Biological Signature and Safety of an Immunomodulatory Probiotic Intervention for Veterans With Co-Occurring Mild TBI and PTSD
Phase: PHASE1
Conditions: Mild Traumatic Brain Injury, Post Traumatic Stress Disorder
Sponsor: VA Office of Research and Development

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COMIRB: 14-1804 
PI: Brenner 
Version: 10/16/17 (v6) 
 
 
Project Title: 
Acceptability and Feasibility of L. reuteri among Veterans: A 
Stress Resilience Model 
 
Principal Investigator:   
Lisa A. Brenner, PhD 
 
Co-Investigators: 
 
Theresa D. Hernández, PhD 
 
 
 
 
Steve Bartlett, RPh, MSPH 
 
 
 
 
Christopher Lowry, PhD 
 
 
 
 
Jeri Forster, PhD 
 
 
 
 
Teodor Postolache, MD 
 
1. Aims/Hypotheses 
Primary Aims:  
To test the acceptability and feasibility of Lactobacillus reuteri (L. reuteri), a probiotic dietary 
supplement for a cohort of Veterans with a history of mild traumatic brain injury (mTBI) and post 
traumatic stress disorder (PTSD). 
 
Exploratory Aim: To collect data to identify potential biological signatures, including 
inflammatory makers and gut permeability among those with mTBI and PTSD. 
 
Exploratory Hypotheses: Evaluation of supplementation requires a stepwise process in which 
initial aims are geared towards identifying biological signatures versus diagnosing, treating, 
mitigating or curing any conditions. Towards the end of identifying potential biological 
signatures, we hypothesize the following. 1) Participants who receive L. reuteri as a dietary 
supplement will have an attenuated physiological stress response to cognitive and emotional 
stressors as measured by lower heart rate, skin conductance, and body temperature when 
compared to those who received the placebo supplement. 2) Participants who receive L. reuteri 
as a dietary supplement will have attenuated perceived psychological stress to cognitive and 
emotional stressors as measured by lower scores on psychological correlates of acute stress 
when compared to scores from those who received the placebo supplement. 
 
2. Background and Significance  
There is now much evidence to suggest that modern man’s lack of exposure to microorganisms 
in the environment is leading to a disordered and hyperactive immune system (Rook, 2009). 
The Old Friends Hypothesis (also known as the Hygiene Hypothesis) postulates that mammals 
co-evolved with an array of microorganisms that have become necessary for proper 
development of the immune system, particularly in quieting the immune response once it is no 
longer needed to eliminate a potential threat (Rook et al., 2013). For example, germ free rats 
have been shown to have poorly developed lymphoid systems and are highly susceptible to 
auto-inflammatory disorders (Kohashi et al, 1985). Similar findings have also been noted in 
humans, growing up with a hot-water tap in the home was found to increase the risk of 
developing Crohn’s disease by five-hundred percent (Gent et al, 1994). Autoinflammatory 
diseases such as asthma have been shown to be significantly more prevalent in more sterile 
w 
COMIRB Protocol 
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Version: 10/16/17 (v6) 
urban environments as compared to the less sterile rural environments (Van Niekerk et al, 
2006). Probiotics are one type of these commensal microorganisms that have a naturally 
occurring, symbiotic relationship with humans and other animals, exerting their beneficial effects 
through immunoregulatory pathways. One probiotic organism in particular, Lactobacillus reuteri 
(L. reuteri), has been shown to induce the proliferation of regulatory T-cells which produce the 
anti-inflammatory cytokine, IL-10 (Smits et al, 2005). This may explain the ability of this 
organism to treat disorders of inflammation as described by further evidence in the following 
sections. In recent years, there has been an increased interest in exploring and demonstrating 
clinical effects of commensal microbes such as probiotics on various systems within the body 
via probiotic supplementation.  
A. Animal Studies 
Animal studies have shown that manipulation of a host’s microbiome via dietary 
supplementation can lead to changes in emotional and cognitive functions.  Specifically, 
impaired gut colonization during development alters the physiological stress axis and may 
significantly contribute to an exaggerated stress response during adulthood, which, in turn, may 
contribute to mood disorders such as generalized anxiety disorder (Messaoudi et al., 2011).  In 
addition to the influence the microbiota has on brain development, animal studies have also 
shown a more acute effect of gut bacteria on emotional behavior.  Following infection with a 
pathogen (or injection of proinflammatory cytokines to mimic a physiological immune response) 
adaptive sickness behavior is elicited, which is similar to that of depression (Rook, 2009).  
Activation of the brain proinflammatory cytokine system is associated with decreases in general 
activity, eating, drinking, and social activity: behaviors all reminiscent of depression (Dantzer, 
2001). Additionally, Lowry and colleagues see stress and immune function linked as rodents 
exposed to chronic mild stress for five weeks were found to have increased levels of the 
proinflammatory cytokine IL-1β and neurodegeneration in the hippocampus, one of the brain 
structures implicated in major depressive disorder (Bansar & Duman, 2007). L. reuteri has been 
shown to produce anti-inflammatory factors that could aid in quieting the immune response 
(Jones & Versalovic, 2009). Additionally L. reuteri colonization has been shown to reduce 
visceral pain in rodents (Kamiya et al, 2006).  
 
B. Safety Trials in Humans 
 
 
Mangalat et al. (2012) conducted a placebo-controlled, safety and tolerability study of 
Lactobacillus reuteri in healthy adults.  At the end of a 2 month supplementation period, the 
authors concluded that L. reuteri is safe and well tolerated in adults as no severe adverse 
events and no significant differences in adverse events were reported relative to the control 
condition (Mangalat et al. 2012).  
Safety and tolerance of L. reuteri was also tested in other studies.  Recently, a research 
team found that no significant differences existed between an L. reuteri treated group and a 
placebo group when it came to hematology results and adverse event reporting (Jones et al. 
2012). There have been numerous studies with vulnerable populations in which probiotics of the 
Lactobacillus genus have demonstrated evidence of safety.  Some of these populations include: 
pregnant women, infants, the elderly, patients with rotavirus, adults with Crohn’s disease, and 
malnourished children to name a few (Snydman, 2008; Sung et al., 2013).  Not only have 
probiotics demonstrated safety in these populations, they have also alleviated symptoms of 
disease.  For example, in a study of 61 cystic fibrosis patients, L. reuteri significantly reduced 
pulmonary exacerbations and upper respiratory infections in those with mild to moderate lung 
infections (Nardo, 2014).  
C. Documented Probiotic Use 
Probiotics have been used as a therapeutic agent in a variety of human diseases. L. 
reuteri has been found to be effective in shortening rotavirus-associated gastroenteritis 
(Shornikova et al, 1997). Further evidence supporting L. reuteri’s efficacy as an anti-
inflammatory agent, supplementation was been found to reduce gingivitis in severe cases 

