INTERSTRESS: Interreality in the Management and Treatment of Stress-Related Disorders (INTERSTRESS)

Psychological stress contributes to many chronic diseases suffered by citizens in today’s society. Exposure to prolonged stress is known to increase the risk of physical and mental health problems, including depression and disabling anxiety conditions. In particular, work-related stress is becoming a major occupational health problem: 80 % of the working population across Europe think that the number of people suffering from job-related stress over the next five years will increase. The economic impact of stress is also huge: in 2002, the annual economic cost of work-related stress in the EU was estimated at EUR 20 billion.

The INTERSTRESS project aimed at developing innovative ICT-based solutions for addressing the problem of psychological stress in professional and social life. From a technological standpoint, the project involves a combination of virtual reality, non-invasive biosensors and mobile tools to provide personalised healthcare devices for stress prevention and management. The specific objectives of this approach are:

1. quantitative and objective assessment of symptoms using biosensors and behavioural analysis;
2. decision support for treatment planning through data fusion and detection algorithms;
3. provision of warnings and motivating feedback to improve compliance and long-term outcome.

Policy Context

Description of target users and groups

The project mainly targets individuals suffering from work-related stress, a condition characterised by the experience of unpleasant emotions, such as tension, frustration, anxiety, anger and depression. According to the Fourth European Working Conditions Survey in 2005, stress was experienced on average by 22 % of workers from 25 Member States and 2 Acceding Countries of the European Union (EU 27 from January 2007). In 2002, the annual economic cost of work-related stress in the EU15 was estimated at EUR 20,000 million. In 2005 the largest group of employees who suffered from occupational stress (about 25 %) were those employed in education and health, public administration and defence and in agriculture, hunting, forestry and fishing.

To validate its concept, the project targeted two user groups: teachers and healthcare professionals (nurses). These targets were chosen because in the stress literature, teachers, nurses and doctors often report high levels of conflict and anxiety. A multi-centric demonstration trial involving a representative sample of these users (80) was conducted in Milan (40 teachers) and Messina (40 nurses).

Description of the way to implement the initiative

From a technological standpoint, the project involves a combination of virtual reality, noninvasive biosensors and mobile tools to provide personalised healthcare devices for stress prevention and management. The specific objectives of this approach are:

1. quantitative and objective assessment of symptoms using biosensors and behavioural analysis;
2. decision support for treatment planning through data fusion and detection algorithms;
3. provision of warnings and motivating feedback to improve compliance and long-term outcome. 

To reach these goals, INTERSTRESS uses a new eHealth concept: Interreality. Interreality is the integration of assessment and treatment within a hybrid, closed-loop empowering experience, bridging physical and virtual worlds into one seamless reality:

• Behaviour in the physical world will influence the virtual world experience
• Behaviour in the virtual world will influence the real world experience

These goals are achieved through:

• 3D Virtual World role-playing experiences in which users interact with one another
• Immersive in the health care centre/Non-immersive in the home setting
• Bio and Activity Sensors (from the Real to the Virtual World)
• Tracking of emotional/health/activity status of the user and influencing the individual's experience in the virtual world (aspect, activity and access)
• Mobile Internet Appliances (from the Virtual to the Real World)
• Social and individual user activity in the virtual world has a direct link with the users’ life through a mobile phone/PDA

Clinical use of Interreality is based on a closed-loop concept that involves the use of technology for assessing, adjusting and/or modulating the emotional regulation of the patient, his/her coping skills and appraisal of the environment based upon a comparison of the individual patient’s behavioural and physiological responses with a training or performance criterion.

The project has provided a proof of concept of the proposed system with clinical validation.

Technology solution

Several applications and ICT tools have been developed to further the INTERSTRESS project.

Positive Technology App is a telehealth tool allowing self-management of stress and enabling mobile-based treatment. It won the WSA mobile award for the best mHealth app.

Research indicates that the use of mobile phones enhances clinical approaches to stress management. Within the context of the INTERSTRESS project, a mobile app was developed to help people cope with stress. Using an engaging 3D virtual reality island, the user can practice effective relaxation techniques. The Positive Technology app also offers biofeedback training to control heart rate variability, thus helping to counter the physiological changes induced by stress. The biofeedback approach used has two outstanding merits. Firstly, heart rate variability is one of the most effective biofeedback techniques. Secondly, the treatment is situated in a virtual environment, the medium of choice for giving users feedback, by being more intuitive and making learning easy. The biofeedback section of the app exploits progress made in the field of wearable low-cost biosensors to allow effective interventions in daily situations.

