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Behavioral issues are inevitable among groups of people, no matter how well selected and trained. Spaceflight demands can heighten these issues. The Institute of Medicine [(IOM )] report, Safe Passage, notes that Earth analog studies show an incidence rate of behavioral problems ranging from 3-13 percent per person per year. The report transposes these figures to 6-7 person crews on a 3-year mission to determine that there is a significant likelihood of behavioral conditions and psychiatric disorders emerging. Impacts of behavioral issues are minimized if they are identified and addressed early. The HRP must provide the best measures and tools to monitor and assess mood and to predict risk for an d management of behavioral and psychiatric conditions prior, during and following spaceflight. – Human Research Program Requirements Document, HRP-47052, Rev. C, dated Jan 2009.



Executive Summary
Space flight, whether of long or short duration, occurs in an extreme environment that has unique stressors. Even with excellent selection methods, behavioral problems among space flight crews remain a threat to mission success. Assessment of factors that are related to behavioral health can help minimize the chances of distress and, thus, reduce the likelihood of behavioral conditions and psychiatric disorders arising within a crew. Similarly, countermeasures that focus on prevention and treatment can mitigate the behavioral conditions and psychiatric disorders that, should they arise, would impact mission success.

Risk, which within the context of this report is assessed with respect to behavioral health, is addressed in terms of occurrence in space flight and analog populations, and of predictors and other contributing factors. Based on space flight and analog evidence, the average incidence rate of an adverse behavioral health event occurring during a space mission is relatively low. While mood and anxiety disturbances have occurred, no behavioral emergencies have been reported to date in space flight. Anecdotal and empirical evidence indicates that the likelihood of a behavioral condition or psychiatric disorder occurring increases with the length of a mission. Further, while behavioral conditions or psychiatric disorders might not immediately and directly threaten mission success, such conditions can, and do, adversely impact individual and crew health, welfare, and performance, thus indirectly affecting mission success.

Identification of predictors and other factors that can contribute to the risk of behavioral conditions and psychiatric disorders at all stages of a mission increases the efficacy of prevention and the treatment of those conditions. Many factors predict or otherwise play a role in the occurrence of a behavioral condition or psychiatric disorder. These include: sleep and circadian disruption, personality, negative emotions, physiological changes that occur when adapting to microgravity, lack of autonomy, daily personal irritants, physical conditions of life in space, workload, fatigue, monotony, cultural and organizational factors, family and interpersonal issues, and environmental factors. Positive or salutary aspects of space flight also contribute to behavioral health outcomes. Some factors have both detrimental and salutary aspects; teamwork, giving and receiving social support, and leadership responsibilities are a few examples of these.

The current approaches to prevent behavioral conditions and psychiatric disorders begin during selection and continue post-flight. The goal of the behavioral health component of the astronaut selection system is to identify individuals who, at the time of application, have diagnoses that are incompatible with the demands of space flight, and also to identify those who are believed to be best suited psychologically to be astronauts. Countermeasures are a second line of defense to prevent behavioral conditions and psychiatric disorders from occurring pre-flight, during flight, and post-flight. For example, psychological support services are provided to crew members and their families before, during, and after missions.

Approaches that prevent or mitigate behavioral conditions and psychiatric disorders often can be used to treat the occurrence of behavioral problems. Private psychological conferences, for example, can provide both prevention and treatment. While anecdotal evidence suggests that current practices may be sufficient, the efficacy of these practices has not yet been assessed systematically.

In sum, evidence indicates that development of behavioral conditions and psychiatric disorders is a risk for human space flight, and that this risk increases as mission length increases. Multiple methods are employed to prevent and treat behavioral problems and appear to have some effect, although the extent to which prevention and treatment are effective has not been quantified.

Introduction
The NASA commitment to long-duration space flight includes astronauts who will be returning to the moon as well as those who will take part in human missions to Mars. Successful exploration will require a better understanding of the effects that extended missions pose for the behavioral health of astronauts, not just during flight but also pre- and post-flight. As space flight missions lengthen, astronauts will spend longer periods away from families and friends. The absence of Earthly conveniences and daily routines will also intensify their feelings of isolation (Category III) because the astronauts will be spending more time confined in the spacecraft and living in an environment that is fraught with potential danger. On their return to Earth, they will have to reintegrate into a world that has adapted and changed without them. Consequently, predicting the effect that extended periods of isolation will have on astronaut performance and psychological well-being becomes increasingly important. Further, the potential for psychiatric disorders developing in long-duration crews during or after missions requires that consideration be given to prevention and treatment (Category IV).

During astronaut selection, applicants who have been identified with a psychiatric disorder that would impede on-the-job success are removed from further consideration. However, important aspects of an individual’s mental health history – e.g., exposure to a traumatic event, family history of mental health struggles such as depression or schizophrenia – may not have been disclosed to NASA at the time of astronaut selection. Not only may potential astronauts be hesitant to share information that would prohibit selection, but some current astronauts have also demonstrated a reluctance to share information if they perceive such information could jeopardize their flight status.

Disorders such as anxiety, post-traumatic stress, sleep loss/insomnia, adjustment, and depression can also develop unexpectedly in otherwise healthy individuals. A recent study by Tozzi et al. indicates that the average age of onset of depression for persons who have no family history of depression is 41 years (standard deviation (SD)=13.67); therefore, even astronauts who have never experienced depression are not immune from its development. The age of astronaut candidates when selected for the Astronaut Corps has ranged between 26 and 46 years. Between 1989 and 2003, the average age of the astronauts who were selected was years. It is important to note that depression could occur at any phase of an astronaut’s career. Furthermore, as reviewed by Collins, behavioral problems that occur during space flight often do not terminate when the mission ends, but can linger with notable aftereffects (Category IV).

Although the incidence of reported psychiatric disorders on shuttle missions has not been significant (Category III), as the length of space missions increases the incidence of behavioral conditions and psychiatric disorders is also expected to increase (Category IV). Additionally, the ramifications of a disorder developing in flight are severe if that disorder is left unresolved. Anecdotal and empirical evidence from space flight and behavioral health incidence rates from space analogs suggest that assessing, preventing, and treating behavioral health problems are essential to protecting the health of crew members and, consequently, the success of a mission.

The NASA Human Research Program (HRP) is organized into topical areas called Elements; the Behavioral Health and Performance (BHP) Element is tasked with the responsibility of managing three risks: (1) risk of performance errors due to sleep loss, circadian desynchronization, fatigue, and work overload; (2) risk of performance errors due to poor team cohesion and performance, inadequate selection/team composition, inadequate training, and poor psychosocial adaptation; and (3) risk of behavioral and psychiatric conditions. While each of these risks is addressed in a separate chapter of this book, they should not be construed to exist independently of one another but, rather, should be evaluated in conjunction with one another. Furthermore, BHP risks overlap with risks in other HRP Elements and, as such, must also be considered in conjunction with one another. Refer to figure 1-1 for an example of these possible overlaps.



The relationships of the BHP Element with other HRP Elements are further outlined in the HRP Integrated Research Plan (IRP). The nature of the IRP implies that the BHP Element is continually reviewing and updating integration points with other elements. While research is designed to address identified gaps, it will be necessary to update and revise each of the BHP evidence reports and the IRP as the element gaps are closed and new gaps emerge.

Assessment of behavioral conditions and psychiatric disorders
An assessment of behavioral conditions and psychiatric disorders improves our understanding of the factors that contribute to the development of these conditions, and the treatment options that are best to manage this risk. Assessments occur within a framework, or a theoretical approach, of assessing behavioral conditions and psychiatric disorders. This theoretical approach, which is taught by NASA BHP to astronauts and flight surgeons, is described below. Evidence of the occurrence of behavioral and psychiatric problems in space flight and space analogs is then presented. Predictors and other factors that contribute to the occurrence of a behavioral condition and psychiatric disorder are then discussed. Lastly, current countermeasures and treatments are described.

The majority of the evidence that is cited is Category III. Please note that from this point on, only categories other than Category III are noted within the text.

Theoretical approach
Behavioral and psychiatric problems can be classified in several ways. NASA relies heavily on the classification system that is used by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual Fourth Edition Text Revision (DSM-IV-TR). In a slight departure from the DSM-IV-TR classifications, behavioral medicine training that is taught by a NASA psychiatrist also incorporates the International Classification of Diseases-10 (ICD-10) standard diagnostic classification system. The ICD-10, which is used worldwide, is a more comprehensive system than the DSM-IV-TR; it is used to classify physical and mental diseases as well as conditions for all general epidemiological and many health management purposes. Mental and Behavioural Disorders is only one chapter in this much broader tome. In contrast, the DSM-IV-TR, which focuses on mental and behavioral disorders, assigns the following classifications:


 * Axis I – clinical disorders
 * Axis II – personality disorders and mental retardation
 * Axis III – general medical conditions
 * Axis IV – psychosocial and environmental problems
 * Axis V – global assessment of functioning

When using the DSM-IV-TR, general medical conditions, psychosocial and environmental problems, and global assessment of functioning are relevant only to the extent that they contribute to or exacerbate psychiatric diagnoses.

Behavioral medicine training for the International Space Station (ISS) teaches NASA flight surgeons, crew medical officers (CMOs), and astronauts that there are three main types of significant mental disorders that  might be encountered in a long-duration mission : (1) delirium, which is a severe behavioral and cognitive response to physical injury or illness; (2) adjustment disorder, which is a severe and negative emotional response to a tragedy; and (3) asthenia, which is a progressive negative psychological response to the isolation and rigors of a long-duration mission. The Russian Space Agency, even more so than NASA, recognizes asthenia as a condition that occurs during long-duration missions. NASA behavioral medical training also instructs astronauts to be vigilant for other possible psychiatric or behavioral conditions. These other conditions fall under the rubric of any other psychiatric disorders, which is the first indication of a preexisting or latent mental disorder that is, perhaps, worsened or triggered by the stress of long-duration space flight.