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(Krass et al, 2006). Interestingly, one study found L. reuteri supplementation aided in reducing 
gastrointestinal symptoms in children receiving therapy to eradicate Helicobacter pylori 
infections (Lionetti et al, 2006). Another study examined L. reuteri supplementation in healthy 
subjects and found the supplemented group to have significantly reduced work “sick-days” 
compared to placebo (Tubelius et al, 2005). L. reuteri seems to be effective both as a 
prophylactic supplement and as an anti-inflammatory interventional treatment. 
As the interest in the gut microbiome and commensal microbes is relatively new, few 
studies exist examining their use closely in humans, and none exist looking specifically at the 
Veteran population. The compiled evidence in rodents suggests this supplement may improve 
cognition and ability to respond to stressful stimuli; furthermore, studies in humans show the 
supplement to be well tolerated. This study would allow for a closer examination of L. reuteri in a 
population that has yet to be examined, as well as examine the behavioral endpoint (biological 
signature) of response to acute stress that has yet to be considered in previous human studies. 
3. Preliminary Studies/Progress Report 
The proposed investigation is a pilot study intended to establish the acceptability and 
feasibility of an L. reuteri probiotic supplement in a population of Veterans. Exploratory data 
regarding biological signatures will also be collected.  
4. Research Methods 
 
A. Participants 
Up to 200 participants will be recruited within the Eastern Colorado Health Care System 
(ECHCS).  
Inclusion Criteria: 
1. Veterans eligible to receive care by a VA provider 
2. History of at least one deployment in support of OEF/OIF/OND 
3. History of mTBI per the Ohio State University (OSU) TBI-ID with any endorsement of 
post concussive symptoms (PCS) associated with an mTBI, which occurred at least 
6 months prior to the baseline assessment 
4. Current symptoms in 3 or more of the following ICD-10 Post Concussive Symptom 
categories as measured by the Rivermead Post Concussive Symptom Questionnaire 
(RPCSQ; score of 2 or greater per symptom to qualify): a) headache, dizziness, 
malaise, fatigue, noise intolerance, b) irritability, depression, anxiety, emotional 
lability; c) subjective concentration, memory, or intellectual difficulties; and/or d) 
insomnia 
5. Current diagnosis of PTSD per the Clinician Administered PTSD Scale-5 (CAPS-5) 
6. Medical clearance by study physicians to participate in the protocol 
7. Age between 18 and 50 
8. Ability to provide informed consent 
9. Willingness not to take probiotic supplements (pills, tablets, oils, etc.) other than the 
product provided in the clinical study until all study procedures are completed 
10. Willingness to provide blood, as well as stool samples. 
 
Exclusion Criteria 
1. Inability to adequately respond to questions regarding the informed consent procedure  
2. Currently involved in the criminal justice system as a prisoner or ward of the state  
3. Current (past month) alcohol or substance abuse or dependence 
4. Lifetime history of bipolar disorder or psychosis or anxiety disorders (excluding PTSD) 

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5. Consistent (e.g., 5x/week or greater) probiotic supplementation within the last month, 
including probiotic food products such as yogurt, as determined by phone screen 
interview and Probiotic Food Check List 
6. Receiving antibiotics within the last month;  
7. Receiving medications that interfere with gut motility (opiates, loperamide, stool 
softeners)  
8. Presence of central venous catheters (CVCs) 
9. Gastrointestinal (GI) barriers as identified by the 2-week run-in period as determined by 
the study team (e.g., daily GI discomfort with frequent diarrhea prior to supplementation) 
10. Participation in conflicting interventional research protocol 
11. Vital signs outside of acceptable range, i.e., blood pressure >160/100, oral temperature 
>100°F, pulse >100 
12. Use of any of the following drugs within the last 6 months: systemic antibiotics, 
antifungals, antivirals or antiparasitics (intravenous, intramuscular, or oral); oral, 
intravenous, intramuscular, nasal or inhaled corticosteroids; cytokines or cytokine 
inhibitors; methotrexate or immunosuppressive cytotoxic agents 
13. Acute disease at the time of enrollment (defer sampling until subject recovers). Acute 
disease is defined as the presence of a moderate or severe illness with or without fever. 
14. Chronic, clinically significant (unresolved, requiring on-going medical management or 
medication) pulmonary, cardiovascular, gastrointestinal, hepatic or renal functional 
abnormality, as determined by medical history or physical examination other than 
irritable bowel syndrome (IBS) 
15. History of cancer except for squamous or basal cell carcinomas of the skin that have 
been medically managed by local excision 
16. Unstable dietary history as defined by major changes in diet during the previous month, 
where the subject has eliminated or significantly increased a major food group in the diet 
17. Positive test for human immunodeficiency virus (HIV), Hepatitis B virus, or Hepatitis C 
virus 
18. Any confirmed or suspected condition/state of immunosuppression or immunodeficiency 
(primary or acquired) including HIV infection 
19. Major surgery of the GI tract, with the exception of cholecystectomy and appendectomy, 
in the past five years. Any major bowel resection at any time. 
20. Regular urinary incontinence necessitating use of incontinence protection garments 
21. Female who is pregnant or lactating 
22. Treatment for or suspicion of ever having had toxic shock syndrome  
23. Those receiving immunosuppressive drugs/medications (e.g. oral corticosteroids) or 
treatment including antineoplastic therapy, post-transplantation immunosuppressive 
therapy, and/or radiation therapy.  
 
B. Recruitment  
Dr. Brenner, Director of the Rocky Mountain MIRECC, will oversee all recruitment 
efforts. Recruitment will occur in the following ways: 1) mailing letters to research participants 
that have previously agreed to enrollment in the VISN 19 MIRECC Recruitment Database (as 
described in COMIRB 10-0554); 2) posting approved flyers around the ECHCS; and 3) 
informing health care staff about the current study and encouraging them to tell their patients 
about the study (interested Veterans will be encouraged to contact members of the study team).  
We may retrieve names and addresses of potential participants from the VA database 
that have the ICD-9 and/or ICD-10 codes of interest for TBI (e.g., S06) and PTSD (e.g., F43.1). 
An initial invitation may be sent by U.S. mail from the PI to participate in the study, including a 
flyer, and a pre-stamped and addressed refusal response card. If the potential participant 
contacts the study team and expresses interest in participating, he/she may then be screened 

