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

Published on: 21/10/2013
Document

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

The main contribution of INTERSTRESS is towards ICT Challenge 5: Towards sustainable and personalised healthcare, with a specific focus on Personal Health Systems (PHS) and mental health. More specifically, INTERSTRESS contributes to this challenge by advancing the state of the art in technology-based strategies for the assessment and management of psychological stress. To realise this objective, the project developed innovative PHS solutions based to implement a continuum of care, in which interaction between the patient and therapist is not limited to short visits in ambulatory or treatment sessions. The main advantages of this strategy are three-fold:

1) Therapeutic treatments initiated in the clinical setting are continued at home or on the go while the patient is performing their daily life activities.

The effectiveness of a mental health intervention is strongly dependent on the quality of interaction between the therapist and the client. This bond does not collapse when patients leave the consulting room, but should continue in daily life. Moreover, the level of patient engagement with their treatment is an important predictor of positive therapeutic outcomes. Therefore, identifying ways for facilitating client-therapist interaction, promoting compliance with treatment and counteracting the possibility of client dissatisfactions are critical challenges in the delivery of mental health interventions. To this end, INTERSTRESS developed a web-based therapy management platform designed to facilitate patient-therapist communication.

The platform allows the therapist to manage several clinical services, including treatment schedule, survey administration, homework assignments, warnings and motivating feedbacks. In addition, the platform provides the patient with a self-tracking service that allows them to monitor distress levels on the mobile phone and share them with the therapist, who can in turn use these data to personalise treatment and monitor compliance.

2. The patient is continuously monitored and data are gathered not only in relation to his physical status but also and primarily to his psychological status; potentiality of the occurrence of relapse episodes are detected and prevented.

The combined use of wearable biosensors and smartphones allows collecting, elaborating and transmitting real-time information related to their conditions and identifying specific trends (i.e. increasing levels of stress). Insights gained by means of this feedback can empower the user to self-engage and manage their own health status, minimising any interaction with other health care actors. To address this issue, the INTERSTRESS project developed a personalised mobile system for the detection of psychological stress from Heart-Rate Variability (HRV) indices.

3. Therapeutic treatment is continuously verified and accordingly managed as well as the adherence of the patient to the treatment.

One of the main limitations of conventional assessment procedures is the lack of possibility to gather information from the individual subject during daily life. Advanced monitoring capabilities provided by INTERSTRESS tools allow the therapist to unobtrusively record a variety of behavioural data in real time, which can improve the sensitivity of measurement of many of the common outcomes measured by studies in clinical psychology. Besides monitoring applications, mobile biosensors are used in the project to implement biofeedback exercises and relaxation techniques for managing stress “on the move”. For example, the Positive Technology App (http://positiveapp.info/) exploits the progress in the field of wearable low-cost biosensors to allow an effective psychological interventions in daily situations. 

All these provisions allow a better management of the stressing situations by the patient themsleves.

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.
Technology choice: Proprietary technology, Open source software

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.

The overall goal of the demonstration trial was to evaluate whether bridging virtual experiences, used to learn coping skills and emotional regulation, with real experiences using advanced technologies (virtual reality, advanced sensors and smartphones) is a feasible way to address actual limitations of existing protocols for psychological stress.

Preliminary findings indicate that:

  • Virtual reality may be more effective than reality in inducing stress in a controlled setting;
  • Sensor data is useful in providing objective, real-time measurement of stress response;
  • Mobile tools are useful in helping patients dealing with stress in everyday situations;
  • Avoiding technological breakdowns and improving usability/portability of wearable sensors is key to the future exploitation of the Interreality approach.

Trial registration: http://clinicaltrials.gov/ct2/show/NCT01683617

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).

Tartarisco G., Baldus G., Corda D., Raso R., Ferro M.,Gaggioli A., Pioggia G. (in press). Personal Health System architecture for stress monitoring and support to clinical decisions. Computer Communications. DOI: 10.1016/j.comcom.2011.11.015

Botella, C., Riva G., Gaggioli, A., Wiederhold, B.K., Alcaniz, M., Banos, R. (2012), The Present and Future of Positive Technology. Cyberpsychology, Behavior, and Social Networking. 15(2):78-84 DOI: 10.1089/cyber.2011.0140.