Occurrences of behavioral conditions and psychiatric disorders
NASA differentiates between a behavioral condition and a psychiatric disorder in the following manner: a behavioral condition is any decrement in mood, cognition, morale, or interpersonal interaction that adversely affects operational readiness or performance; whereas a psychiatric disorder is one that meets the diagnoses criteria as outlined in the DSM-IV-TR. In other words, a behavioral condition is a sub-clinical, off-nominal set of behavioral and psychological circumstances or symptoms that, if left unchecked or unmitigated, may lead to the development of a psychiatric disorder that will, at that time, be considered an illness that requires a specific medical and psychiatric treatment plan. In the future, the title of the risk that is described in this chapter is expected to change to more clearly reflect these distinct definitions.

Space Flight
The flight surgeon is usually the confidant if, and when, an astronaut reports behavioral signs and symptoms. Thirty-four behavioral signs and symptoms were reported among the 208 crew members who flew on 89 shuttle missions between 1981 and 1989, spending a total of 4,442.8 person-days in space. This is an incidence rate of 0.11 for a 14-day mission; in other words, behavioral signs and symptoms, regardless of the type of sign or symptom, occurred at the rate of approximately one per every 2.86 person-year. The behavioral symptoms that were most commonly reported in these 89 missions were anxiety and annoyance. Between March 1995 and June 1998, seven astronauts flew on the Russian space station Mir; during this time, psychiatric events were reported twice for an incidence rate for astronauts of 0.77 per person- year. The actual incidence rate for both shuttle and Mir is likely to be understated, however, because of astronaut reluctance to report such symptoms. The actual reported behavioral events and recurrences can be reviewed in the U.S. Medical Events Tables found in the chapter appendix.

Behavioral and psychiatric emergencies
NASA considers any behavioral condition or psychiatric disorder that causes serious behavioral or cognitive symptoms leading to incapacitation and severe mission impact as a behavioral emergency. Examples include the development of delirium due to a head injury, or a brief psychotic disorder following a tragic event such as the death of a family member or an international catastrophe. To date, no behavioral emergencies have occurred before or during any U.S. space flight. As previously mentioned, however, as the length of space missions increases, the probability of a behavioral and psychiatric emergency occurring also increases (Category IV).

Not a lot of data are available from which to assess the many types of behavioral conditions and psychiatric disorders that could occur during a long-duration mission. This is due, in part, to the relatively few numbers of long-duration flyers, and to the fact that the consistent length of a mission for most of these flyers is approximately 6 months. Based on past NASA experience, one estimate of the possible rate of a behavioral or a psychiatric emergency occurring in flight as the result of depression or anxiety ranges from 0.000087 to 0.000324 cases per person-year). The likelihood of such an emergency occurring would further increase as mission length exceeds 1 year. Calculation of this estimate, which is based on NASA space flight data, is discussed more fully in the Mood and Mood Disorders section below.

Some Russian space flight missions in the 1970s and 1980s were terminated early due to psychological factors. In 1976, during the Soyuz-21 mission to the Salyut-5 space station, the crew was brought home early after the cosmonauts complained of a pungent odor. No source for this odor was ever found, nor did other crews smell it. Since the crew had not been getting along, the odor may have been a hallucination. In 1985, the crew of the Soyuz T-14 mission to Salyut-7 was brought home after 65 days because cosmonaut Vladimir Vasyutin complained that he had a prostate infection. Doctors later believed that the problem was partly psychological. The Soyuz TM-2 mission in 1987 was similarly cut short because of some apparent psychosocial factors. The early termination of these missions may have prevented escalation of behavioral and psychiatric occurrences.

The stress of space flight does not end at landing. In early 2007, an astronaut who had recently returned from a space mission allegedly engaged in actions that might be considered indicative of a behavioral and psychiatric emergency. Space flight is not necessarily the sole or even the primary cause of post-flight behavioral conditions and psychiatric disorders. Other stressors in life, such as marital distress or the death of a family member, also may contribute to similar behavioral conditions and psychiatric disorders. Nevertheless, space flight and its associated factors – e.g., isolation, confinement, workload – can become significant triggers or sources of stress. These space flight stressors, when they are paired with traditional life stressors, will likely have an exponential impact on behavioral health for long-duration astronauts.

Mood and mood disorders
Mood states can be dichotomized into positive and negative moods. Positive moods have been linked to increased helping behavior toward others. A positive mood may result in better performance through interpersonal processes such as helping others. Further, employees in positive moods may perform better through a motivational process such as higher self-efficacy and task persistence. George and Brief found that people who were in positive moods were more likely to view their progress toward task goals positively and engage in increased task diligence.

Like positive moods, negative moods can be functional. They can cause individuals to better identify problems by focusing on their current situation rather than on their underlying assumptions, attending to shortfalls in the status quo, identifying opportunities, and exerting high levels of effort to improve a situation. Additionally, negative moods promote creativity under certain conditions, which can facilitate problem-solving.

The effects of positive mood are discussed in later sections of this chapter and address salutogenesis in space flight and analogs, respectively. Space-flight-related research, albeit quite limited, has focused on the displacement of negative mood from crew members to Mission Control personnel, and from Mission Control personnel to management.

Mood disorders, which are categorized in the NASA integrated medical model (IMM) as depression and anxiety, have occurred during space flight. Data that were collected for 28.84 person-years of NASA space flight reveal that 24 cases of anxiety occurred in space flight for an incidence rate of .832 cases per person- year. Over the same 28.84 person-years, four astronauts experienced signs and symptoms of depression during space flight for an incidence rate of .139 per person-year. In other words, signs and symptoms of anxiety during space flight occurred once every 1.2 years, and signs and symptoms of depression occurred once every 7.2 years.

According to a National Institute of Mental Health (NIMH) pamphlet (Category III), approximately one in 10 adults during a given year will suffer from some form of depression. Despite careful selection, a depression-free past does not guarantee a depression-free future.

The data that were collected in the general population as well as in NASA are not definitive enough at this time to accurately predict the likelihood of an astronaut becoming depressed or suffering from a mood disorder while in flight. Rather, it emphasizes that the risk is real and should not be ignored. Therefore, NASA is continuing to gather the data that are needed to define and mitigate the risk of an astronaut developing an anxiety or a depressive disorder.

Asthenia
Russian medical personnel view asthenia as one of the greatest problems affecting the emotional well-being of cosmonauts. This syndrome, which is also called neurasthenia and asthenization, has been defined as “a nervous or mental weakness manifesting itself in tiredness…and quick loss of strength, low sensation threshold, extremely unstable moods, and sleep disturbance”. It can be caused by excessive mental or physical strain, prolonged negative emotional experience or conflict, as well as somatic illness. The diagnostic criteria for asthenia and neurasthenia are listed in the ICD-10. However, this diagnosis is not recognized in the DSM-IV-TR (APA, 2000). Other diagnoses with similar symptoms that are listed in DSM-IV-TR are adjustment disorder, dysthymia, major depressive disorder, and chronic fatigue syndrome.

Examination of cosmonauts suggests that asthenia is particularly likely to occur when space flights last longer than 4 months. Symptoms and signs of asthenia have been reported anecdotally by U.S. astronauts who flew during Mir and Skylab. Kanas et al., however, failed to find empirical support for the occurrence of asthenia during Mir missions. This failure to find support could be due to the method that was used to operationalize asthenia. Only the psychological component of asthenia was examined; furthermore, the study used an instrument that was not specifically designed to measure asthenia.

At present, the occurrence of asthenia in space flight crews does not require medications; this may be due in part to the current space flight parameters (e.g., length of flight, contact with the ground, Progress and shuttle flights, etc.). Furthermore, this is likely due in part to stringent selection methods that select out those with psychiatric problems, and to diligent monitoring and application of countermeasures when symptoms first appear. Longer-duration missions may demonstrate a need for asthenia medications.

Psychosomatic reactions
Psychosomatic reactions occasionally have been reported during space flight. Psychosomatic is defined as “pertaining to a physical disorder that is caused by or notably influenced by emotional factors”. These health struggles are not imaginary; in fact, more than half of all individuals who are seeking medical attention are suffering from psychosomatically induced or exacerbated illnesses. For example, an otherwise healthy cosmonaut experienced a cardiac arrhythmia that required medication after being exposed to sustained stressors related to on-board equipment failure.

There are direct self-reports of somatizing by cosmonaut Valentin Lebedev during the record-breaking length of his Salyut 7 mission. Other psychosomatic reactions include complaints of toothaches after dreams of tooth infections and fears of impotence due to perceived prostatitis.

Salutogenesis
Not all of the effects of long-duration space flight are expected to be negative. Antonovsky, in 1979 (Category IV), coined “salutogenesis” as the opposite of pathogenesis. Salutogenic experiences are those  that promote a sense of health. The key factor of salutogenesis, according to Antonovsky, is a person’s sense of coherence. He defined this sense of coherence as “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected.” Kobasa et al. described individuals who stay healthy, even when they find themselves in challenging circumstances, as having the following characteristics: believing that they exert control over their environment; embracing life as meaningful; and experiencing changes in life as normal and beneficial. Factors contributing to salutogenesis are comprehensibility, manageability, meaningfulness, social support, spirituality, happiness, humor, and love. Smith commented that “an organism with a salutogenic brain would experience the world as manageable and coherent ... with a self-perpetuating cycle for enhancing self-confidence and well-being.”

