposure), with 12 probiotics out of 15
treatment arms (10 studies) showing evidence for restoration
from normal baseline.51
None of the studies in this pooled analysis examined the
microbiota at baseline or after treatment. It is important to
note that there is significant interindividual variation of
species of microbes in the gut and other areas, and no
standard definition of ‘‘normal’’ microbiota.51 Nevertheless,
the absence of chronic disease in the participants of this
analysis likely excludes the existence of dysbiosis. It has
been shown that in healthy individuals, the use of certain
strains of probiotics have a small to medium effect
6 MCKEAN ET AL.
(SMD = 0.34, where SMD 2 = small and SMD 5 = medi-
um52) on subclinical psychological symptoms, and therefore
may have benefits in a preventative capacity.
Current understanding suggests that these effects are
mediated via the gut–brain axis.45,53 The gut–brain axis
ensures maintenance of GI homeostasis and digestion.3 This
system involves endocrine, immune, and neuronal afferent
signaling from the gut, conveying information from the gut
lumen to the brain stem via extrinsic vagal afferents and to
the spinal cord via spinal afferents. At the same time, me-
chanical stimuli such as stretch, pressure, distortion, and
shearing forces within the GI tract can also directly activate
spinal, vagal, and intrinsic primary afferents.3 Impairment of
this axis can result in a number of pathophysiological con-
sequences, including inflammatory GI disorders, obesity,
and eating disorders, along with effects on brain function,
cognition, and behavior, often resulting in psychological
disorders.1 Additionally, physical and psychological stress-
ors can alter the composition and metabolic activity of the
gut microbiome in a ‘‘top-down’’ brain-to-gut mechanism
via the autonomic nervous system and systemic circulation.3
These mechanisms are not completely understood. How-
ever, they are supported by results of studies that have ex-
amined the effect of stress mediators such as catecholamines
on the microbiome directly and via interactions with the
intestinal mucosa,45 and also the knowledge that a number
of bacterial species are responsive to stress hormones.54
As the gut microbiota has been seen to have a direct
significant impact on the gut–brain axis, this study consid-
ered the therapeutic potential for live probiotic bacteria due
to their direct interaction with the gut microbiota.12,13 Po-
tential favorable effects of probiotics include their ability to
modify the composition of the mucosa to prevent the ad-
herence of pathogens, ameliorating the state of the immune
system.55,56 The human intestinal tract supports the largest
concentration of immune cells within the human body,
along with 500 million neurons.57 It has been suggested that
certain depressive symptoms may derive from activation of
the inflammatory immune system through the secretion of
signaling molecules such as proteases, histamine, serotonin,
and cytokines by immune cells within Peyer’s patches and
the gut epithelium.45 These molecules are believed to act via
receptor activation in a paracrine fashion on vagal and
spinal afferents to the CNS.45 Additionally, luminal factors
such as nutrients, toxins, and antigens are said to activate
enteroendocrine cells, leading to the release of gut peptides,
hormones, and neuropeptides, all of which reach brain tar-
gets systemically.3
The literature suggests different mechanisms by which
probiotics could affect CNS function. In general, the mod-
ification of normal gut microbiota and regulation of multiple
signaling pathways, including neural pathways, immune
pathways, and metabolic pathways, are proposed as poten-
tial mechanisms of probiotic action.45 Some mental disor-
ders such as anxiety and depression are associated with
increased inflammatory activation.58 Therefore, altering mi-
crobial composition of the gut, decreasing pro-inflammatory
cytokine production, reducing inflammation, and having a
favorable effect on gut–brain signaling as a result is one of
the possible ways to change the emotional state.58,59 Given
the two-way communication between the immune system
and the CNS, probiotics are also capable of increasing the
integrity of the gut wall, which is the result of gut-microbiota
composition improvement, and it leads to lower immune
activation in response to bacterial translocation.60
A number of preclinical studies have been carried out in
an attempt to characterize the bidirectional interactions of
the gut–brain axis. These studies have been successful in
identifying potential links between changes in gut flora and
changes in affective behaviors in animals, reviewed in
Wang et al.7 Several probiotic species have been confirmed
to produce neurotransmitters such as acetylcholine, seroto-
nin, and GABA,61 which act both directly and indirectly on
CNS targets. Information from the heart, lungs, pancreas,
liver, stomach, and intestines are delivered tonically to the
brain via sensory fibers in the vagus nerve.62 Bravo et al.
identified the vagus nerve as a major constitutive of this
communication pathway, and confirmed that neurochemical
and behavioral effects were not found in vagotomized
mice.63 They established that the probiotic effects of Lac-
tobacillus rhamnosis on the host’s GABA receptor expres-
sion were absent without an intact vagus nerve. These
results confirm that in animals, experimental changes made
within the gut microbiota can have an effect on emotional
behavior and related brain systems.64
In another animal study, D’Mello et al. were able to
demonstrate that treatment with a high-potency probiotic
medical food formulation,VSL#3, can reduce sickness be-
havior development in mice without affecting severity of
liver disease, gut microbiota composition, or gut perme-
ability.65 This attenuation of sickness behavior was associ-
ated with lower microglial activation and cerebral monocyte
infiltration, and paralleled by a decrease in circulating TNF-
a. Germ-free rodent studies have also demonstrated the in-
fluence of gut microbiota on the development of emotional
and social behaviors, stress- and pain-modulatory systems,
and brain neurotransmitter systems.66 This influence appears
to be of particular importance during critical neurodeve-
lopmental windows and therefore may have an effect on the
lifelong functionality of these systems.67 Probiotics and
antibiotics are also known to exert modulatory effects on
some of these measures in adult animals.66 It has also been
shown that many bacterial metabolites can act as epigenetic
modifiers.68 This is of significance, as the role of epigenetic
mechanisms in influencing brain function and behavior is
shifting the understanding of the ways by which probiotics
may attenuate psychological symptoms.69
Limitations
To the best of the authors’ knowledge, this study is the
first to review the effect of probiotics on symptoms of
anxiety, depression and stress on normal healthy volunteers
systematically by pooling the results of individual control
trials. This study investigated the effect of different species
and durations of probiotics on specific preclinical psycho-
logical symptoms. However, the current review has several
limitations that should be discussed. There was significant
heterogeneity as several factors varied across the studies.
Supplement administration varied between the included
studies in terms of the duration, probiotic type and dose
(CFU), and the type of the carrier. The number of studies and
sample sizes are also small, which can lead to lower confi-
dence in the meta-analytic results. Moreover, as included
EFFECTS OF PROBIOTICS ON PSYCHOLOGICAL SYMPTOMS
studies were conducted in healthy participants, they are not
translatable to participants with diagnoses of existing psy-
chological conditions such as anxiety or depression. The
baseline characteristics of participants varied, which may
have influenced the meta-analysis outcome, and this should
be considered in future studies. In particular, there is the issue
of variance in a healthy gut microbiome, which may influence
response to supplementation with particular strains of pro-
biotics. As no assays are currently able to detect the complete
microbiota, this must be acknowledged as a current limitation
in the field.51 A further limitation is the different measures
used for anxiety, depression, and stress. For anxiety and de-
pression, all studies used well established and previously
validated measures, although they differed between studies.
For stress, two studies used 1–10 scales to describe stress.24,31
One study considered cold/flu symptom intensity as the stress
measure—a further limitation, as it would be difficult to
distinguish between physiological symptoms and psycho-
logical symptoms.30
Conclusion and Future Directions
The results of this review and meta-analysis suggest that a
probiotic intervention may have an advantageous effect on
mental health by reducing psychological symptoms includ-
ing anxiety, depression, and perceived stress in healthy adult
volunteers. These results support the notion that probiotic
supplementation may have an influence on certain cognitive
functions known to determine susceptibility to mood dis-
orders. It has become clear that the gut microbiome has a
number of important roles within the body, and appears to
be intricately involved with both the systemic immune
system as well as the nervous system. For these reasons, the
gut microbiome presents as a potential target for the treat-
ment of cognitive and mood disorders. The studies and
discussion outlined in this review indicate the increasing
need to understand the gut microbiome better and the role it
plays in communication via the gut–brain axis, but also
highlights the need to understand individual variation. Fu-
ture studies may allow for the development of novel pro-
biotic treatment strategies for gastrointestinal-related
disorders that are associated with impaired communication
between the gut and the brain. Such studies will require
larger sample sizes and participants with various health
conditions, which are matched in baseline characteristics,
including microbiome features, to confirm the health benefit
and role of probiotics on psychological symptoms. In par-
ticular, studies need to be carried out to detect benefits of
specific strains as effects may be strain specific.
Author Disclosure Statement
No competing financial interests exist.
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(Appendix follows /)
 Appendix. Methodology Assessment Summary and Rosendal Score of Studies Included in Systematic Review
for the Effect of Probiotics on Psychological Symptoms
Method
Sample Blinding Blinding and Non- Measures and Between- Adverse
Method for size Pre-trial Baseline of of evaluation completers Stats variability group stats effects Reproducibility Familiarization %
a b c d e f g h i j k l m
Authors (References) Eligibility Randomization randomization calculated conditions measures subjects investigators of blinding described described described comparisons describedn reportedo performancep Score