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for possible enrollment into the study. If the potential participant returns the refusal response 
card, that individual’s name will be flagged as do not contact. The refusal response card will not 
include any PHI, nor the study name or Veteran’s name. The refusal response card only states, 
“I do not wish to participate in this study”. So that the research staff is able to identify a Veteran 
who would no longer like to be contacted, the refusal response card will include a unique 
identifier. One reminder letter may be sent if the participant has not expressed either interest or 
no interest in being contacted within 4 weeks. 
All potential participants will convey interest directly to a member of the research team. 
Patients who convey interest to their provider will be directed to a member of the research team, 
who will speak with the potential participant to discuss study procedures and obtain informed 
consent.  
Those who contact a member of the research team and are interested in participating 
will be screened for eligibility for the study. This screening process, which will be conducted by a 
member of the research team, will consist of a brief phone or in-person interview (at the 
convenience of the Veteran). Use of the study Screening Form (i.e. verbal consent) and HIPAA 
and consent waivers will be obtained to facilitate this process. If the potential participant does 
not meet study criteria, he/she will be informed of this immediately and will be thanked for their 
interest. Screening forms for these persons will not be destroyed per VA regulations. De-
identified data already collected on the Screening Form may be used for comparative purposes 
only.  
For those who pass the initial screening for the study and provide verbal consent, 
permission to contact a PCP or a licensed provider chosen by the study team will also be 
verbally obtained. A member of the research team will contact the provider either in person, via 
phone, and/or encrypted email. Veterans’ potential participation in the study will be discussed 
with the provider, and the provider will be asked to complete a medical clearance form and 
indicate whether there are medical barriers to the Veteran participating in the study. If barriers 
are identified, the Veteran will not be eligible to participate. A research team member will 
contact the Veteran by phone to inform them of medical eligibility to participate in the study. 
If the potential participant meets study criteria, is medically approved to participate, and 
is willing and able to commit to the study, he/she will be scheduled for an in-person appointment 
at the ECHCS to complete the informed consent process and the initial baseline procedures.   
C. Consent  
All members of the research team will have been trained in COMIRB procedures and will 
be under the direct supervision of Lisa Brenner, PhD. The nature of the study and potential risks 
and benefits will be discussed in a calm environment in a private office at the ECHCS and 
participants will have the opportunity to ask questions. After the informed consent document and 
purpose of the study are explained and provided to the participants and all questions are 
answered, the participants will be asked to answer six questions. These questions will ensure 
participants' ability to adequately provide informed consent. If participants are not able to 
adequately respond to these questions, they will be excluded from participation: 1) Why is this 
study being done? 2) What is the study asking you to do? 3) What are the risks/side effects of 
being in the study? 4) What are the benefits of being in the study? 5) Is the study voluntary? 6) 
What do you do if you have questions or possible side effects?  
The informed consent document includes an option to be voluntarily included in a 
database of research participants for possible recruitment into VISN 19 MIRECC study 
protocols. On the study consent, participants are asked to check a box indicating whether they 
would like to be contacted to participate in future studies and to initial their choice. Willing 
participants, as determined by a “Yes” response and participant initials, will be given the option 
to sign a HIPAA B form and a separate consent document pertaining to the VISN 19 MIRECC 
Research database. 

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Participants will be provided with a copy of the study consent form, and will be assured 
that their decision regarding participation will in no way affect the care they receive from the VA 
nor their access to care although the consent process will be documented in the participant’s 
electronic VA medical record. 
Participants will be informed that the researcher will review their responses to the items 
regarding safety, and if necessary, will discuss these responses with them in an effort to ensure 
their safety.  For participants who reveal clinically meaningful risk as indicated on the UWRAP, 
specifically if the participant rates suicide risk at or higher than a rating of 4 on the Pre-
Assessment Risk Assessment (page 2 of the UWRAP), study personnel will review, and if 
necessary, will discuss these responses with them to ensure their safety. Responses may be 
also shared with the Veteran’s treating clinician, if determined necessary by Dr. Brenner or her 
designee. Additional mental health interventions, such as escorting the Veteran to the 
Psychiatric Emergency Services will be determined at this time, by Dr. Brenner, her designee, 
or the treating clinician and appropriate notation will occur. 
All researchers who will be interacting with study participants are trained in the area of 
risk assessment and management, and will be receiving supervision from Dr. Lisa Brenner, a 
licensed clinical psychologist, or her designee. 
D. Re-Engagement of those Previously Excluded  
Participants who have previously consented but were excluded due to C-Reactive 
Protein (CRP) < 3.0 mg/L, current major depressive disorder, and/or BMI less than 18 or greater 
than 35 will be given the option to re-consent into the study. A member of the research team will 
reach out to those participants by phone to explain that they are now eligible for the study. This 
visit may take place in person or over the phone, if all assessments were collected at Visit 1. 
The following measures will be re-administered: UWRAP, Neurobehavioral Symptom Inventory 
(NSI), Probiotic Food Checklist, Rivermead Post Concussive Symptom Questionnaire 
(RPCSQ), Pittsburgh/Epworth Sleep Scale, and Psychological Stress Measure-9 (PSM-9). If all 
measures were not completed during the initial visit 1- the participant may be asked to come for 
an in person visit to complete study measures. Individuals who are re-engaged will restart study 
procedures (e.g., Study Procedure Week) as outlined in Section G. Re-engagement will not 
require re-consenting or resigning HIPPA Waiver of Authorization forms.  
 
E. Authorization 
For recruitment, a waiver of consent and a HIPPA Waiver of Authorization will be 
obtained to allow members of the research team to view selected medical charts of patients who 
contact the PI or study coordinator and express interest in participating in the study. Review of 
the medical records allows members of the research team to screen for other criteria that would 
exclude participation (e.g., certain medical conditions or prescriptions). 
For enrollment, an authorization to collect protected health information (PHI) will be 
obtained by a member of the research team (VA Authorization B: Enrollment into Research 
Form).  A signed and dated copy of the release will be provided to the participant. All data in 
electronic format will be limited to data sets and stored in password protected spreadsheets on 
the VA shared drive, behind the VA firewall. Only members of the research team will have 
access to the limited data set. 
The PI and/or Study Coordinator will maintain a master list of participant names, social 
security numbers, contact information (telephone numbers), and randomly assigned research 
identification numbers in a separate, password-protected, electronic file. All data in paper format 
or original documents containing sensitive information will be stored in locked filing cabinets 
within the MIRECC offices. Of note, the original signed informed consent forms and HIPAA 
authorization forms will be stored in locked filing cabinets separate from the rest of the paper 

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study data. Only the PI, VA co-Investigators, and Research Assistants on the protocol 
application will have access to the paper documents. 
F. Study Design 
The proposed study is a longitudinal, randomized, placebo-controlled, between groups 
design. The study is expected to provide feasibility and acceptability data regarding 
supplementation. Basic information regarding biological signatures will also be collected. 
 
G. Study Procedures 
In addition to the paragraphs below, please refer to the consort diagram on page 8. 
Upon confirming eligibility and obtaining medical clearance, participants will complete 
the baseline assessment (Visit 1). History of mTBI and PTSD will be confirmed during Visit 1.  A 
blood draw will be performed to confirm CRP levels. If CRP levels are not at the level necessary 
to participate in the study, participants will no longer be eligible to participate. 
Between Visits 1 and 2, all participants will be asked to complete a daily diary of 
gastrointestinal (GI) symptoms (GI Symptom Diary including the Bristol Stool Scale). 
Participants reporting abnormal stool form (Bristol Stool Scale 1, 6, or 7) or frequency (>3 bowel 
movements per day or <3 bowel movements per week) or abdominal pain/discomfort on more 
than 2 days in a row will be excluded from further participation. This careful screening for 
gastrointestinal symptoms will be performed with the goal of facilitating evaluation of 
acceptability/feasibility (changes in GI symptoms pre- and post-supplementation). Participants 
will also be asked to provide a gut/fecal sample (the kit and instructions will be given to the 
participant at Visit 1) and send or bring this sample (per directions given to participant) to Visit 2. 
After 2 weeks, participants will complete the Visit 2 assessment measures. At this point 
individuals will be randomized to one of two conditions, active or placebo group via random 
sampling by the research pharmacist. Half of participants will be given a probiotic oil solution 
and the other half will receive a placebo version of the oil solution. The study team will provide 
the participant with information regarding the supplement (e.g., How to take it? When to take it? 
How to note having taken it in their probiotic log?) and contact information regarding who to call 
if any questions arise during the trial regarding the supplements. Materials to track supplement 
usage and adverse events will be given to the participant during this meeting by the MIRECC 
Research Team.  
Between Visit 2 and Visit 3, Veterans will independently complete daily GI Symptom 
Diary and Probiotic Usage Logs, and will speak with study staff by phone or in person one time 
per week to respond to questions (see measures table below). After the 8-week (+/- 2 weeks) 
supplementation intervention, participants will be invited back to the lab to complete the follow-
up appointment (Visit 3). The Visit 3 assessment will occur within 2 weeks of the 8-week trial; 
that is, participants may complete the follow up assessment as early as 6 weeks and as late as 
10 weeks post intervention initiation, depending on the research team and Veteran’s scheduling 
capabilities. Participants will be asked to provide a gut/fecal sample (the kit and instructions will 
be given to the participant at Visit 2) and send or bring this sample (per directions given to 
participant) to Visit 3. 
At Visit 3, Veterans will complete the final study visit. In addition to self-report measures, 
participants will complete the Trier Social Stress Task (TSST; see description below). 
Physiological Biomarkers of Stress Response. Heart rate and skin conductance (e.g., 
galvanic skin response) will be measured continuously during task performance with a centrally 
placed remote heart rate monitor around the base of the sternum (heart rate) and the distal 
phalanges of the first and second fingers of the non-dominant hand (skin conductance). A 
sphygmomanometer will be used to measure blood pressure at 5-minute intervals throughout the 
task, by wrapping the cuff around the non-dominant arm. Signals from each of these stress 