Suedfeld differentiates between positive environmental aspects and the positive personal and social aspects of space flight. Environmental aspects concern the external environment (e.g., mystery; beauty of space; views of Earth) and the capsule environment (e.g., safe haven; familiarity; free time). The positive personal and social aspects of space flight were likewise dichotomized into astronaut group dynamics (e.g., membership in an elite group; superordinate goals) and post-mission consequences (e.g., self-confidence; respect; new skills and values).

Preliminary results suggest that a salutogenic response to space flight is common across astronauts and endures for some time post-flight. Astronauts and cosmonauts have reported experiencing transcendental, religious experiences or a sense of the unity of humankind while in space. Analysis of the memoirs of four astronauts reveals that all four reported post-flight feelings of increased spirituality, defined as “meaning and inner harmony through transcendence”. Ihle et al. examined the positive psychological outcomes of space flight. All 39 astronauts and cosmonauts who responded to the survey reported a positive reaction to being in space. The most frequently endorsed benefit of space flight related to the perception of the Earth; i.e., its beauty and fragility. Analysis of photographic images taken from ISS during Expeditions 4 through 11 indicates that most images taken by crew members were self-initiated (84.5% of 144,180 photographs) and that photography was considered a leisure activity. During missions to Mars, however, the Earth will not always be visible. The effects of not being able to see Earth could have a detrimental effect on the psychological well-being of crew members.

Psychosocial adaptation and disorders
Anecdotal evidence from crew members illuminates the distress that some individuals encounter during long-duration space flight missions. Psychosocial adjustment is, by definition, the psychological and social process of adapting or conforming to new conditions. Unsuccessful psychosocial adaptation can lead to adjustment disorders that are characterized by decrements in performance.

In-flight diaries of cosmonauts and astronauts recount periods of psychological distress experienced during extended periods in space. Even crew members with otherwise cheerful dispositions may demonstrate changes in temperament when meeting the challenges of space flight adaptation. Lebedev wrote in his journal, “[M]y nerves were always on edge, I get jumpy at any minor irritation”(p. 291). One astronaut described his inability to fully prepare for long-duration space flight challenges, “I was astounded at how much I had underestimated the strain of living cut off from the world in an otherworldly environment”(p. 151).

Ineffective adjustment to life in space can take many forms. Withdrawal from fellow crew members or ground support crew is one form of ineffective adjustment. Discord or tense relations with fellow crew members is another form of ineffective adjustment.

A third form of ineffective adjustment is deviant behavior. One expert of isolated and confined environments has identified two categories of deviant behavior in U.S. Antarctic winter-over crews: (1) individuals who fail to conform to group norms/expectations; and (2) individuals who act as the station class jester, whose behavior is outside of the mainstream yet not outrageously disruptive or threatening. Deviant types of behavior in space may fall into these same two categories. For example, Lebedev admitted that he disregarded safety procedures when he became frustrated. In his haste to access new letters from home, he did not wear safety goggles because “they fogged up, but if metal dust had entered my eye the flight would have ended” (p. 304). Illustrating the second category of deviant behavior is Linenger’s coping behavior: “I also made my own diversions … Playing the space version of ‘sneaking up’ … Flying silently down the length of a module, I would approach one of my crewmates and, still undetected by him, move very close. I would then hover patiently until he turned around. I knew that I had gotten him whenever he would gasp and flail his arms backward”(p. 159). Anecdotal evidence from space flight suggests that astronauts and cosmonauts at times engage in disruptive coping behaviors that could presage larger behavioral issues.

Crew size may be another factor contributing to different behavioral outcomes. In examining rates of deviance in seven polar and three space flight missions (Salyut 7; Apollo 11; and Apollo 13), Nolan and Dudley-Rowley determined that deviance rates were highest for crews of three. These researchers classified deviant behavior in three general categories: (1) bizarre or puzzling behavior, such as withdrawal; (2) acts of violence, either verbal or physical; and (3) acts of deliberation, such as hoarding resources. They found that when crew size increases to four, there is an apparent significant decrease in the amount of deviant behavior exhibited.

Summary
Based on our past space flight experiences, various types of behavioral conditions and psychiatric disorders  are expected to be a risk for future Exploration missions (Table 1-1). While current selection and countermeasure strategies have prevented the occurrence of any behavioral health emergencies during space flight that could have jeopardized mission success, the uniquely long durations and distances of future Exploration missions necessitate comparisons with analog environments that might indicate the other types of occurrences that could be expected.

Analog Populations
Ground-based analogs, such as those in the Arctic and Antarctica or undersea habitats, are frequently used as a comparison to space flight because they are more accessible than space flight and provide an Earth environment in which to test and validate the feasibility of BHP countermeasures, tools, and procedures. Analogs, however, are also frequently criticized. It has been suggested that their fidelity, especially in laboratory simulation studies, is not always high. Natural analogs, such as those found in Antarctica and on submarines, frequently depart from actual space flight conditions. Most frequently, there are more individuals in analog settings than the two to six crew members that are common to current, and expected in future, long-duration space flight operations. Regardless of their limitations, however, some of the higher-fidelity mission analogs are the best, and often the only, method that is available for gathering the data that are necessary to successfully prepare for Exploration missions. Presenting data from his Antarctic mission, Astronaut Donald Pettit succinctly summed up the value  of analogs when he stated that “analog physics might be wrong, but the mindset is right”.

Behavioral and psychiatric emergencies
Examining actual occurrences in Antarctica between 1994 and 1997, Palinkas et al. found that 12.5% of the crew members at two Antarctic stations, McMurdo and South Pole, presented to the clinic with symptoms that met the DSM-IV-TR criteria for one or more disorders. This translates to an overall incidence rate of 5.2% over an 8.5-month austral winter. Age, gender, year, level of education, and prior winter experience were not statistically correlated to the DSM-IV-TR diagnoses. (It is important to note that an individual may have symptoms without qualifying for a diagnosis or a disorder in the DSM-IV-TR.)

Another analog environment for space flight is submarines, with their typical mission lengths of 3 months. As with space missions, submarine missions occur in a physically confined, socially and physically isolated, and extreme environment. For submariners, the incidence of psychiatric disorders that were severe enough to result in either the loss of a workday or the need to be medically evacuated ranged between 0.44 and 2.8 per person-year.

Mood and mood disorders
Palinkas et al. found that the most common category of disorders for individuals who were wintering-over in Antarctica was mood disorders; these accounted for 30.2% of all diagnoses. Depressive symptoms were significantly related to gender (females were at greater risk), military occupation (rather than civilian), station (all diagnosed individuals were stationed at McMurdo; none were stationed at South Pole), year of expedition, and having a DSM-IV diagnosis.

Otto based his research on 12 years of data from the South Pole Station. At the South Pole Station, between 1994 and 2005, the overall incidence rate for depression that required pharmacological intervention was 2.03%. This means that one case of depression can be expected every 1.1 winter seasons. The incidence rate for diagnoses of overall mental disorders, including depression, was 4.5% at the three Australian stations according to the Australian National Antarctic Research Expeditions (ANARE) and 6.4% at McMurdo Station. These incidence rates appear to be lower than those for the general public, which average 9.5%. Antarctic incidence rates could be artificially lower, however, due to a selection process that disqualifies individuals with existing diagnoses from wintering-over. Alternatively, the lower rate in Antarctica could be a result of self-selection, whereby individuals who apply to serve in winter-over crews tend to have better behavioral health than the general population.

Winter-over syndrome
Winter-over syndrome consists of a cluster of symptoms that includes interpersonal tension and conflict, cognitive impairment, sleep disturbance, and negative affect. This syndrome usually is not severe enough to warrant a DSM-IV diagnosis. Rather, it might more accurately be considered a subclinical condition. Some research has shown that symptoms peak shortly after the mid-point of an expedition. This effect, which is called the third-quarter effect, is independent of the length of the expedition. It is believed to occur as a result of individuals realizing that their expedition is only half over. Evidence regarding this third-quarter effect is inconclusive, however, and researchers continue to debate its existence.

Winter-over syndrome shares many similarities with asthenia. Perhaps the most telling similarity is that they both reflect de-adaptation to a stressful situation.

Salutogenesis
Palinkas and Suedfeld (Category IV) dichotomize the salutary effects of polar expeditions as being: (1) the enjoyable characteristics inherent in the situation, and (2) the positive reactions that come from having successfully met and overcome the challenges of the environment. The former are positive effects that are felt during the mission. These effects can require coping and resilience. The latter are positive effects that are more long-term in nature, and they are met through post-return growth (Category IV).

The isolated, confined, and extreme (ICE) environment, for some individuals, provides personally rewarding experiences. For example, the number of people requesting repeated winter-over assignments in Antarctica is evidence of the positive benefits that are associated with the ICE experience.

These kinds of effects are also seen in simulation studies. For example, three crew members were isolated in the Mir space station simulator for 135 days. They reported more expressiveness and self-discovery and less tension than during their pre-isolation training session.

Cognitive changes
Some evidence from Antarctic research suggests that clinical cognitive changes may occur in individuals who are exposed to ICE environments, such as space, for long periods of time. Investigators studying animal research have further speculated that behavioral changes in such environments may even be attributable to the effects of chronic stress on the hippocampus.

Physical aspects of the environment can also produce cognitive changes. Exposure to high levels of radiation, for example, can damage the subcortical basal ganglia and hippocampus that are critical to cognitive functioning. For specifics regarding the risks of space radiation, please refer to Chapters 4 through 7 in this book.