P Cipresso, S Serino, D Villani, C Repetto, L Selitti, G Albani, A Mauro, A Gaggioli, G Riva (2012), Is your phone so smart to affect your states? An exploratory study based on psychophysiological measures. 84:23-30 Neurocomputing. DOI:  10.1016/j.neucom.2011.12.027

P Cipresso, A Gaggioli, S Serino, F Pallavicini, S Raspelli, A Grassi, G Riva (2012), EEG alpha asymmetry in virtual environments for the assessment of stress-related disorders. Stud Health Technol Inform, Vol. 173, pp.: 102-104 DOI: 10.3233/978-1-61499-022-2-102

Giakoumis D, Drosou A, Cipresso P, Tzovaras D, Hassapis G, et al. (2012) Using Activity-Related Behavioural Features towards More Effective Automatic Stress Detection. PLoS ONE 7(9): e43571. doi:10.1371/journal.pone.0043571

Cipresso P, Serino S, Gaggioli A, Riva G (2012). Modeling the social networking experience objectifying the subjective. Stud Health Technol Inform, vol. 181, p. 12-16, ISSN: 0926-9630, doi: 10.3233/978-1-61499-121-2-12

Cipresso P, Gaggioli A, Serino S, Raspelli S, Vigna C, Pallavicini F, Riva G (2012). Inter-reality in the Evaluation and Treatment of Psychological Stress Disorders: the INTERSTRESS Project. Stud Health Technol Inform, vol. 181, p. 8-11, ISSN: 0926-9630, doi: 10.3233/978-1-61499-121-2-8

Gaggioli A, Pioggia G, Tartarisco G, Baldus G, Ferro M, Cipresso P, Serino S, Popleteev A, Gabrielli S, Maimone R, Riva G (2012). A System for Automatic Detection of Momentary Stress in Naturalistic Settings. Stud Health Technol Inform, vol. 181, p. 182-186, ISSN: 0926-9630, doi: 10.3233/978-1-61499-121-2-182

D Giakoumis, A Drosou, P Cipresso, D Tzovaras, G Hassapis, A Gaggioli, G Riva (2012)  Real-time Monitoring of Behavioural Parameters Related to Psychological Stress.   Stud Health Technol Inform 181: 287-291. DOI: 10.3233/978-1-61499-121-2-287

A Riera, A Soria-Frisch, A Albajes-Eizagirre, P Cipresso, C Grau, S Dunne, G Ruffini (2012)  Electro-physiological data fusion for stress detection.   Stud Health Technol Inform 181: 228-232. DOI: 10.3233/978-1-61499-121-2-228

G Riva (2012) What is Positive Technology and its impact on CyberPsychology Stud Health Technol Inform 181: 37 -41. DOI: 10.3233/978-1-61499-121-2-37

Castiglione F, Diaz V, Gaggioli A, Liò P, Mazzà C, Merelli E, Meskers CG, Pappalardo F, von Ammon R Physio-Environmental Sensing and Live Modeling Interact J Med Res 2013;2(1):e3 doi: 10.2196/ijmr.2092 URL: http://www.i-jmr.org/2013/1/e3/

Serino S., Cipresso P., Gaggioli A., Riva G. The potential of pervasive sensors and computing for Positive Technology. In S. C.Mukhopadhyay and O. A. Postolache (Eds.) PERVASIVE AND MOBILE SENSING AND COMPUTING FOR HEALTHCARE. Smart Sensors, Measurement and Instrumentation Springer, New York, 2013, Volume 2, 207-232, DOI: 10.1007/978-3-642-32538-0_10

Pallavicini F, Cipresso P, Raspelli S, Grassi A, Serino S, Vigna C, Triberti S, Villamira M, Gaggioli A, Riva G (2013). Is Virtual Reality Always an Effective Stressors for Exposure Treatments? Some Insights from a Controlled Trial. BMC PSYCHIATRY, 13:52 ISSN: 1471-244X DOI: 10.1186/1471-244X-13-52 URL: http://www.biomedcentral.com/1471-244X/13/52

Lessons learnt

1. Involving end-users in the design process is key to the success of any eHealth system. All types of users (both primary users, i.e. patients, and secondary users, i.e. therapists) should be involved from the early stages of system prototyping. Although the formative evaluation (usability testing of the system in small samples) is of fundamental importance, it is still an overlooked issue.

2. Focus on end-user’s acceptance: developing a technology that no one uses, is just a waste of time and money. To ensure users’ acceptance, two key criteria should be satisfied: i) users must perceive that the proposed solution is useful for them: in the case of clinical therapists, they should immediately understand the added values of the system for their practice - it is not just because the system is “innovative” that they doctors will adopt it; ii) users should perceive that the system is easy to learn and use; it is better to invest more on usability and less on “innovation”; in other words, sometimes it is better to do more with less and focus on what users really need, instead of adding features and functionalities just to be “beyond the state of the art”. 

3. Evidence-based design: it is not possible to collect data for any design choice, but basic research can help system developers to reduce system complexity, by focusing on most promising features. For example, it might not be necessary to have the user wearing a lot of sensors to collect multiple sources of data. Research done in the lab can help selecting the biomarkers that are most informative - use Occam's razor!

Scope: International