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biomarkers will be recorded with an ADInstruments system, with appropriate bioamplifiers and 
software allowing for data acquisition in real time. 
Psychological Markers of Stress Response (e.g. Perceived Stress). The individual’s 
perception of stress will be assessed using a Distress Thermometer-Visual Analog Scale (VAS) 
for stress appraisal. This measure has been used reliably in the literature and by members of this 
team. 
 In addition to the procedures described above, phlebotomy of an antecubital vein to 
obtain 30 cc of blood will be performed. Blood will be drawn by certified technicians at Visits 1, 2 
and 3. After centrifugation and separation of plasma, specimens will be coded and “blinded” and 
plasma will be stored in -80°C freezers at the Denver VA, and, once data collection has 
completed, all specimens will be securely delivered to University of Colorado Boulder 
Behavioral Neuroendocrinology Laboratory (WOC and Co-I Christopher Lowry). Data Transfer 
Agreements will be signed prior to the transport of any specimens. Blood samples will be 
analyzed and destroyed per VA policy. To minimize biohazard risk for others, the use of gloves, 
biohazard bags, and biohazard coolers will be assured, as well as documentation of relevant 
TMS training for all VA staff will be in place for every personnel handling blood or blood 
products. 
In order to minimize the burden on participants, any study assessments that have been 
previously completed in a specified timeframe through participation in another MIRECC protocol 
may not be re-administered. Instead, assessment data will be shared as outlined in an internal 
standard operation procures (SOP) for sharing of assessment data. 
 

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Participation in the study will require 3 in person visits. In total, participation will be 
approximately 6 hours over the course of approximately 12 weeks. Participants will be 
compensated $25 for completion of each of the Visit 1, 2, and 3 appointments. Participants who 
are re-engaged (see Section D above) will also receive $25 for their participation in the 
additional visit. Participants will be paid $5/week for monitoring gastrointestinal (GI) symptoms 
including bowel movements and $5 for mailing/bringing in the stool sample between Visits 1 and 
2 (for a total of up to $15). Individuals will be compensated $5/week for participating in the 
weekly calls/visits and $5 for keeping diaries between Visits 2 and 3, as well as $5 for sending 
mailing/bringing in the stool sample (for a total of up to $85). If the participant leaves the study 
early, or is no longer eligible, they will be paid only for the visits completed. Compensation for 
completion of study visits may occur in the form of cash, check, gift card or direct deposit. 
Supplements will be provided at no cost to the participants. Participants will be asked to bring 
the remainder of their supplement solution to the post-intervention appointment so that 
adherence to the suggested dosage can be verified. There will be no follow up visits or 
laboratory studies after the Visit 3 appointment associated with the proposed project, although 
medical records may be reviewed for up to two years prior and post participation. 
 
Measure 
Format 
Time 
(min) 
Domain 
Purpose 
Visit 1 
UWRAP  
Interview 
5 
Risk Assessment 
Safety 
Rocky Mountain 
MIRECC 
Demographic 
Questionnaire 
Questionnaire 
5 
Control Variables 
Sample Characteristics 
BMI  
Weight and 
Height 
Measurement 
5 
BMI 
Sample Characteristics 
Clinician 
Administered PTSD 
Scale-5 (CAPS-5) 
Interview 
20 
PTSD 
Inclusion/Exclusion 
Neurobehavioral 
Symptom Inventory 
(NSI) 
Questionnaire 
5 
Symptom 
Evaluation 
Sample Characteristics 
Ohio State University 
TBI-ID (OSU-TBI-ID) 
Interview 
25 
Lifetime TBI 
Identification 
Inclusion/Exclusion 
Probiotic Food Check 
List 
Interview 
5 
Diet 
Inclusion/Exclusion 
Rivermead Post 
Concussive Symptom 
Questionnaire 
(RPCSQ) 
Questionnaire 
5 
Symptom 
Evaluation 
Sample Characteristics 
Credibility/Expectancy 
Scales 
Questionnaire 
5 
Credibility of 
Supplementation/ 
Expectancy 
Primary Aim 
Generic Assessment 
of Side Effects 
(GASE) 
Questionnaire 
5 
Side Effects 
Primary Aim 
Rome III Diagnostic 
Questionnaire 
Questionnaire 
20 
GI Symptoms 
Sample Characteristics 

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Structured Clinical 
Interview for DSM-V 
(SCID-IV) 
Interview 
40 
Psychiatric 
Evaluation 
Inclusion/Exclusion; 
Sample Characteristics 
Harvard Food 
Frequency 
Questionnaire Booklet 
Questionnaire 
20 
Food Frequency 
Sample Characteristics 
Pittsburgh/Epworth 
Sleep Questionnaire 
Questionnaire 
5 
Sleep 
Sample Characteristics 
Psychological Stress 
Measure 9 (PSM-9) 
Questionnaire 
5 
Perceived Stress 
Exploratory Aim 
C-Reactive Protein 
(CRP) 
Blood Draw 
5 
Inflammation 
Sample Characteristics 
qPCR quantification 
of 16S rDNA 
Blood Draw 
- 
Gut Permeability 
Exploratory Aim 
  Visit 1 Total Time: 175 min  
 
 
 
Up to 2 Weeks Between Visits 1 and 2 
Gastrointestinal (GI) 
Symptom 
Diary/Bristol Stool 
Scale (BSS) 
Diary 
5 
GI Symptoms 
Inclusion/Exclusion 
Irritable Bowel 
Severity Scoring 
System (IBS-SSS) 
Questionnaire 
3 
GI Symptoms 
Primary Aim 
Gut Microbiome 
Gut/fecal 
sample 
5 
Microbiome 
Exploratory Aim 
Between Visits 1 and 2 Time: 13 min/week 
 