Analog mission duration of 2 or more years
Available evidence from assignments in any analog lasting 2 or more years, as will occur for a Mars mission, is scant. In Biosphere 2, an eight-member team was isolated on a 3.15-acre artificial, closed ecological system in Arizona for 2 years (September 1991 to September 1993). Although they were in a relatively lush and diverse environment – with access to television and radio, and daily contact via an observation window – the inhabitants of Biosphere 2 nevertheless experienced psychological stress. The team split into two factions within 6 months; stolen food was hoarded; and daily tasks were reported as monotonous. One month after the midpoint, some crew members reported experiencing depression that was severe enough to interfere with their ability to complete daily tasks. The severity of these behavioral and psychiatric responses was most likely due, in part, to a need for more rigorous psychological evaluation when selecting those who were best suited for this study. Problems that were experienced with Biosphere 2, in comparison to those of space flight, include poor selection of participants and lack of adequate preparation and training. Extensive publicity also may have influenced the experiences of the Biosphere 2 team by sensationalizing them. Although the reader is cautioned about over-interpreting data as well as misapplication of the study to space flight, the Biosphere 2 experience is included in this report because it is one of the few examples of very long-duration isolation and confinement.

Two-year assignments, which are common at the Russian Antarctic Station of Vostok, provide additional evidence that lengthier periods spent in isolation and confinement increase behavioral and psychiatric problems. Alcohol consumption contributed to the main power-generating building burning down as well as to the death of a station physician due to alcoholic liver failure. The depth of psychological stress that was experienced by some at the Vostok station is vividly illustrated by the example of a wintering-over Russian male who, after losing a game of chess, murdered his opponent with an axe.

These examples most likely do not generalize to astronauts and space travel due to the differences between analog and astronaut populations as well as the differences in mission characteristics. However, these examples are alarming and have been included to emphasize the increased risk of behavioral health and psychiatric problems that is associated with extended stays in highly isolated, confined, and extreme environments; such long durations are clearly at the outside boundary of our experience and evidence base.

Predictors and contributing factors
Precursors of behavioral health distress serve as warning signals, and many factors contribute to an individual’s behavioral health. Monitoring the presence of predictors and contributing factors will allow for the development of better screening methods to prevent behavioral conditions and psychiatric disorders from emerging and the implementation of countermeasures more quickly and, thus, more effectively.

As noted previously, numerous factors contribute to an individual’s behavioral health status. Certain factors such as crew member personality together with the quality and quantity of sleep predict the likelihood that behavioral and psychiatric distress will develop. These factors, which can be viewed as “stressors,” are discussed in the following section. Note that not all “stressors” are negative in terms of their impact on the behavioral health of an individual.

The Space Studies Board of the U.S. National Academy of Sciences (NAS) differentiates between physical and psychosocial environmental stressors as factors that contribute to changes in behavioral health. Physical environmental stressors include microgravity and the inherent hazards of space flight. Psychosocial environmental stressors include the isolation, confinement, and monotony of life in space.

Personality
The results of personality tests have been used to predict job performance for many years. As mission length and distances from Earth increase, selecting astronauts and, latterly, composing entire crews/space flight teams based on personality traits becomes increasingly critical.

Some personality evidence that is specific to astronauts exists. Generally speaking, the following types  of personality comparisons are found. These are comparing: (1) astronauts or astronaut applicants to a normative group; (2) astronauts to another occupational group; and (3) astronauts to peer/supervisor performance ratings or selection decision. No research has been undertaken that examines the relationship between personality and objective job performance. This lack of objective job performance limits any true attempt to identify the “right stuff.” Further, no known research has examined astronaut personality with respect to successful reintegration post-flight.

To date, the published research that is related to space flight has focused on two approaches of personality. One examines instrumentality and expressivity, while the other delineates personality in terms of the “Big Five” factors (i.e., openness, conscientiousness, agreeableness, extroversion, and neuroticism). The findings of each approach are discussed below.

Instrumentality and expressivity
Personality can be examined in terms of the broad categories of instrumentality and expressivity. The first of these, instrumentality, describes the degree of goal-seeking and achievement orientation. Individuals who rate highly in instrumentality are highly goal-oriented and have an elevated need for achievement. Those who are low in instrumentality tend to be considered egotistical, dictatorial, and arrogant. Expressivity, which is the second of the broad categories, is defined as social competence or how an individual behaves in interpersonal relationships. High expressivity is reflected as kindness, emotionality, and warmth. Those who are low in expressivity demonstrate negative communion (e.g., submissiveness, servility, gullibility) and are verbally aggressive.

Viewing personality in terms of instrumentality and expressivity has been found to be predictive in flight crews as well as in other aviation and space populations    and in the analog environments of submarines, hyperbaric chambers, polar expeditions, and the military (Sandal et al., 1996, 1998, 1999).

Categorizing personality in terms of instrumentality and expressivity has led to three groups that have  been informally termed the “right stuff,” the “wrong stuff,” and “no stuff”. The right stuff, which is characterized as high on instrumentality and on expressivity, is related to higher peer evaluations of job and interpersonal competence. Having the right stuff in settings that involve complex group interaction is related to superior performance. In contrast, those who have the wrong stuff are high on instrumentality and low on expressivity. Individuals that are low on both instrumentality and expressivity are considered to have “no stuff.”

Males and females who make it to the final round of astronaut selection are generally high on instrumentality compared to normative (student) scores; no differences are apparent on expressivity. Those who are astronauts demonstrate the same pattern as that of final-round astronaut applicants suggesting that personality between the groups is homogenous enough to warrant the use of other attributes to further distinguish the best applicants for the job.

The Big Five
As stated earlier, neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness comprise the Big Five. Individuals who are highly neurotic are prone to psychological distress. Those who  are highly extroverted direct a significant amount of energy toward others. Persons who are highly open to experience actively seek that which is new. Agreeable individuals prefer interactions that are compassionate rather than tough-minded. Those who are highly conscientious show a level of goal-directed behavior that is organized, motivated, controlled, and persistent (Costa and McCrae, 1992). While agreeableness is closely related to aspects of positive expressivity, the other four factors (i.e., neuroticism, extroversion, openness to experience, and conscientiousness) do not easily map onto the instrumentality/expressivity approach.

A 1991 meta-analysis suggests that conscientiousness is positively related to job performance (defined as job proficiency, training proficiency, and personnel data) across occupations as varied as professionals, managers, sales, police, and skilled/semi-skilled. Whether this holds true in Antarctica and possibly other ICE environments such as space flight is uncertain. Palinkas et al. found the opposite to be true in Antarctica, namely that better job performance was related to lower conscientiousness. These results could be artifacts of the sample or a function of how job performance was operationalized, however.

Musson, in his examination of human performance data that were collected by the Human Factors Research Project at the University of Texas, found that males who made it to the final round of astronaut selection were high on agreeableness and conscientiousness and low on neuroticism. As with males, female applicants were high on agreeableness and conscientiousness and low on neuroticism. Female applicants were also high on extroversion.

Regarding astronauts rather than astronaut applicants, Musson found that male astronauts follow the same pattern as male astronaut applicants; i.e., they are high on agreeableness and conscientiousness and low on neuroticism. Female astronauts, on the other hand, appeared much different from their female applicant counterparts. This may be an artifact of the small sample size for female astronauts (N=10); interpretation of the apparent differences is not recommended.

Tying personality to performance, Rose et al. found that agreeableness is positively related to four ratings of performance (i.e., peer-rated interpersonal, technical, and leadership competence as well as supervisor-rated job performance) for U.S. astronauts. Openness to experience was negatively related to peer-rated technical and leadership competencies and to supervisor-rated job performance. No other significant correlations were found between these performance ratings and the Big Five. It is possible that a lack of significant correlations concerning conscientiousness could lend credence to the finding that conscientiousness is not a positive predictor of performance in ICE environments. Alternatively and perhaps more likely, the lack of additional significant relationships could be due to the fact that subjective rather than objective job performance ratings were used.

Antarctica research suggests that ideal candidates for wintering-over in such an isolated and confined environment are relatively low in neuroticism but also relatively low in extroversion and conscientiousness. Rosnet et al. confirm that ideal individuals would be low on extroversion. In a third study, polar workers were found to place more highly than the normative group in all factors except neuroticism. Breaking these findings down by occupation reveals that scientists are lower than military personnel on extroversion and lower than technical/support staff on both agreeableness and conscientiousness. Differentiating by South vs. North Pole, Antarctic workers are higher than those in the Arctic in terms of extroversion, agreeableness, and conscientiousness.

Personality as a predictor of adjustment
Individuals who are wintering-over in Antarctica tend to adapt better when they are low in extroversion and assertiveness. Gunderson found that “achievement needs, needs for activity, needs for social relationships and affection, aesthetic needs, needs for dominance or leadership, a sense of usefulness in one’s job, and control of aggressive impulses [are] particularly important for adjustment in Antarctic small groups” (p. 4). Three individual characteristics that are related to adaptation in isolated and confined conditions in Antarctica are: high social compatibility, high emotional stability, and high task motivation.

Emotional Reactions
Emotional reactions, according to the NRC report by the Committee on Space Biology and Medicine, have three primary response systems: language, behavioral acts, and the physiological response of alterations to the hypothalamic-pituitary-adrenal (HPA) axis. Language can be used to voice reactions to stress through reports of feelings and other communications. Behavioral reactions to emotions are more physical in nature, however, and include acts of avoidance or attack. Negative emotions are associated with decreased performance and motivation; disruptions to short-term memory, attention, and other cognitive processes; increased interpersonal conflict; isolation from others; and various psychosomatic and psychophysiological symptoms. HPA activation can be affected by or cause inadequately regulated emotions, thereby suppressing the immune system and leaving the individual at greater risk for disease. HPA is a major component of the stress system that regulates the secretion of corticosteroids. Activation of HPA during depression is common, although whether HPA activation causes or results from a depressed mood is not known. Alterations of the HPA axis are known to be associated with negative emotion in ICE environments. Thus, during long-duration missions, it is possible that changes may take place in the HPA axis that might also affect mood and memory and the immune system.

