NOTE: Element change to Human Factors & Behavioral Performance; previously Behavioral Health & Performance (Ed., 1/18/17)

This proposal addresses these risks and gaps by examining and evaluating existing behavioral health techniques and determining the best practices for addressing behavioral health concerns that could arise on exploration missions where asynchronous communication can be a barrier to delivering real-time behavioral healthcare.

Our final research product comprised several components. The main deliverable is data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques which was a self-guided internet-based cognitive behavioral therapy program (iCBT) in comparison to videoconference-delivered psychotherapy focusing on a behavioral health condition of relevance to spaceflight (i.e., stress, depression, and/or anxiety). The behavioral health techniques examined are evidence-based (i.e., CBT), transdiagnostic in content, and do not consist of new or unvalidated treatments. The RCT was conducted at UCLA (University of California Los Angeles) with high functioning participants (i.e., UCLA Medical Center faculty, residents, medical or dental students, or STEM (Science, Technology, Engineering and Mathematics) graduate students)) who reported current symptomatology (i.e., stress, anxiety, and/or depressive symptoms, and functional impairment). The techniques examined in the RCT were selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health clinicians at NASA Johnson Space Center (JSC) and subject matter experts. We also conducted a systematic review of the literature of behavioral health approaches (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, in comparison to in-person psychotherapy.

The results of our RCT (N=108) comparing iCBT (N=55) to videoconference delivered CBT (N=53) was that both conditions improved on all major outcome measures of symptomatology and functioning with no significant differences between conditions.

Based on information from our reviews and data from the RCT, we formulated a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines comprise implementing an autonomous or self-guided tiered (or stepped) approach to behavioral health care at NASA where users would essentially train and treat themselves with remote support from NASA behavioral health experts. The first step involves training, in advance of a mission, to build resilience by learning and implementing evidence-based skills (e.g., CBT and mindfulness) that ideally can prevent the onset of a behavioral health issue on a long duration mission. Programs such as SMART-OP (Stress Management and Resilience Training for Optimal Performance) developed and evaluated, by this research team, in prior projects would be an example of such training. The second step, if needed, is to treat an issue should it arise using programs/approaches such as those tested in our RCT. The stepped approach should use evidence-based approaches that are transdiagnostic and address the most likely behavioral health issue of concern (i.e., anxiety, depression, stress). This stepped approach to care would encompass pre-mission, mission, and post-mission phases of exploration class missions.

There are many potential challenges and dangers in carrying out human spaceflight. From a behavioral health standpoint, stress and anxiety-related problems, fatigue/sleep disturbance, and interpersonal conflict, are common problems that can arise for those working in operational environments. Such problems, if not addressed in advance via training, can potentially escalate into significant problems (i.e., anxiety disorder, depressive episode, severe sleep disturbance or conflict) that can seriously impact performance, safety, and well-being. Furthermore, exploration missions present unique challenges to addressing behavioral health issues due to communication delays where real-time communication limitations could hamper the delivery of behavioral health support. The NASA Human Research Roadmap (HRR) identifies the following risks involved with human spaceflight relevant to Behavioral Health and Performance: “Risk of Adverse Behavioral Conditions and Psychiatric Disorders; Risk of Performance Decrements due to Inadequate Cooperation, Coordination, Communication, and Psychosocial Adaptation within a Team; and Risk of Performance Errors Due to Fatigue Resulting from Sleep Loss, Circadian Desynchronization, Extended Wakefulness, and Work Overload.” The NASA Human Research Program Integrated Research Plan (IRP) also identified the following potential gaps in training; “BMed1: We need to identify and validate countermeasures that promote individual behavioral health and performance during exploration class missions." “BMed6: We need to identify and validate effective treatments for adverse behavioral conditions and psychiatric disorders during exploration class missions.”

This proposal addressed these risks and gaps by examining and evaluating existing behavioral health techniques and determining the best practices for addressing behavioral health concerns that could arise on exploration missions where asynchronous communication can be a barrier to delivering real-time behavioral healthcare.

Our final research product comprised several components. The main deliverable is data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques which was a self-guided internet-based cognitive behavioral therapy program (iCBT) in comparison to videoconference-delivered psychotherapy focusing on a behavioral health condition of relevance to spaceflight (i.e., stress, depression, and/or anxiety).

The behavioral health techniques examined in our RCT are evidence-based (i.e., CBT), transdiagnostic in content, and do not consist of new or unvalidated treatments. The RCT was conducted at UCLA with high functioning participants (i.e., UCLA Medical Center faculty, residents, medical or dental students, or STEM graduate students) who reported current symptomatology (i.e., stress, anxiety, and/or depressive symptoms, and functional impairment). The techniques examined in the RCT were selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health experts at NASA Johnson Space Center (JSC) and other subject matter experts. We also conducted a systematic review of the literature of behavioral health approaches, (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, and reviewed a selected number of those programs.