Diop et al., 2008 1 1 0 0 0 1 1 1 1 1 1 1 1 1 0 0 69%

Langkamp-Henken 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 94%
et al., 2015
Messaoudi et al., 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 75%
2011
Mohammadi et al., 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 0 81%
2015
Steenbergen et al., 1 1 0 0 0 1 1 1 1 1 1 1 1 0 0 0 62%
2015
Kato-Kataoka et al., 1 1 0 0 1 1 1 1 1 1 1 1 1 NA 0 0 73%
2016
Takada et al., 2016 1 1 0 0 1 1 1 1 1 1 1 1 1 1 0 0 75%

10
a
A clear description of the inclusion and exclusion criteria was provided.
b
The trials were randomized.
c
The method used to generate the random allocation sequence, including details of any restrictions (e.g., blocking, stratification) was described.
d
Sample size was justified (e.g., by power calculation).
e
Attempts were made to control and/or monitor pretrial condition (e.g., diet, exercise).
f
Design incorporated measures of important baseline variables.
g
There was blinding of all subjects.
h
There was blinding of all investigators involved in the trials.
i
Both the method of blinding and the evaluation of the successfulness of blinding were described.
j
Details were provided regarding the inability of subjects to complete study requirements.
k
Statistical methods used to compare groups for primary outcome measure, and methods for additional analyses, such as subgroup analyses and adjusted analyses, were described.
l
Both point measures and measures of variability for the primary outcome measure were provided.
m
The results of between-group statistical comparisons were reported for the primary outcome measure (e.g., an estimated effect size), and its precision (e.g., 95% confidence interval).
n
The method used to assess adverse effects was reported.
o
Reproducibility of the primary outcome measures was reported.
p
If a performance test was used, a familiarization trial was conducted.