 
Visit 2 – Visit 2 Measures, Randomization & Intervention 
Credibility/Expectancy 
Scales 
Questionnaire 
5 
Credibility of 
Supplementation/ 
Expectancy 
Primary Aim 
GASE 
Questionnaire 
5 
Side Effects 
Primary Aim 
Psychological Stress 
Measure 9 (PSM-9) 
Questionnaire 
5  
Perceived Stress 
Exploratory Aim 
Irritable Bowel 
Severity Scoring 
System (IBS-SSS) 
Questionnaire 
3 
GI Symptoms 
Primary Aim 
CRP, Tumor Necrosis 
Factor (TNF)-α, 
Interleukin 6 (IL-6), IL-
8 
Blood Draw 
5 
Inflammation 
Exploratory Aim 
qPCR quantification 
of 16S rDNA 
Blood Draw 
- 
Gut Permeability 
Exploratory Aim 
Visit 2 Total Time: 23 min 
 
 
 
Between Visits 2 and 3 
Probiotics Usage Log Diary 
5 
Acceptability/ 
Feasibility 
Primary Aim 

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GI Symptom Diary/ 
BSS 
Diary 
5 
GI Symptoms 
Inclusion/Exclusion 
IBS-SSS 
Questionnaire 
3 
GI Symptoms 
Primary Aim 
Generic Assessment 
of Side-Effects – 
Probiotics (GASE-P) 
Questionnaire 
5 
Acceptability/ 
Feasibility 
Primary Aim 
Adult AIDS Clinical 
Trials Group (AACTG) 
Follow-up: Section G. 
Questionnaire 
3 
Feasibility 
Primary Aim 
Modified Morisky 
Medication-Taking 
Adherence Scale 
(MMAS) 
Questionnaire 
3 
Acceptability/ 
Feasibility 
Primary Aim 
Modified Treatment 
Satisfaction 
Questionnaire for 
Medication (TSQM) 
Questionnaire 
5 
Acceptability 
Primary Aim 
Gut Microbiome 
Gut/fecal 
sample 
5 
Microbiome 
Exploratory Aim 
Between Visits 2 and 3 Time: 34 min/week 
 
 
Visit 3 
UWRAP 
Interview 
5 
Risk Assessment 
Safety 
Credibility/Expectancy 
Scales 
Questionnaire 
5 
Credibility of 
Supplementation/ 
Expectancy 
Primary Aim 
GASE 
Questionnaire 
5 
Side Effects 
Primary Aim 
GASE-P 
Questionnaire 
5 
Acceptability/ 
Feasibility 
Primary Aim 
Physiological 
Biomarkers of Stress 
Response 
Physiological 
Measurement
s 
During 
Trier 
Biological 
Measure of 
Stress Response 
Exploratory 
Hypotheses 
Visual Analog Scale 
(VAS) 
Questionnaire 
During 
Trier 
Perceived Stress 
Exploratory 
Hypotheses 
Psychological Stress 
Measure 9 (PSM-9) 
Questionnaire 
5 
Perceived Stress 
Exploratory 
Hypotheses 
Irritable Bowel 
Severity Scoring 
System (IBS-SSS) 
Questionnaire 
3 
GI Symptoms 
Primary Aim 
AACTG 
Questionnaire 
3 
Feasibility 
Primary Aim 
MMAS 
Questionnaire 
3 
Acceptability/ 
Feasibility 
Primary Aim 
TSQM 
Questionnaire 
5 
Acceptability 
Primary Aim 
CRP, TNF-α, IL-6, IL-
8 
Blood Draw 
5 
Inflammation 
Exploratory Aim 
qPCR quantification 
of 16S rDNA 
Blood Draw 
- 
Gut Permeability 
Exploratory Aim 
Visit 3 Total Time: about 93 minutes 
 
 
 
 

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Adult AIDS Clinical Trials Group (AACTG) Follow-up: Section G. The AACTG developed 
an adherence measure for HIV/AIDS patients receiving medication. This questionnaire has 
been used in at least six AACTG clinical trials and has been widely disseminated (Chesney et 
al., 2000). We will use only section G of this follow-up measure which queries why one might 
not take medication as directed (e.g. forgetfulness). This will lend to our primary aim assessing 
feasibility. 
 
Clinician Administered PTSD Scale-5 (CAPS-5). The CAPS-5 (U.S. Department of 
Veterans Affairs, 2014) is a structured clinical interview used to determine PTSD diagnosis, 
using the Diagnostic and Statistical Manual of Mental Disorders-V criteria. 
Credibility/Expectancy Scales. The scale that determines credibility (Shapiro, 1981) 
assesses participants’ willingness to endorse the intervention, whether or not the intervention's 
effects could be generalized to similar situations, and willingness to recommend it to others.  
An expectancy questionnaire (Myers et al., 2008) assesses specific expectations regarding the 
intervention period.  In the context of an efficacy RCT, this measure would be utilized as a 
potential cofounder. 
Gastrointestinal (GI) Symptom Diary. Participants will be provided with a handout 
document to track their bowel movements for two weeks during between visits 2 and 3 of the 
study, and 8 weeks during the intervention. The participants will record their number of daily 
bowel movements and the consistency of their stool using the Bristol Stool Scale (Lewis & 
Heaton, 1997). This careful screening for gastrointestinal symptoms will be performed with the 
goal of isolating probiotic effects on emotional systems, rather than observing secondary 
changes due to potentially observable improvements in gastrointestinal symptoms. 
Generic Assessment of Side Effects (GASE)/ Generic Assessment of Side Effects - 
Probiotics (GASE-P). GASE consists of 36 symptom descriptions organized by body parts (Reif 
et al., 2009).  Participants are asked to rate if these “symptoms” were either “not present”, 
“mild”, “moderate”, or “severe” in the past week. After making the rating, the participant is asked 
whether the symptom is related to current medication. GASE-P is identical to GASE expect it 
queries whether the side effect is related to their probiotic rather than their medication. The 
GASE will be administered at baseline; the GASE-P will be administered during weekly phone 
call check-ins, and at the follow up appointment. The GASE-P will include a question regarding 
whether any new medications or supplements have been started in the past week. 
Harvard Food Frequency Questionnaire 2007 Booklet (Harvard FFQ). The Harvard FFQ 
(Willet et al., 2007) is a comprehensive 101-item semi-quantitative food frequency questionnaire 
that includes questions on specific foods, diet types, and supplements. Analysis of the 
questionnaire provides a wide range of macro- and micronutrient quantities. A number of 
studies have demonstrated fair to good validity and fair to good reproducibility depending upon 
nutrient of interest. 
Irritable Bowel Severity Scoring System (IBS-SSS). The IBS-SSS (Francis et al., 2003) 
is a 5-item questionnaire used as a multidimensional measure of severity of abdominal pain, 
frequency of abdominal pain, severity of abdominal distension, dissatisfaction with bowel habits 
and interference with quality of life. 
Modified Morisky Medication-Taking Adherence Scale (MMAS). The MMAS is available 
as a four or eight item questionnaire that is designed to test whether or not a subject adheres to 
taking a particular medication or supplement. Both the 4 and 8 item versions of the MMAS have 
been shown to demonstrate concurrent and predictive validity in regard to the measurement of 
patient adherence in clinical studies (Morisky et al., 1986, Morisky et al., 2008). Our modified 
scale simply alters the word medication to supplement, with permission from the author of the 
scale. 
Modified Treatment Satisfaction Questionnaire (TSQM v1.4). The modified TSQM v1.4 is 
a nine-item questionnaire that is designed to measure side effects associated with the 
supplement itself and the ease of administration of the supplement. The TSQM has been found 