The results of our RCT (N=108) comparing iCBT (N=55) to videoconference delivered CBT (N=53) was that both conditions improved on all major outcome measures of anxiety, depression and stress symptomatology as well functioning, with no significant differences between conditions. This suggests that both self-guided iCBT and video-conference delivered CBT are equally effective for addressing anxiety, depression, and stress. Video-conferencing is the current standard of behavioral health delivery on International Space Station (ISS) so this RCT demonstrates that self-guided or asynchronous behavioral health care works as well as the current NASA standard for addressing the most common behavioral health conditions (i.e., anxiety, depression, and stress). Additional qualitative analyses showed that both conditions were viewed as very useful and acceptable and had very good treatment completion rates. This finding is important in addressing prior literature findings of high dropout rates in self-guided behavioral health care studies. The user experience can also impact other barriers to care among the broader population such as stigma, not having access to evidence-based care, or not having time or knowing where to receive such care. Self-guided approaches have unlimited scalability.

Based on information from our literature and program reviews, and data from our RCT, we formulated a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines comprise implementing an autonomous or self-guided tiered (or stepped) approach to behavioral health care at NASA where users would essentially train and treat themselves with remote support from NASA behavioral health experts. The first step involves training, in advance of a mission, to build resilience by learning and implementing evidence-based skills (e.g., CBT and mindfulness) that ideally can prevent the onset of a behavioral health issue on a long duration mission. Programs such as SMART-OP (Stress Management and Resilience Training for Optimal Performance) developed and evaluated, by this research team, in prior projects would be an example of such training. The second step, if needed, is to treat an issue should it arise using programs/approaches such as those tested in our RCT. The stepped approach should use evidence-based approaches that are transdiagnostic and address the most likely behavioral health issue of concern (i.e., anxiety, depression, stress). This stepped approach to care would encompass pre-mission, mission, and post-mission phases of exploration class missions.

NOTE: Element change to Human Factors & Behavioral Performance; previously Behavioral Health & Performance (Ed., 1/18/17)

Our final research product will comprise several components. The main deliverable will be data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques in comparison to videoconference-delivered psychotherapy focusing on a behavioral health condition of relevance to spaceflight (i.e., stress, depression, and/or anxiety). The behavioral health techniques examined are evidence-based (e.g., cognitive-behavioral therapy--CBT), transdiagnostic in content, and do not consist of new or unvalidated treatments. The RCT is being conducted at UCLA with high functioning participants (i.e., UCLA Medical Center personnel or medical students) who report current symptomatology (i.e., stress, anxiety, and/or depressive symptoms, and functional impairment). The techniques examined in the RCT were selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health clinicians at NASA Johnson Space Center (JSC) and subject matter experts. We also conducted a systematic review of the literature of behavioral health approaches, (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, in comparison to in-person psychotherapy. Based on information from our reviews and data from the RCT, we will formulate a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines will comprise behavioral health training and treatment that address pre-mission, mission, and post-mission phases of exploration class missions.

Our progress this year covered several areas, including enrolling participants into the study, randomizing them to the two treatment conditions, and collecting data as they completed either the This Way Up program or the videoconferencing sessions. We renewed our IRB (Institutional Review Board) approvals from NASA JSC and UCLA to conduct the RCT, participated in monthly teleconferences with NASA Human Factors & Behavioral Performance (HFBP) personnel to address various areas of study implementation, and conducted monthly teleconferences with co-investigators from different institutions to maintain regular communication. We implemented our assessment protocols, which included training research assistants in completing assessment procedures. Measures of treatment outcome include three computerized tasks designed to evaluate distress tolerance, willingness to work for reward, and approach and avoidance tendencies, self-report questionnaires assessing areas such as mood, physical symptoms, impairment, emotion regulation, sleep, personality, and demographic variables, and a diagnostic interview pertaining common psychological problems such as anxiety, depression, and substance use. Two research assistants were trained in administration of a psychiatric diagnostic interview (i.e., MINI: Mini International Neuropsychiatric Interview). During and after treatment we also measure therapist alliance, treatment credibility, usefulness, and usability in both conditions. Poster presentations on this project were reported at several scientific conferences.

Participant recruitment is addressed by the UCLA team in collaboration with collaborators at the UCLA Medical School and Medical Center. The study is being advertised via targeted emails and flyers in designated areas in the Medical Center.

We began recruitment in January 2017 and at the time of this report, 260 people have expressed interest in participating in the study, 235 of those have been screened for eligibility, and 127 have met inclusion criteria. Of those, 123 have completed a clinical phone interview and 109 have completed the pre-assessment. So far, 104 participants have been randomized, 51 in the online CBT condition, and 53 in the videoconference condition, and 80 participants have completed the post-assessment. Forty-five participants have completed three-month follow-up questionnaires. Since the 2017 Task Book report we have randomized 64 additional participants. Overall, we have exceeded our pre-study sample goal of N=70. Enrollment will end in May 2018, and our primary data collection phase will conclude in July 2018, with three-month follow-ups continuing until October 2018.