Sleep and Circadian Rhythm
While it is difficult to predict who will or will not develop depression, sleep disruption is one early warning sign. Sleep disturbances are common diagnostic criteria for many psychiatric disorders. Comorbidity of a sleep disorder with a psychiatric disorder is also common; e.g., 40% of individuals who are diagnosed with insomnia also have a psychiatric disorder. This comorbidity is higher for hypersomnia, where 46.5% of individuals also have a psychiatric disorder. Insomnia is both a risk factor for and a manifestation of major depression. Research indicates that 15% to 20% of individuals who are diagnosed with insomnia also suffer from major depression.

The circadian rhythm of the human body is linked to patterns of biological activities such as brain wave activity, hormone production, and cell regeneration. Circadian rhythms can be affected by environmental factors; e.g., the amount of ambient light (Category I). Humans require 2,500 lux to entrain their circadian cycles; however, the illumination that is available on ISS at this time is limited to between 108 and 538 lux. Sleep is a large component of the daily circadian cycle and, as such, is affected by changes that influence the underlying circadian rhythm. Recent Category III unpublished data from the ISS and shuttle confirm the findings of previous assessments of sleep quantity and quality on orbit; i.e., sleep in flight is indeed reduced in comparison to terrestrial sleep. Changes in work schedule also can adversely affect a crew member’s circadian rhythm. During the Russian Soyuz program, sleep schedules were occasionally set counter to the local time of the launch site. This change in sleep schedules was associated with decreased quantities of sleep and decrements in performance among the cosmonaut crews. Indeed, the Space Studies Board states that a lack of sleep leads to increased stress and decreased cognitive and psychomotor functioning.

Current ISS operations often require slam shifting (i.e., sudden shifts in sleep/wake schedule), which can result in sleep loss and fatigue for the astronauts. Such schedule changes force critical mission operations to occur against the natural circadian rhythm of the body. The commander of Expedition 3, Frank L. Culbertson, Jr., did not consider slam shifting to be a problem for the flight crew as long as they had “adequate recovery time following the sleep shift and ensuing activities.” He advised that sleep/slam shifting did have some physiological effects on the crew with respect to insufficient rest time. Slam shifting also impacts the ground teams that support the ISS during critical operations as well as the ground teams that work overnight against the homeostatic drive to sleep. For detailed information on the performance risk that  is associated with sleep loss and circadian rhythm disturbances, please refer to Chapter 3 in this book.

Monotony and Boredom
Monotony is a frequent complaint of individuals in ICE environments such as space flight. In particular, it is the combination of monotonous work with requirements for high degrees of alertness and penalties for errors that is seen as especially stressful. Even in the face of monotony, however, performance remains high enough for mission success, provided that the motivation is high. The lack of variety in social interactions and the physical environment can lead to boredom, interpersonal conflict, and loss of energy and concentration. Members of Biosphere 2 reported that finding sources of stress relief was a major part of working in the Biosphere. Of major concern during long-duration missions is the possibility of too much monotonous free time. Boredom has long been known to be the worst enemy of polar explorers. As missions become longer, the focus on the amount of work that humans can safely perform changes from how much to how little (Weiner, 1977).

Environment and Job Design
In an environment in which an individual floats freely, distinctions between up and down are no longer meaningful. Environmental design, or habitability, is thus no longer confined to the Earthly distinctions among floors, walls, and ceilings; this is an asset when the size of the ship or the station is limited. How readily a crew member adapts to this truly three-dimensional world varies by individual (Connors et al., 1986).

The lack of privacy, which has been associated with impaired individual well-being in analog studies, is a major psychosocial stressor in space flight. Individuals who are in confined spaces tend to withdraw from one another during leisure time. Further, the leisure time is characteristically spent in more passive activities. Having private crew quarters in which a crew member can be alone thus becomes extremely important on long-duration missions.

Anecdotal evidence suggests that interior décor can affect well-being. Use of many different colors and the wide use of darker colors are contraindicated. Colors can also be used to orient crew members since gravitational cues, which are missing in space, no longer provide navigational aids.

Windows promote well-being in ICE environments by decreasing the sense of confinement and monotony of the environment. Anecdotal evidence from the earliest space flights supports the importance of being able to look outside. Kelly and Kanas provide empirical evidence that “watching” activities became more important.

In addition to designing the environment to promote well-being, jobs can be designed in such a way as to promote well-being and performance. To the extent possible, crew members should have autonomy in planning their work schedules, managing their workloads, and deciding when to perform nonessential tasks. Further, the appropriate amount of work that is to be performed daily must be determined. Overworking can result in performance errors as physical and mental exhaustion occur. At the same time, a lack of sufficient meaningful work can adversely affect mental well-being. Quoting the first U.S. astronaut on Mir, Norman E. Thagard: “[T]he single most important psychological factor on a long-duration flight is to be meaningfully busy. And, if you are, a lot of the other things sort of take care of themselves” (p. 44).

For greater detail, please refer to Chapter 10 in this book.

Daily Hassles and Major Life Events
Although some stressors that are found in space are a result of the fact that space is an ICE environment, other stressors are unique to space itself. The number and extent of daily hassles of life, i.e., those “irritating, frustrating demands that occur during everyday transactions with the environment” (p. 465), are significant predictors of health  since increased stress can lead to diminished health. Daily hassles that are associated with the physical environment that is unique to space include: a growing accumulation of garbage, limited facilities for sanitation, the need for constant vigilance, and a relative lack of privacy. The noise and vibration of ISS are acoustic stressors that can affect sleep quality and quantity, the low level of illumination on ISS is a photic stressor, and the physical space on ISS or in any space vehicle is limited. Social density is thus an added stressor.

Cultural and Organizational Factors
Cultural and organizational factors can contribute to the stress of space flight. Both organizational and national cultural differences between the Russian Space Agency and NASA can influence crew dynamics. Perceived stress can be aggravated by cultural differences in interpersonal distance. An “us vs. them” attitude can develop between the crew and its off-site support, as well as feelings of animosity toward the same off-site support. This dynamic is sometimes termed “displacement” because the team is displacing the intra-group tension onto safer, more remote individuals. Although displacement is not an uncommon occurrence between remote teams and their support centers, it nevertheless becomes more critical for space flight as the missions grow longer and the conditions of isolation expand.

In 1974, friction between crew members and Mission Control during a Skylab mission resulted in a work stoppage in which crew members insisted on taking a scheduled day off after weeks of work without a day of rest. Russian crews have also experienced conflict with their ground support teams. The crew of one Salyut space station shut down communications with Mission Control for 24 hours. Lebedev and crew members failed to report a fire to the ground because “it would have just caused more panic” (p. 309). In addition, Antarctic winter-over crews report having avoided communicating with their administrative support or deliberately misleading their administrative support.

Family and Social Support
According to the NASA Family Support Office, astronauts have reported feeling more relaxed and able to concentrate on tasks at hand when they believe that someone is taking care of their families (Category IV). Worrying about family and family events that might occur at home while the crew member is away can be extremely stressful. Psychiatric intervention was required post-flight for an Apollo 11 astronaut due to his marital distress and depression (Aldrin, 1973; Kanas, 1987). The death of his mother caused cosmonaut Vladimir Nikolaevich Dezhurov to withdraw for 1 week during his mission.

Astronaut Daniel M. Tani experienced an unexpected personal loss during his ISS mission when his mother died in an accident in her hometown. A fuel gauge problem required that a shuttle mission be postponed for 2 months. This resulted in Tani’s duties as a space station flight engineer being extended by 4 months. It was during this extension period that Tani’s mother died. At his return home ceremony, which was held in Houston on February 21, 2008, Tani commented on the importance of psychological support: “We so rightfully thank every technical trainer we have, but when you go and live on the station, there is a whole aspect of living that we have to think about and anticipate.” He expressed his gratitude for flight surgeons and psychologists as well as the implication for future missions: “That was invaluable to me. This is something we will have to learn how to really support and develop for long-duration flights to the moon and Mars”. Such tragedies affect all crew members, including those who are on the ground crews, and they can be especially challenging for mission commanders who seek to lend support to a grieving crew member.

World Events
In addition to family events, world events viewed from space, can be stressful. In 1991, the Mir space station crew launched as Soviet Union cosmonauts yet later returned to Earth as Russian Federation cosmonauts. On board ISS, Astronaut Frank L. Culbertson, Jr., used video and still cameras  to document the aftermath of the Twin Towers attack on September 11, 2001. On being told of the attacks, he writes that he “zipped around the station” (Culbertson, 2001) until he found a window that would give him a view of New York City. Culbertson states, “It was pretty difficult to think about work after that, though we had some to do, but on the next orbit we crossed the U.S. farther south. All three of us were working one or two cameras to try to get views of New York or Washington”. Although far from home, astronauts and cosmonauts are not untouched by political turbulence.

Prevention and treatment countermeasures
Psychological support is provided to prevent or mitigate the impact of potential stressors and to minimize the risk of occurrence of behavioral conditions and psychiatric disorders for all current long-duration space flight missions. If conditions do arise, a psychological support system allows for early detection of the condition and timely application of countermeasures. If necessary, more aggressive treatment methods can be applied. Countermeasures can be dichotomized into those that prevent the occurrence of a risk or mitigate the potential severity of the risk and those that monitor or treat the risk if it does occur.

