Real-Time Assessment of Stress and Stress Response Using Digital Phenotyping: A Study Protocol

Abstract

Background: Stress is a complex phenomenon that may have a negative influence on health and well-being; consequently, it plays a pivotal role in mental health. Although the incidence of mental disorders has been continuously rising, development of prevention and treatment methods has been rather slow. Through the ubiquitous presence of smartphones and wearable devices, people can monitor stress parameters in everyday life. However, the reliability and validity of such monitoring are still unsatisfactory. Methods: The aim of this trial is to find a relationship between psychological stress and saliva cortisol levels on the one hand and physiological parameters measured by smartphones in combination with a commercially available wearable device on the other. Participants include cohorts of individuals with and without a psychiatric disorder. The study is conducted in two settings: one naturalistic and one a controlled laboratory environment, combining ecological momentary assessment (EMA) and digital phenotyping (DP). EMA is used for the assessment of challenging and stressful situations coincidentally happening during a whole observation week. DP is used during a controlled stress situation with the Trier Social Stress Test (TSST) as a standardized psychobiological paradigm. Initially, participants undergo a complete psychological screening and profiling using a standardized psychometric test battery. EMA uses a smartphone application, and the participants keep a diary about their daily routine, activities, well-being, sleep, and difficult and stressful situations they may encounter. DP is conducted through wearable devices able to continuously monitor physiological parameters (i.e., heart rate, heart rate variability, skin conductivity, temperature, movement and acceleration). Additionally, saliva cortisol samples are repeatedly taken. The TSST is conducted with continuous measurement of the same parameters measured during the EMA. Discussion: We aim to identify valid and reliable digital biomarkers for stress and stress reactions. Furthermore, we expect to find a way of early detection of psychological stress in order to evolve new opportunities for interventions reducing stress. That may allow us to find new ways of treating and preventing mental disorders. Trial Registration: The competing ethics committee of the Canton of Zurich, Switzerland, approved the study protocol V05.1 May 28, 2019 [BASEC: 2019-00814]; the trial was registered at ClinicalTrials.gov [NCT04100213] on September 19, 2019.

Keywords: cortisol; digital phenotyping; ecological moment assessment; stress; trier social stress test.

Figure 1

Study Outline. The initial and final evaluations (green) include a psychological test battery and the collection of cortisol samples. Well-being and basal cortisol levels are assessed daily at fixed time frames (only morning and night assessment shown). During the TSST-G (blue) DP, stress and cortisol levels are conducted. Coincidentally experienced challenging of stressful situations/events (red) are assessed shortly after they occur (shown for illustrative purposes only). Physiological parameters are continuously assessed through wearable devices.

Figure 2

SPIRIT Study Schedule (EMA, Ecological Momentary Assessment; TSST-G, Trier Social Stress Test for Groups). The bar denotes the different parts of the intervention (compare Figure 3). t_i−2/−1 briefing and tension release exercise previous to the TSST-G; t_i1TSST-G Speech; t_i2TSST-G Math; t_i3/9TSST-G debriefing and tension release.

Figure 3

Outline for the Trier Social Stress Test (for Groups). Physiological parameters are continuously monitored. At each time point, a psychological stress response assessment takes place and a saliva cortisol sample is collected.