Several other tools were developed and video demos are available through the INTERSTRESS website (http://www.interstress.eu/index.php/en/openlab):

• The virtual reality platform NeuroVR-2 (http://www.neurovr2.org), featuring a set of virtual environments for stress inoculation targeting two highly-stressed professionals: teachers and nurses.
• Virtual relaxation and biofeedback training: users learn some stress-relieving exercises in virtual reality, which can be experienced again in the real-life context before or during stressful activities.
• Personal Biomonitoring System (PBS): a wireless system consisting of independent lycra-based wearable band allows collection of heart rate variability (HRV), breathing rate and physical motion.
• The Camera and Accelerometer-Based Activity Recognition (CBAR) system is able to detect specific stress-related gestures and also extract qualitative characteristics of the patient’s activity within the clinical setting. This way, the INTERSTRESS platform is augmented with behavioural features of the patient that can improve effectiveness towards automatic stress level estimation in the clinical setting.
• EEG Correlates of Stress: Starlab has developed the wireless and wearable ENOBIO sensor that can record EEG, ECG and EOG signals. ENOBIO is being used in INTERSTRESS to detect and manage stress.
• A Decision Support System (DSS) for automatic classification of stress levels during exposure to VR environments. The DSS integrates different biosensor data (ECG, breathing rate, EEG) and behavioral data (stress-related body gestures), following a training process in which self-rated and clinical-rated stress levels are used as ground truth. Detected stress events for each VR session are reported to the therapist as an aggregated value (from 0 to 1) and graphically displayed on a diagram accessible by the therapist through a Web-based interface (Patient Management System). 
• Patient Management System (PMS) is a service module of INTERSTRESS platform. The PMS allows the clinicians and patients to set and control the INTERSTRESS system based on the different relevant parameters required for managing patients’ therapy. The goal of PMS is to allow the therapist to manage the clinical services, schedule treatment, assign home exercises and monitor compliance. In addition, the PMS provides the patient with a self-tracking service that allows him/her to monitor the stress levels.
• Psych-Log (http://sourceforge.net/projects/psychlog/), a mobile sampling platform that allows real-time collection of psychological, behavioural and physiological data for research and clinical applications.

Main results, benefits and impacts

The clinical use of Interreality is based on a closed-loop concept that involves the use of technology for assessing, adjusting and/or modulating the emotional regulation of the patient, their coping skills and appraisal of the environment based upon a comparison of that patient’s behavioural and physiological responses with a training or performance criterion. The project provided a proof of concept of the proposed system with validation in clinical settings.

Psychological stress is becoming increasingly recognised as a phenomenon that has a negative effect on a growing population in the workplace. Many EU countries have put into action laws (for example Italy’s law 30.7.2010 n. 122) that provide that all employers must assign a budget to detect, consider and possibly avoid any consequences related or caused by the level of work-related stress of the employees. For this reason, the focus of our project was extended to reach the working population, thus widening the INTERSTRESS impact and results which will be not limited to medical and healthcare environments but will interest, potentially, all working environments.

Scientific, clinical and technological impact

From a scientific point of view the INTERSTRESS project had the following impacts:

(1) definition of a multidimensional, technology-enhanced approach to the assessment of psychological stress, able to integrate traditional measures with real-time assessment of the quality of the individual experiences, through the integration of biosensors and behavioural analysis;

(2) laboratory experiments carried out in the first and second year of the project have been successful, allowing to identify the behavioural, physiological and contextual markers of stress that are relevant to the goals of the project. These findings were reported in several scientific publications.

(3) project concept for psychological stress prevention evaluated through an evidence-based approach in real-world organisational settings.

Societal & economic benefits expected

Stress is an increasingly recognised phenomenon that has negative effects on growing numbers of people. Chronic stress is responsible for premature mortality in Western countries, and work-related stress accounts for premature cardiovascular mortality rates. In 2006, Health Canada released a report indicating that work stress accounted for $1,950,000 of organisations’ losses.

INTERSTRESS aims to improve links and interaction between patients and doctors, facilitating more active participation of patients in the care process.

Also, it expects that there will be a reduction in hospitalisation and improved disease management and treatment at the point of need, through more precise assessment of health status. This will reduce healthcare costs and provide greater accessibility for individuals.

Overall, INTERSTRESS envisions a better quality of life, where personalised, immersive e-therapy in which biosensors, virtual reality simulations, and presence allow the ability to detect and manage stress anytime, anywhere are key components of the INTERSTRESS solution. This speaks to the continued call for the active participation of individual citizens in their own health and well-being, and the need for affordable healthcare in the palm of the users’ hands.

Clinical Trial

The release of the main INTERSTRESS technological components was completed in November 2011, and the integrated service platform is currently in an advanced development stage. The formative evaluation studies have included over 100 participants from three EU countries – Italy, Spain and Germany.

To validate its concept, the project targeted two user groups: teachers and healthcare professionals (nurses). These targets were chosen because in the stress literature, teachers, nurses and doctors often report high levels of conflict and anxiety. A multi-centric demonstration trial involving a representative sample of these users (80) was conducted in Milan (40 teachers) and Messina (40 nurses). 

The demonstration trials began in March 2012 and lasted for about 18 months, during which time the efficacy and effectiveness of the Interreality approach in supporting stress management were compared with conventional cognitive-behavioral therapy programmes. Participants included in the experimental group received a treatment based on cognitive behavioural techniques combined with virtual reality, biofeedback and mobile phone, while the control group received traditional stress management cognitive-behavioural based training, without the use of new technologies. Psychometric and physiological outcomes are used as quantitative dependent variables, while subjective reports of participants will be used as the qualitative dependent variable.

Track record of sharing

The project results were shared in different communities, targeting the general public, academic experts and industry stakeholders. A list of selected articles published in international peer-reviewed journals and conference proceedings is provided below (the full list is available on the INTERSTRESS website).

Lessons learnt