Prevention Countermeasures
Seyle’s model of the General Adaptation Syndrome states that as a stressor appears and continues, an individual’s coping resources are first mobilized, deployed, and depleted if not resolved. Seyle termed these stages alarm, resistance, and exhaustion. One of the goals of prevention is to avoid distress by providing crew members with the wherewithal to minimize or negate a stressor.

The lack of behavioral and psychiatric emergencies during flight is evidence of the efficacy of current countermeasures, given current mission lengths of approximately 6 months. The current practices and services that are offered by the BHP Operational Psychology Group at NASA include: pre-flight, in-flight, and post-flight preparation; training and support; resources from the Family Support Office; in-flight monitoring; clinical care for astronauts and their families; and expertise in the workload and work/rest scheduling of crews on ISS. These services are shaped in part by a crew member’s personal preferences, family requests, and specific events during the missions, as well as by programmatic requirements and other lessons learned.

Pre-flight
Prevention begins with selection. Those individuals with the greatest likelihood of having a behavioral  and psychiatric emergency in flight are eliminated during the selection process; i.e., they never become astronauts. This facet of the selection process is commonly called “select-out.” The NASA select-out system is thorough, but the predictive ability of all selection systems diminishes over time. Individuals and circumstances change as time passes so that a test that was administered during selection 10 years before an individual is assigned to a mission has a limited ability to predict in-flight and post-flight behavior. Not only are the individuals who are most likely to have a behavioral and psychiatric emergency selected-out, but the individuals who are best suited to being astronauts are identified. This aspect of selection is typically termed “select-in.” In the current NASA selection system rather than being “selected-in,” this aspect of selection is more accurately considered “suitability.”

A suitability score, which is given to each interviewee, is a clinical judgment of the degree to which that interviewee would make a good astronaut. Factors that are considered when determining suitability include: personality, emotional stability, and family demands. Again, as with select-out tests, select-in suitability scores are less predictive over time. To counteract the deterioration of the selection data, annual psychological assessments were recommended in the “NASA astronaut health care system review committee: report to the administrator (February – June, 2007)”. Annual BHP assessment interviews, which are performed by an experienced flight surgeon who is also board-certified in psychiatry, started in October 2008. This assessment is comprised of a 30-minute interview in the NASA Johnson Space Center (JSC) Flight Medicine Clinic and covers broad areas of occupational relevance, including space flight experience, workload, fatigue, sleep, peer relationships, family, challenges, goals, and future plans. These annual assessments are not intended to be comprehensive psychological screenings for mental disorders or psychiatric illness, however. Such an assessment would be very time-consuming and produce an extremely low yield of any useful data. Of greater importance operationally are the ISS pre-flight assessments that begin 1 year prior to an astronaut being given a backup assignment. These interviews are longer (90 minutes) and far more intensive in terms of content.

Despite the annual and pre-flight BHP assessments, there is a risk of unpredicted in-flight behavioral degradation due to unforeseen circumstances such as mishap, personal tragedy, interpersonal conflict, or the development of symptoms of a mental disorder that was latent before flight. In this regard, there remains a risk of mission-impacting mental distress and performance degradation that cannot be ignored, one that requires further review, improved assessment techniques, and autonomous intervention methods.

The Operational Psychology (Op Psy) component of BHP provides psychological support to ISS crew members (Category IV). While the majority of Op Psy support occurs in flight, preparations begin pre-flight as astronauts express their preferences for support options such as crew member Website content, movies, games, and food. These decisions allow crew members to take some of the familiarity and comfort of home with them.

“Lessons learned” are shared both formally and informally among astronauts and family members. Formal Astronaut Office briefings are scheduled following each short- and long-duration mission as well as between the assigned crew members of adjacent missions. These lessons learned are documented and distributed among astronauts and their families. Formal briefings and training sessions are also scheduled with crew and family members before each mission. Informal briefings occur between experienced and inexperienced astronauts, as well as between their spouses or significant others. Other opportunities to share information are provided by the Astronaut Spouses Group (ASG) during social and educational events. General advice that is not targeted to a specific individual or family is available from a variety of resources such as the ASG newsletter, Astronaut Office documents, and Flight Medicine Clinic handouts.

The JSC Family Support Office (FSO) acts for astronauts and their family members by liaising with the Astronaut Office, the ASG, BHP, JSC security, the Flight Medicine Clinic, the Military Liaison Office, the Public Affairs Office (PAO), and others. An organizational FSO is needed when employee tasks include lengthy deployments or hazardous duties that affect employee families. Personnel in the FSO assist with all issues or concerns in a confidential manner. They also connect and communicate with families so that these families are informed and ready in the event of an emergency. To support families in their readiness preparations, the FSO provides publications, newsletters, email notices, training and educational classes, and specialized seminars. The FSO was created to address the unique challenges that face astronauts and their families during astronaut training cycles and flight assignments. As several astronauts have noted, the FSO provides the support that enables them to more easily concentrate on their work in space because they believe that their family needs are being met by FSO personnel in their absence.

One method for providing crew members with additional coping mechanisms is to teach them specific coping skills. BHP Op Psy provides classes to astronauts and, in some cases, their families. These classes are discussed below:


 * In-flight Resource Plans 1 and 2 provide astronauts with an overview of the support that BHP provides to ISS astronauts. This course familiarizes astronauts with BHP and its functions, and provides them with a first look at some of the coping mechanisms that are available.


 * Self-care/self-management refers to keeping oneself satisfied and productive under demanding circumstances and managing one’s own stress. This class teaches astronauts to apply strategies of self-care/self-management as they encounter the stressors that are common to long-duration missions.


 * Psychological Factors 1 exposes crew members to the psychological effects of long-duration space flight. The manifestations of various psychological factors are discussed, as well as the procedures that are used to manage any contingencies.


 * Psychological Factors 2 continues the discussion of the support resources that are available during  a mission for the crews and their families. It also identifies the principle environmental, interpersonal, and programmatic factors that can impair psychological health and performance during extended confinement.


 * Psychological Support Planning 1, Psychological Support Planning 2, and ISS Crew/Family Psychological Support Familiarization classes brief crew members on the psychological support program that is established to assist crew members and their families during the pre-flight, in-flight, and post-flight phases of the mission. Each crew member begins to identify his or her desired in-flight support resources, based on the options that are currently available. At the crew member’s discretion, family and/or primary support individuals will be invited to the meeting.


 * Practical Planning for Long-duration Missions encourages crews and family members to consider important personal arrangements before long-duration missions. This class stresses critical actions (e.g., wills, emergency contact information), reviews “lessons learned,” and provides tools and checklists to help simplify the personal preparation process. The FSO offers this class in conjunction with BHP and the Astronaut Office. Spouses, significant others, and other key family members may attend this event at crew member discretion.


 * Conflict Management is a discussion-oriented lesson that introduces a three-point cycle that drives, escalates, and de-escalates conflict. The course reviews methods for breaking the cycle at each of the three points so that conflicts are resolved in ways that preserve relationships with colleagues, friends, and family. Techniques include “rules” for fair fighting, checking the accuracy of interpreted meanings, and recognizing and managing emotions that can perpetuate conflict. This training was based on ma- terials that were developed in a National Space Biomedical Research Institute (NSBRI)-supported study.


 * Cross-cultural Training exposes U.S. astronauts to special circumstances that can arise from working with crew members and ground control personnel from the International Partners of NASA. The course addresses cultural factors, communication and negotiation styles, and work and social factors. Potential positive and negative effects of cultural differences are identified. Methods, strategies, and resources that can be used to handle cross-cultural challenges are described and practiced within the context of case-situations that occurred previously. This course was devised in answer to the interview requests of astronauts who flew on ISS and Mir for more and better cross-cultural training.

ISS Behavioral Medicine Training is provided to CMOs and flight surgeons. This training provides an overview of the psychiatric symptoms and disorders that might be seen during a mission. Discussion includes the therapeutic clinical response and resources that are available on ISS should a crew member exhibit seriously disordered behavior. The focus of this training is on serious psychiatric symptoms or illness as opposed to behaviors that fall within the norm for persons who are living in stressful circumstances.

Behavioral medicine psychiatric interviews begin 12 months before launch and at 30 days post-return. These interviews are the mainstay of pre-flight detection and prevention of in-flight psychological or psychiatric problems (NASA, 2008). Interviews focus on mission training issues, crew-crew interaction, family issues, sleep and fatigue, workload, crew-ground communication, mood, cognition, ground re-adaptation, and family reintegration.

Another behavioral medicine requirement on the ISS is the WinSCAT (space flight cognitive assessment tool for Windows), which is an 11- to 15-minute computer-based cognitive screening test. Baseline testing begins 6 months before launch, and the astronaut is requested to take it once a month while in orbit. WinSCAT is an operational medical requirement that will be used after an astronaut has suffered any unexpected medical event (e.g., head trauma, decompression sickness (DCS), exposure to toxic gases, medication side effects); it will serve as a data point for crew surgeon medical assessment/disposition (Kane et al., 2005). Off-nominal WinSCAT scores are evaluated in context before adjusting the work-rest schedule or taking another course of action.

These extensive ISS pre-flight behavioral medicine interviews and assessments, along with the BHP training classes and other support that are provided, help to prepare crews for long-duration space flight and act as another behavioral health-screening aid.

In-flight
Currently, provision of psychological support is at its most intensive when the astronauts are in flight as opposed to during the pre- or post-flight periods. This support system, which is provided by BHP Op Psy, includes crew care packages, contact with family and friends, communication technologies, and leisure/recreation activities. Crew care packages are either sent with the crew to be opened later or via resupply to ISS. They consist of items that are selected by crew members and their families and friends, such as favorite foods. In a Mir simulator study, researchers found that after a resupply event, crew anxiety, total mood disturbance, and overall crew tension significantly lessened (Stuster, 1996) (Category II).