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to be a valid measure of the major components of satisfaction with a medication (Atkinson et al., 
2004). We have modified the TSQM so that it may be applied to dietary supplements with the 
permission of the authors of the scale. 
Neurobehavioral Symptom Inventory (NSI). The NSI (Cicerone & Kalmar, 1995) is a 
widely used measure of post concussive symptoms among military personnel and Veterans and 
is recommended by the Veterans Health Administration for screening and evaluation. 
Ohio State University TBI Identification Method (OSU TBI). The OSU TBI-ID is a 
structured interview developed using recommendations from Centers for Disease Control (CDC) 
for the detection of history of exposure to TBI. It was designed to elicit self-reports of TBI 
occurring over a person’s lifetime. In a study including 119 participants, the OSU TBI-ID was 
found to have high inter-rater reliability. From this study and another including 103 participants, 
the authors concluded that the results provide preliminary support for the reliability and validity 
of summary indices of lifetime history of TBI elicited via a structured interview (Corrigan and 
Bogner, 2007). This study will use the OSU TBI-ID to identify whether a participant has 
experienced a moderate or severe TBI that would exclude them from the study. For participants 
who are re-consented, we will inquire if there have been any injuries since their first 
assessment. 
Pittsburgh/Epworth Sleep Questionnaire. Sleep, quality of sleep and sleepiness (Johns 
et al., 1991; Buysse et al., 1988) using a rating scale from 0-3 (0= would never doze to 3=high 
chance of dozing) with which to assess the chance of dozing in various situations.  In addition, 
sleep quality and frequency of sleep disturbance will be assessed using a frequency chart 
ranging from “not during the past week” to “three or more times a week”.   
Probiotic Food Checklist. The Probiotics Checklist for food was created from a list of 
probiotic food products and supplements developed for a Scoping Review regarding probiotics 
and mental health. As the list was originally created with the rigor appropriate for a systematic 
literature search, it encompasses foods from a variety of regions and diets. The list is being 
developed into a checklist for this pilot study with the goal of inventorying the amount of 
probiotics already present in the participant’s regular diet. The measure will query weather the 
participant has consumed a particular probiotic containing food product in the last month, and if 
so, how often in the past week and past month. If this checklist shows that a participant is 
consuming a significant amount of probiotics on a regular basis before study initiation, the 
participant may be excluded from the study or re-screened after 2 weeks (See “Exclusion 
Criteria”).  
Probiotics Usage Log. Participants will be provided with a handout to document the date, 
time, and amount of each probiotic dose. On this same sheet there will be space provided to 
document symptoms and their severity; definitions to indicate mild, moderate, or severe 
interference are provided. The document is modeled after the Dana-Farber Harvard Cancer 
Center (DF/HCC) Oral Chemotherapy Drug Diary.  
Psychological Stress Measure 9 (PSM-9). The PSM-9 will assess the participant’s 
perception for stress appraisal (Lemyre & Tessier, 1988 and 2003).  
Rivermead Post Concussive Symptom Questionnaire (RPCSQ). The RPCSQ (King et 
al., 1995) is a brief measure of post concussive symptom severity. Individuals completing the 
measure are asked to compare any current symptoms to pre-injury levels. The measure has 
demonstrated good inter-rater and test-retest reliability and internal construct validity. 
Rocky Mountain MIRECC Demographic Questionnaire. Information will be gathered on 
topics such as participant age, gender, race/ethnicity, education, period of military service, and 
combat exposure. 
Rome III Diagnostic Questionnaire. The Rome III Diagnostic Questionnaire (Rome 
Foundation, 2009) classifies disorders of the digestive system. 
 
Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental 
Disorders -IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen 

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(SCID-I/P W/ PSY SCREEN). The SCID (First et al., 2002) is a reliable and valid semi-
structured interview used to diagnose Axis I psychiatric disorders in clinical and research 
settings 
Trier Social Stress Task (TSST). Our procedures are entirely consistent with the 
extensive TSST literature and have been used routinely in Dr. Brenner’s laboratory and by her 
collaborators at CU Boulder. Biological markers (e.g. blood pressure) will be collected. Specific 
procedures will be outlines in an internal SOP document.  
Single question regarding perception of treatment type (probiotic or placebo): After all 
measures have been completed, the individual will be asked to state which type of supplement 
he/she received (probiotic or placebo) and this will be noted by researcher.  The researcher will 
then inform the participant that they will receive a letter at the end of the study (upon completion 
of data collection and analysis) revealing which supplement they received during their 
participation in the study. 
University of Washington Risk Assessment Protocol-Revised (UWRAP). The UWRAP 
(Reynolds, Lindenboim, Comtois, Murray, & Linehan, 2006) will be used to assess and address 
any potential risk associated with participating in the study. Participants will be asked to 
articulate pre-test potential stressors (Pre-Assessment Risk Assessment Questions). Post-test 
administration, a debriefing checklist and protocol will be initiated. Using results from the 
debriefing, members of the research team will be trained to evaluate responses and access 
additional assistance if necessary. The UWRAP has been recommended by National Institute of 
Mental Health, and has been used in over 20 years of research with potentially high-risk 
patients. The UWRAP will be utilized pre and post Visits 1 and 3. 
Visual Analog Scale (VAS). Stress will be measured during the TSST using a VAS. This 
psychological stress marker will work in conjunction with the physiological stress markers 
described above.  
Participants will also have blood samples collected to obtained information regarding: 
Inflammation. We will use high sensitivity ELISA assays, conducted in duplicate wells, 
from R&D Systems to measure a biological signature of exaggerated inflammation. Biweekly 
assessment of baseline plasma hsCRP concentrations for determination of eligibility of subjects 
for treatment allocation will be done using R&D Systems hsCRP ELISA (Cat. No. DCRP00). 
Plasma concentrations of hsCRP, TNF-α (Cat. No. HSTA00D; R&D Systems), IL-6 (Cat. No. 
HS600B; R&D Systems), and IL-8 (Cat. No. HS800; R&D Systems) will be measured at Time 2 
and Time 3 assessments. The baseline CRP assay may be conducted at the University of 
Colorado Hospital CTRC. The remaining assays will be conducted in the Lowry lab at CU-
Boulder. However, if there are throughput challenges with obtaining results, initial or follow-up 
assays may be conducted at either lab. Both labs have extensive experience conducting ELISA 
assays for measurement of plasma cytokine concentrations in clinical samples. 
Gut Permeability. Total quantity of bacterial cell copy numbers in plasma samples will 
provide measurement of gut permeability (Abad-Fernandez et al., 2013). Plasma will be 
separated from cells via chilled centrifugation. DNA extraction will be conducted with the Qiagen 
DNA EZI mini kit per manufacturer recommendations. Amplification and measurement of DNA 
in triplicate will be conducted with universal bacterial primers and SYBR® green qPCR supermix 
on the Applied Biosystems 7500 Real-Time PCR System. Standard curves will be created 
concurrently to plasma bacterial sample measures with purified E. coli DNA, concentrated over 
six orders of magnitude. Additional quality control measures will include melt curve analysis and 
verifying no amplification of negative controls. 
5. Security, Risks, and Justifications 
A. Protected Health Information (PHI) 

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PHI to be collected includes first and last name, date of birth, telephone number, and 
last 4 digits of social security number. This information is needed in order to accurately 
document each participant's study involvement into the electronic medical record. The 
participant will not be identified by name in any study reports, which will be used for research 
purposes only. The Denver VAMC Research Department may inspect the records of this study. 
COMIRB may inspect the PHI. Every effort will be made to keep the participants' personal 
medical data confidential. If, following screening or eligibility assessment, an individual is 
determined ineligible to participate, the only information to be kept will be non-PHI demographic 
descriptors for comparative purposes. These descriptors will include age range, gender, and 
race/ethnicity, in addition to their reason for exclusion. 
 