Providing crew members with the opportunity to keep up regular contact with their families is important for maintaining crew member behavioral health. Private family conferences are conducted via video between crew member and family from within the privacy and comfort of the family home. The internet protocol (IP) telephone is an additional link between a crew member and that crew member’s family. The crew member can call home when Ku-band coverage is available. The NASA tracking and data relay satellite uses Ku-band to communicate with both the shuttle and the ISS.

Other social contact with the ground that is not necessarily family-specific helps to broaden the social support networks of crew members and acts to lessen crew member feelings of being objectified and separated. According to BHP Op Psy, Expedition crew members received approximately 20 greetings during one Christmas season. A greeting is a short message, usually in the form of a video that is recorded by family, friends, or coworkers, that is sent to a crew member.

The crew Webpage, the IP telephone, and email can help crew members feel more connected to events on Earth. The crew Webpage, which is updated twice weekly for each crew member, is specifically tailored to a crew member and, thus, provides that crew member with a gateway to personal news selections, videos, MP3s, and photographs.

Providing choices of leisure activities for crew members is another tool that can prevent behavioral health distress. Before flight, crew members request movies, music, and electronic books that will be uploaded to them. Even equipment can be requested; for example, in response to the request of various ISS crew members, several musical instruments are now on board the station. Astronauts have stated that they use movies and music to accompany their required daily exercise regimes. In addition to its physical benefits, exercise also is an effective countermeasure for maintaining positive mood.

Regular private psychological conferences begin once an astronaut is in flight and continue throughout the duration of the mission. Private psychological conferences, which are held between a psychologist or a psychiatrist and a crew member, are normally conducted every 2 weeks for at least 15 minutes. These conferences enable the psychologist or psychiatrist to assess the behavioral health of the astronaut and provide that astronaut a venue for venting and voicing concerns.

The WinSCAT, which, as mentioned earlier, assesses cognitive functioning, is scheduled to be taken once a month by crew members while they are in orbit. The WinSCAT scores that are recorded after an astronaut has sustained any unexpected medical event are compared to that astronaut’s baseline and other pre-insult scores. The WinSCAT, along with other data, allows the crew surgeon to make an evaluation regarding the severity of an event.

Post-flight
Prevention and treatment of post-flight behavioral conditions and psychiatric disorders rely primarily on behavioral medicine interviews after a crew member returns to Earth. These post-flight interviews may not be of sufficient length to be of benefit, since time is required to allow astronauts to feel comfortable and open up. Before astronauts will speak candidly, they must also trust the individual who is conducting the interview and believe that the contents of the interview will not adversely affect their future flight status.

Other post-flight prevention and treatment methods could be incorporated. For instance, the annual psychological exams for current astronauts that are recommended in the Bachmann report (2007) would provide post-flight support for flown astronauts. A similar psychological exam could be implemented for retired astronauts. As all of the effects of flight and return might not be present immediately, continuing the behavioral medicine interviews for a longer period of time would provide astronauts with opportunities to discuss issues that might arise post-flight. If necessary, pharmacological aids can be prescribed.

In addition to providing the best measures and tools to monitor and assess mood and predict risk for and management of behavioral conditions and psychiatric disorders before and during space flight, the HRP BHP Element is required to continue this provision after an astronaut’s return from space flight. When astronauts return to Earth, reintegration back into the family is not easy. It takes time and will require adjustment from all family members. A class for astronauts and their families that specifically targets the challenges of reintegration could be developed or an existing class could be modified. Education of astronauts and their families regarding reintegration is especially important for those who have no deployment experience.

Pre-flight
Astronauts and their families have pre-flight access to counseling. There might be some hesitancy to use these services, however, given the NASA culture and astronaut concern that flight status might be negatively impacted.

In-flight
Medical kits that are aboard space shuttle and ISS missions contain supplies to help crew members cope with a variety of possible medical emergencies. These kits include medications that can be used in the treatment of space motion sickness, sleep problems, illnesses, injuries, and behavioral health problems. For example, space shuttle medical kits have included medications that can help to counter anxiety, pain, insomnia, fatigue, depression, psychosis, and space motion sickness. Putcha et al. evaluated the in-flight use of medications from astronaut debriefings that were conducted after 79 U.S. shuttle missions. The results show that 94% of the records indicated that medication was used during flight.

Space motion sickness accounted for 47% of the medications that were used, while sleep disturbances accounted for 45%. The remainder of the medications was reportedly taken for headache, backache, and sinus congestion. These findings are an increase from the findings of Santy, who reported that 78% of crew members took medications in space, primarily for space motion sickness (30%), headache (20%), insomnia (15%), and back pain (10%). Currently, the ISS medicine kit contains two anxiolytics, two antidepressants, and two antipsychotics. While the use of these medicines would be unexpected and unlikely, their inclusion is necessary in the event of an actual emergency, just as flying a defibrillator is a medical requirement, although no cardiac arrests have occurred to date. In extreme situations, a physical restraint system is available. Sedatives are also included in the medical kit if a crew member requires sedation to ensure the crew member’s or fellow crew members’ safety.

As described above, several non-pharmacological tools are available to monitor behavioral issues on U.S. spacecraft. The first, and perhaps most important, is the private psychological conference that is held between a psychologist or a psychiatrist and a crew member. Private psychological conferences are useful both as a monitoring tool and in cases in which an intervention is required. They also can be used to counsel or treat astronauts. Initial statistical data that were compiled by BHP experts representing European, Russian, and U.S. space agencies indicate that private psychological conferences are accepted by crew members. During private psychological conference debriefings, astronauts have praised the pre- flight briefings as well as the psychological services that are provided by operational psychology during flight (e.g., private family conferences, crew discretionary events, crew care packages, recreational items) and the behavioral medicine support (pre-flight briefings and private psychological conferences). Astronauts have told BHP in debriefings that they did not realize how important “that psych stuff” was until after they were on the ISS.

The flight surgeon is also an important line of defense for reducing the likelihood of a behavioral condition or psychiatric disorder occurring or developing. The role of the flight surgeon is to monitor the physical health and well-being of the astronaut. To ensure this, the flight surgeon conducts a 15-minute private medical conference once a week with the astronaut. As with the psychologist or psychiatrist, the flight surgeon may be able to recognize early signs of behavioral health distress in an on-orbit crew member. Lebedev describes his crew doctor intervening during his Salyut 7 flight: “I kept myself under control but I was irritated. Our crew doctor, Eugeny Kobzeb, sensed it, and during the evening period of communication said, ‘Wait a minute.’ Suddenly I heard a very familiar Ukrainian melody. I couldn’t understand where it came from. Finally it dawned on me: it was my son playing the piano. It was so wonderful and unexpected that tears ran from my eyes” (p. 77).

Post-flight
Several of the methods that are used to prevent the occurrence of post-flight behavioral conditions and psychiatric disorders can also be used to treat these conditions if they occur post-flight. Annual psychological exams for current and retired astronauts can be used as a springboard for targeting treatment options; e.g., continued counseling or pharmacological aids. As not all effects of space flight and reintegration are immediately present at the time at which an astronaut returns, post-flight behavioral medicine interviews could be continued at additional intervals beyond those intervals that currently occur post-flight. To the extent that a family is experiencing difficulty with an astronaut reintegrating, family counseling is another treatment option that is available post-flight.

Summary
The operational set of activities that was described in the previous sections consists of specific medical requirements that are determined to be necessary by an international group of behavioral health specialists. If flight surgeons as well as astronauts had seen no value in these activities, they would have been waived or removed. Instead, astronauts have communicated their appreciation of and desire for these services. According to the lead NASA psychiatrist (personal communication), every ISS astronaut has stated that these training measures and countermeasures of behavioral medicine and operational psychology support are both valued and beneficial. Areas of enhancements that were cited by these astronauts include: crew morale, mood, motivation, crew cohesion, and family ties during the mission.

Astronaut use of many BHP operational services is voluntary. They are presented to the crew member and family from the first meeting as a “buffet” from which they can choose all, some, or none, and they have an opportunity to request their own services. The fact that crew members and their families consistently have requested more operational psychology support as the program has developed and continue to request specific services that are already offered are indicators that these services are needed and should be continued. The internationally publicized death of a crew member’s family member during Expedition 16 tested the value and benefit of the services that are currently offered by BHP.

This type of tragedy is addressed in pre-flight behavioral medicine training with all crews. As humans continue to explore space, it will surely not be the last time that this type of event occurs. The response to such a tragedy requires the implementation of all facets of operational psychology and behavioral medicine countermeasures. Lastly, the high number of Silver Snoopy awards11 that have been awarded by the astronauts to the BHP Op Psy Behavioral Specialists who have directly supported these services demonstrates astronaut appreciation of BHP training, treatment, and prevention services.

Risk in Context of Exploration Mission Operational Scenarios
Depression is becoming more common in the general population. The WHO, in its annual report, predicts that depression will become the second-largest cause of disability worldwide by the year 2020. It is already the leading cause of disability in the U.S. according to the NIMH. In a given year, approximately 20.9 million U.S. adults, or about 9.5% of the population who are age 18 or older, will develop a mood disorder.

To assess and quantify the risk of behavioral conditions and psychiatric disorders in the context of future Exploration missions, it is important to consider the crew member’s nationality and age. Annual rates of depression differ from one region to another. In the U.S., depression is the third-most-frequent psychiatric diagnosis. In other countries, however, the rate of depression is considerably lower. The likelihood of a mood disorder developing also varies by age group. Close to one-half of the psychiatric disorders that led to U.S. Naval aviation personnel waivers were for persons who were older than age 30. Major depression along with manic depressive disorder and obsessive compulsive disorder are highly likely to develop for the first time in North American and Western European astronauts’ age groups.

The total incidence rate for the general adult population is a summation of the incidence rates for each subgroup based on age and gender. The incidence rates for the subgroups are therefore lower than the total adult population incidence rate. More specifically, tailoring the incidence of depression in the general population to the age range of the astronaut population will yield a considerably lower rate than the 9.5% that is estimated for the general U.S. population. The NASA IMM uses an incidence rate of depression and anxiety (for males 0.00029 cases per person- year and females 0.0036 cases per person-year) that is extrapolated from the Longitudinal Study for Astronaut Health, whose incidence rate is limited to the average age range of the astronauts (i.e., 40 to 49 years). Behavioral emergencies in the general population occur in 3% to 9% of depression cases. Extrapolating from these rates, the overall incidence rate of behavioral emergencies due to depression for astronauts can be estimated as 0.000087 to 0.000324 cases per person-year. However, it is important to note that the rates that were used in these calculations were based on reported symptoms only and were not derived from a confirmed diagnosis. Therefore, the incidence of depression and anxiety may or may not be higher in crew members  in space flight than in the age-adjusted general population due to the high workload and stressors that are associated with some aspects of space flight missions.

Rather than basing his estimate on the incidence rate of depression in the general population, Stuster predicted that the incidence rate of behavioral problems that could be expected on long-duration Exploration missions is based on known incidence rates in analog environments. Reporting physicians defined behavioral problems as symptoms that normally would warrant hospitalization. Stuster’s analyses show that as the length of a mission increases, so will the incidences of psychiatric disorders (see Table 1-2). Stuster’s assumptions are as follows:

The figures in the row labeled Behavioral Problem assume a 6% per year incidence rate of serious behavioral problems throughout the durations of the two mission options considered (i.e., Mars Long Stay, 905 days total; and Mars Short Stay, 661 days total). This predicted incidence rate is based on incidence rates of behavioral problems reported from Antarctic experience. The row labeled Differential assumes a 6% incidence rate per person-year during the interplanetary transit phases and a 2% rate per person-year while on the surface of Mars, when confinement would probably be less of a factor and other stressors might be offset by the novelty of task performance. The expected occurrence of a behavioral problem serious enough to require hospitalization on Earth in a crew of six is estimated to be .534 for the long-stay option and .626 for the short-stay option. Using the differential values, these translate to a 53.4% probability that a serious behavioral problem will occur during the long-stay option and a 62.6% probability during the short-stay option. Stuster asserts the probability of a serious problem occurring to be greater for the short-stay option [on Mars], due to the substantially longer time that must be spent by the crew confined to the space craft than in the long-stay option. However, the long-stay option will always generate a higher probability if the incidence rate were to remain constant throughout the mission. A uniform 6% incidence rate per person-year would increase the estimated probability of a serious behavioral problem to 65.2% for the short-stay option and 89.3% for the long-stay option.

The two approaches (IMM and Stuster’s analog-based) to estimating the incidence rate of behavioral conditions and psychiatric disorders yield very different predictions. Further investigation of the discrepancies between the two estimates is warranted. What is noteworthy in both approaches is the predicted occurrence of a behavioral problem during a long-duration mission.

Conclusion
Evidence that was gathered from long-duration stays in ground analogs demonstrates that, despite the focus on screening and selection for suitability, behavioral conditions and psychiatric disorders such as depression develop. Of greater relevance, anecdotal reports from the earlier long-duration space missions (i.e., Mir and Skylab) and evidence from current long-duration missions on the ISS reveal that the signs and symptoms of depression and other behavioral disorders also have occurred in flight. The relevance of the risk of behavioral conditions and psychiatric disorders is supported further by the implementation by NASA of the Family Support Office as well as by the psychiatric support that is made available to the ISS crews and their families.

Exploration missions will require crews to live in ICE environments for as many as 3 years. This is a significant leap from the 6-month duration of lower Earth orbit missions. To date, only five individuals have lived and worked in space for longer than 1 year. The incidence of behavioral and psychiatric disorders is expected to increase as the length of the mission increases   (Category IV). The additional, unique stressors of radiation exposure, remote distances, and unknown dangers that will be experienced during long-term Exploration missions to the moon and Mars also may contribute to an increased likelihood of this risk.

If a behavioral condition or psychiatric disorder should develop on an Exploration mission, the consequences could jeopardize mission objectives. Therefore, future research addressing the prevention of behavioral problems, as well as the early detection and treatment of problems that do occur, is recommended.

The current rigorous astronaut selection system prevents some behavioral problems from manifesting themselves. Refining and updating the system could prevent the onset of additional problems. Recommended improvements to the selection system include: validation of the current system and implementation of a true select-in system (i.e., one that identifies the interviewees who are most likely to succeed as astronauts). Periodic psychological reassessment also could possibly detect early signs of a behavioral condition or psychiatric disorder. Further, if those who assign astronauts to crews and missions were to employ psychological selection methodology, they might increase the likelihood that those astronauts who are selected for a crew would be unlikely to experience an in-flight behavioral medicine emergency.

Early detection is important in deterring and treating behavioral and psychiatric problems. Research that investigates the best assessment measures to detect behavioral and psychiatric disorders is warranted. Thus, one example of a possible future research topic is which personality measures best predict astronaut psychosocial adjustment to space flight.

NASA has many countermeasures in place and will need to develop additional countermeasures that are tailored to long-term lunar and Mars missions. The efficacy of the current countermeasures for future Exploration mission scenarios needs to be formally assessed. The astronauts who will be venturing out on long-duration space flight missions beyond low-Earth orbit (LEO) will face unique challenges, including the need to manage behavioral health problems autonomously. Research is needed to address appropriate countermeasures that are specific to the Exploration mission environment. A better understanding of factors affecting positive emotional reactions also will be important when developing countermeasures for use during long-duration Exploration missions.

Early, quick, and effective treatment of any behavioral problems that do occur is essential. Future research should include investigation of other treatment options and an assessment of the efficacy of those treatment options.

This review of the evidence to date reveals that much work has been done to identify, prevent, and treat the behavioral conditions and psychiatric disorders that might affect astronauts and their performance during all phases of a mission. Given the relative lack of behavioral conditions and psychiatric disorders that have occurred within the astronaut population, the lack of behavioral and psychiatric emergencies in flight, and the number of long-duration mission successes, the current system for mitigating the risk of behavioral conditions and psychiatric disorders appears to be effective. As missions return to the moon and then look toward Mars, changes to behavioral medicine will be required. Our view of the “right stuff” will need to be adjusted. Factors such as personality might play a greater role, while other factors, such as pilot experience, might play a lesser role than they do at present. The selection system will therefore need to reflect those changes. Countermeasures will need to evolve. Some current countermeasures will not be relevant for longer flights, while other, new ones will need to be developed (e.g., alternative to seeing Earth). Effective countermeasures will help to protect and ensure astronaut behavioral health and performance, and, in turn, help NASA achieve mission success on the most challenging Exploration missions that humankind has dared to undertake to date.

Acknowledgments
We acknowledge the important and thoughtful contributions that were made by our BHP community, including flight surgeons and medical operations, researchers from the NSBRI, our external investigators, and many others as noted below. These efforts, while time-consuming, are critical for understanding and communicating what is known and unknown regarding the risks that are associated with human space flight, particularly as we embark on Exploration missions to the moon and Mars. Such knowledge will enable us to meet these future challenges and succeed.

Contributors and reviewers
Pamela Baskin, B.S.; Research Scientist, BHP, Space Medicine Division; NASA Johnson Space Center; Wyle Integrated Science and Engineering Group; Houston.

Gary Beven, M.D.; U.S. Air Force Flight Surgeon, Board-certified general and forensic psychiatrist, Chief, BHP, Space Medicine Division, NASA Johnson Space Center; Houston.

Frank E. Carpenter, M.D.; U.S. Air Force Senior Flight Surgeon, board-certified general psychiatrist; (Formerly) Chief, BHP, Space Medicine Division, NASA Johnson Space Center; Houston.

James (Carter) Cartreine, Ph.D., Research and Clinical Psychologist; Beth Israel Deaconess Medical Center; Instructor in Medicine and Psychiatry, Harvard Medical School; Boston, Mass.

Jonathan B. Clark, M.D.; Space Medicine Liaison, NSBRI, Baylor College of Medicine; Houston. Edna R. Fiedler, Ph.D.; Liaison for Health and Science, NSBRI, Baylor College of Medicine; Houston.

Kathy A. Johnson-Throop, Ph.D.; Information Systems, Decision Support Systems, Knowledge Management, and Healthcare Systems; Chief, Medical Informatics and Healthcare Systems Branch, Space Medicine Division, NASA Johnson Space Center; Houston.

Kathryn Keeton, Ph.D.; BHP, Industrial Organizational Psychology, Research Scientist, Wyle Integrated Science and Engineering Group; Houston.

Christian A. Otto, M.D.; Remote Operational Medicine Scientist, Division of Emergency Medicine, University of Ottawa; Canada.

Lawrence A. Palinkas, Ph.D.; Professor, School of Social Work, University of Southern California; Los Angeles, Calif.

Walter E. Sipes, Ph.D.; Lead, Operational Psychology, BHP, Space Medicine Division, NASA Johnson Space Center; Houston.

Jack W. Stuster, Ph.D.; CPE, Human Performance in Extreme Environments; Habitability, Equipment, and Procedural Design. Vice President and Principal Scientist, Anacapa Sciences, Inc.; Santa Barbara, Calif.

Steve Vander Ark, M.S.; BHP, Operational Psychology; Section Manager for Space Medicine, Wyle Integrated Science and Engineering Group; Houston.