B. Estimated duration of study 
Each participant will complete approximately 4 hours of laboratory testing. The laboratory 
procedures will be completed over three visits to the ECHCS. The 2-week run in period is 
expected to take participants 15 minutes each week. The check-ins and usage logs are 
estimated to take 35 minutes per week. It is expected to take approximately 2 years to accrue 
and evaluate participants for the entire study. 
 
C. Data Security and Storage 
For the purposes of this research project a screening database and master record 
database will be developed as well as a limited data set. The screening database will contain 
subject identification, such as name, last 4 digits of the Social Security Number, and telephone 
number. Upon enrollment in the study, the participant and their identifying information will be 
added to the master record database. There will be no clinical data stored in either database. A 
unique identifier (UI) will be assigned to each of these records. Both databases will be password 
protected with only Dr. Brenner and Research Study Coordinator(s) knowing the password. 
Eligible participants’ screening and verbal consent form will be kept with the participant’s 
informed consent, HIPAA authorization, and medical clearance form per VA requirements. 
Ineligible participants’ screening and verbal consent form and medical clearance form will be 
kept in a separate paper research folder. Screening and verbal consent forms for potential 
participants who were not eligible and/or interested in the study will remain de-identified and 
stored in a separate research folder, located in a locked filing cabinet in secure MIRECC offices 
within the Denver VAMC.  Only authorized members of the research team will have access to 
paper documents. Forms containing PHI will be stored in a locked filing cabinet separate from 
the rest of the paper data.  
A dataset including study variables and limited PHI (i.e., dates) obtained from either the 
measures or medical records will be stored on the VA file server. The UI from the master 
database will be used identify records in this limited data set. All data will be password-
protected and stored within the VA firewall in a Microsoft Access database. The data can only 
be retrieved from within the VA network and only by members of the research team. These data 
will not be kept on laptops that do not meet the VA standards for encryption, anti-virus 
protection, and firewall security. Data will not leave the ECHCS campus except as an aggregate 
dataset. Paper data will be stored in locked file cabinets in a locked office.  
Study data may also be managed using REDCap (Research Electronic Data Capture). 
REDCap is a secure web application approved by the VA Office of Information & Technology 
(OI&T), and designed to support data capture for research studies, providing user-friendly web-
based case report forms, real-time data entry validation (e.g. for data types and range checks), 
audit trails and a de-identified data export mechanism to common statistical packages (SPSS, 
SAS, Stata, R/S-Plus). The system was developed by a multi-institutional consortium which 
includes the Department of Veteran’s Affairs and was initiated at Vanderbilt University. The 
database is hosted on VA Informatics and Computing Infrastructure (VINCI) virtual servers. 

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REDCap is flexible enough to be used for a variety of types of research and provides an intuitive 
user interface for database design and data entry. 
All data and statistical endeavors will be performed with assistance from the Denver 
MIRECC Data and Statistical Core. Procedures designed to maintain confidentiality will include 
formal training sessions for all study personnel in the importance of confidentiality and 
procedures to be followed, as well as formal mechanisms for limiting access to all information 
that can link data to individual participants.  
After centrifugation and separation of plasma, specimens will be coded and “blinded” 
and plasma will be stored in -80°C freezers at the Denver VA, and, once data collection has 
completed, specimens will be securely delivered to University of Colorado Hospital CTRC or 
University of Colorado Boulder Behavioral Neuroendocrinology Laboratory (WOC and Co-I 
Christopher Lowry). Blood samples will be analyzed and destroyed per VA policy. To minimize 
biohazard risk for others, the use of gloves, biohazard bags, and biohazard coolers will be 
assured, as well as documentation of relevant TMS training for all VA staff will be in place for 
every personnel handling blood or blood products. 
 
D. Risks 
Veteran participants may become upset or frustrated during administration of the 
interviews or questionnaires due to the nature of the topics of the study. Although it is not 
believed that participating in this study places the participants at increased risk for suicide, the 
UWRAP will be utilized to assess and address potential risks with participating in the study. 
Participants will be informed that the researcher will review their responses to the items 
regarding safety, and if necessary, will discuss these responses with them in an effort to ensure 
their safety.  For participants who reveal clinically meaningful risk as indicated on the UWRAP, 
specifically if the participant rates suicide risk at or higher than a rating of 4 on the Pre-
Assessment Risk Assessment (page 2 of the UWRAP), study personnel will review, and if 
necessary, will discuss these responses with them to ensure their safety. Responses may be 
also shared with the Veteran’s treating clinician, if determined necessary by Dr. Brenner or her 
designee. Additional mental health interventions, such as escorting the Veteran to the 
Psychiatric Emergency Services will be determined at this time, by Dr. Brenner, her designee, 
or the treating clinician and appropriate notation will occur. 
All researchers who will be interacting with study participants are trained in the area of 
risk assessment and management, and will be receiving supervision from Dr. Lisa Brenner, a 
licensed clinical psychologist, or her designee. 
 Immediately following completion of study measures the participants will undergo a 
debriefing and post-assessment risk. The results of this assessment will be used to evaluate the 
participant’s suicide risk. At a time deemed clinically appropriate, the PI or his/her designee will 
be notified if a participant is judged to be at either elevated (with respect to the participant’s 
baseline level of risk) or imminent suicide risk. Responses may be also shared with the 
Veteran’s treating clinician, if determined necessary by Dr. Brenner or her designee. Assessors 
will have emergency contact information available at all times for the PI or designee and 
emergency services (e.g. VA National Veterans Crisis Line). For assessments done over the 
phone, as clinically indicated, assessors will stay on the telephone with the participant until they 
are able to consult with the PI or designee, determine next steps, and follow-through with them. 
Assessors will ask participants to provide the assessor with the address of the location they are 
at while completing the phone assessment so that the assessor can direct emergency services 
as needed to the participant’s location. 
If a participant is judged by clinical impression to be at imminent suicide risk during the: 

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All visits (at the Denver VA facility):  
• 
If the assessment occurs at the Rocky Mountain MIRECC, the participant will be 
escorted to Psychiatric Emergency Services, where s/he will be assessed for risk 
and potential need for hospitalization.  
 
All visits (over the telephone):  
• 
If the assessment occurs over the telephone, the assessor will immediately 
contact 911 to initiate an on-site rescue if such action is clinically indicated. As 
clinically indicated, the assessor may stay on the phone with the participant until 
emergency services arrive. 
 
If, based on clinical impression, a patient appears to be at elevated but not imminent risk of 
suicide with respect to the participant’s baseline level of risk during the: 
All visits (at a Denver VA facility):  
• 
The assessor will contact the PI or her designee to complete a risk assessment 
and facilitate the Veteran accessing additional resources (e.g., Psychiatric 
Emergency Services, Veteran’s Crisis Line) as is clinically indicated. 
 
All visits (over the telephone):  
• 
The assessor will contact the PI or her designee to complete a risk assessment 
and facilitate the Veteran accessing additional resources (e.g., Psychiatric 
Emergency Services, Veteran’s Crisis Line) as is clinically indicated. 
 
Assessors and clinicians will receive training and supervision on suicide risk assessment 
and suicide crisis procedures. These procedures include reporting these incidents to the PI and 
initiating appropriate emergency response interventions as indicated. For any participants who 
demonstrate high levels of emotional distress, suicide, or self-harm risk, appropriate follow-up 
actions outlined above will be implemented. Members of the research team will be trained to 
assist participants in completing the protocol while minimizing psychological distress. Further, 
Dr. Brenner, a Licensed Clinical Psychologist, or her designee, will assist if difficulties arise. 
There are no other risks to completing study measures known to the investigators. 
Although Lactobacilli are “generally regarded as safe” (GRAS), there is theoretical risk 
associated with their use. These theoretical risks include the potential for transmigration, 
negative impact on gastrointestinal physiology and function, and the potential for antibiotic 
resistance transfer within the gastrointestinal tract.  These risks are indeed largely theoretical 
and, in cases where evidence is available, occur in immunocompromised individuals or in those 
with specific gastrointestinal diseases; such individuals are excluded in the present study 
(Snydman, 2008).  Involvement in the study requires a medical clearance form be signed by 
each participant’s VA health care provider and a 2-week run in period.  Veterans with certain 
medical conditions will be excluded from the study (see Exclusion criteria). As this is an 
acceptability and feasibility pilot study, any potential adverse events will be closely monitored 
and documented.  
In the unlikely event of prolonged bleeding during blood sampling, local pressure will be 
applied to achieve hemostasis. In the unlikely event of local infection, the subject will be advised 
to seek appropriate medical evaluation and treatment.  
 
 

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E. Benefits 
There are no direct, guaranteed benefits to Veterans participating in this study. Increased 
knowledge regarding the potential benefits and feasibility of future trials using probiotic 
supplementation for Veterans will be obtained.  Findings from this study will be shared with 
mental health and other health care communities through journal publications and conference 
presentations. Such knowledge may contribute to treatment options and inform future studies.  
F. Data Analysis 
 
As this study is a pilot study the primary outcomes to be tracked will speak to feasibility 
and the effects on Veterans health via the outcome measures. Specifically, outcome measures 
of interest will be evaluated to detect differences between active and placebo groups. All 
measures will be scored using standard methods for each to assess within- and between 
subject changes. Missing Values: In instances in which participants fail to complete occasional 
items on questionnaires, scale scores will be prorated. If participants omit numerous or all items 
on a particular measure, their scale scores will be set to missing values and they will be omitted 
from analyses involving that measure.  
G. Safety Monitoring Plan 
Veteran participants may have the potential to become frustrated, fatigued, or distressed 
during the assessments. Although it is not believed that participating in this study places the 
participants at significantly greater risk than daily living, the UWRAP will be utilized to assess 
and address potential risks with participating in the study. Immediately following completion of 
study measures, the participants will undergo a debriefing and post-assessment risk evaluation. 
If a participant’s risk or another individual’s risk is elevated at pre- or post- testing we will access 
additional assistance from Dr. Brenner or another MIRECC licensed mental health professional 
designated by Dr. Brenner, or Psychiatric Emergency Services. 
Probiotics are safely being used in clinical practice as well as other research arenas and 
are readily available in many pharmacies and health food stores. Millions of people around the 
world consume probiotics daily in hopes they will confer a health benefit (Snydman, 2008). Side 
effects associated with probiotic use are being tracked throughout the study as the primary aim 
of this study is to document the acceptability and feasibility of probiotic use in the Veteran 
population. Further, participants are educated about the potential side effects associated with 
probiotic use before agreeing to participate. As such, minor side effects typically associated with 
probiotic use, such as flatulence, will not be formally submitted to the Colorado Multiple 
Institutional Review Board (COMIRB) as Adverse Events per say. Any significant or severe 
adverse events will be reported per COMIRB guidelines.  
 
 

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6. References 
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Atkinson MJ, Sinha A, Hass SL, et al. (2004). Validation of a general measure of treatment  
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Bansar M & Duman RS. (2007). Regulation of neurogenesis and gliogenesis by stress and  
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Basco, M.R., Bostic, J.Q., & Davies, D. (2000). Methods to improve diagnostic accuracy in a  
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Beck, A.T., Steer, R.A., & Ranieri, W.F. (1988). Scale for suicidal ideation: Psychometric  
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Buysse, D.J., et al. (1988). The Pittsburgh Sleep Quality Index: A New Instrument for  
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Chesney  MA, Ickovics  JR, Chambers  DB, Gifford  AL, Neidig  J, Zwickl  B, Wu  AW.   
(2000). Self-reported adherence to antiretroviral medications among participants in HIV 
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Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group 
(AACTG). AIDS Care, 12(3), 255-66 
Cicerone KD, Kalmar K. (1995). Persistent PCS: the structure of subjective complaints after mild  
TBI. J Head Trauma Rehabil, 10(3), 1-17. 
Corrigan JD, Bogner J. (2007). Initial reliability and validity of the Ohio State University TBI  
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Dantzer R. (2001). Cytokine-induced sickness behavior: where do we stand? Brain, Behavior,  
and Immunity, 15(1), 7-24. 
First MB, Spitzer RL, Miriam G, et al. SCID DSM-IV-TR Axis I Disorders, Research Version,  
New York, NY: Biometrics Research, New York State Psychiatric Institute; 2002. 
Francavilla R, Lionetti E, Castellaneta SP et al. (2008). Inhibition of Helicobacter pylori  
infection in humans by Lactobacillus reuteri ATCC 55730 and effect on eradication 
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Francis CY, Morris J, Whorwell, PL. (1997). The irritable bowel severity scoring system: a  
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Gent AE, Hellier MD, Grace RH, Swarbrick ET, Coggon D. (1994). Inflammatory bowel disease  
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Godin G, Shephard RJ. (1985). A simple method to assess exercise behavior in the community. 
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Hasson-Ohayon, I., Roe, D., Kravetz, S. (2006). A qualitative approach to the evaluation of  
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Johns, M.W. (1991). A New Method for Measuring Daytime Sleepiness: The Epworth  
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Jones, M., Martoni, C., Di Pietro, E., Simon, R., Satya, P. (2012). Evaluation of Clinical Safety  
and Tolerance of Lactobacillus reuteri NCIMB 30241 supplement capsule: A randomized 
control trial. Regulatory Toxicology and Pharmacology, 63: 313-320. 

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