Our final research product will comprise several components. The main deliverable will be data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques in comparison to traditionally delivered psychotherapy (i.e., videoconference) focusing on a behavioral health condition of relevance to spaceflight (i.e., stress, depression, or anxiety). The behavioral health techniques examined are evidence-based (e.g., cognitive-behavioral therapy--CBT) and do not consist of new or unvalidated treatments. The RCT is being conducted at UCLA with high functioning participants (i.e., UCLA Medical Center personnel or medical students) who report current symptomatology (i.e., stress, anxiety, or depressive symptoms). The techniques examined in the RCT were selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health clinicians at NASA Johnson Space Center (JSC) and subject matter experts. We also conducted a systematic review of the literature of behavioral health approaches, (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, in comparison to traditional psychotherapy. Based on information from our reviews and data from the RCT, we will formulate a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines will comprise behavioral health training and treatment that address pre-mission, mission, and post-mission phases of exploration class missions.

Our progress this year covered several areas, including selecting the asynchronous behavioral health treatment program based on an extensive literature review and several evaluations of potential programs conducted the previous year, developing a treatment protocol for matching the asynchronous treatment in the in-person condition, training two advanced clinical psychology PhD students in delivering the treatment to the in-person condition, obtaining IRB (Institutional Review Board) approvals from NASA JSC and UCLA to conduct the RCT, monthly teleconferences with NASA Behavioral Health and Performance (BHP) personnel to address various areas of study implementation, bimonthly teleconferences with co-investigators from different institutions to maintain regular communication, and selecting measures to assess treatment outcomes, and creating assessment protocols, and training research assistants in completing assessment procedures. Measures of treatment outcome include three computerized tasks designed to evaluate distress tolerance, willingness to work for reward, and approach and avoidance tendencies, self-report questionnaires assessing areas such as mood, physical symptoms, impairment, emotion regulation, sleep, personality, and demographic variables, and a diagnostic interview pertaining common psychological problems such as anxiety, depression, and substance use. Two research assistants were trained in administration of a psychiatric diagnostic interview (i.e., MINI: Mini International Neuropsychiatric Interview). During and after treatment we also measure therapist alliance, treatment credibility, usefulness, and usability in both condtions.

Participant recruitment is addressed by the UCLA team in collaboration with associates at the UCLA Medical School and Medical Center. The study is being advertised via targeted emails and flyers in designated areas in the Medical Center. We began recruitment in January 2017 and at the time of this report, 97 people have expressed interest in participating in the study, 87 of those have been screened for eligibility, and 47 have met inclusion criteria. So far, 40 people have been randomized, 20 in each condition, and 14 people have completed the treatment phase of the study. Our final aim is at least an N of 70 participants.

Our final research product will comprise several components. The main deliverable will be data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques in comparison to traditionally delivered psychotherapy (i.e., in-person) focusing on a behavioral health condition of relevance to spaceflight (e.g., stress, anxiety, depression). The behavioral health techniques examined will be evidence-based (e.g., cognitive-behavioral therapy--CBT) and will not consist of new or unvalidated treatments. The RCT will be conducted at the UCLA Psychology Clinic with high functioning participants (i.e., medical center personnel) who report current symptomatology (e.g., stress, anxiety, or depressive symptoms). The techniques examined in the RCT will be selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health clinicians at NASA Johnson Space Center (JSC) and subject matter experts. We will also conduct a systematic review of the literature of behavioral health approaches, (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, in comparison to traditional psychotherapy. Based on information from our reviews and data from the RCT, we will formulate a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines will comprise behavioral health training and treatment that address pre-mission, mission, and post-mission phases of exploration class missions.

• Teleconferences with NASA JSC Behavioral Health Support: We conducted individual teleconferences with all the members of the NASA JSC behavioral health support team including psychiatrists and psychologists. From these teleconferences we learned that the most likely behavioral health concern/problems to occur on a long duration mission are low-grade anxiety/ depression and stress reactions to workload, conflict, and frustration related to crew-ground interactions, family separation issues, and isolation. We also received feedback from psych support personnel on the types of resources they would like to have on a long-duration mission to help aid the health and welfare of the crew. The JSC psych support team said that having a way to monitor and provide feedback on a crewmember’s progress with a treatment program would be helpful. Any behavioral health program would also have to be engaging, succinct, and easy to follow and allow for ground support to get data that could be reviewed and used to form personalized feedback to the user.

• Literature Reviews: Our UCLA team conducted extensive literature reviews addressing the literature on spaceflight and other relevant literatures (e.g., military) to assess state of current treatment approaches and most likely behavioral health problems. We also reviewed the literature on evidence-based treatment programs that could be used in an asynchronous communication environment.

• Program Reviews and Evaluation: We then reviewed various programs for possible inclusion in our study. The programs had to have an evidence-based content approach, have a structured approach to treatment (i.e., clear session by session content), be succinct, engaging, and easy to follow. We also were looking for programs that have been tested on various populations including those who had low levels of symptomatology and varied backgrounds in terms of employment and education. Lastly the program had to have a transdiagnostic treatment approach so it could be used to treat anxiety, depression, or stress. We narrowed our review of 20+ programs down to 4 and individuals who were not familiar with these types of programs use and evaluate them on usability and acceptability. Based on all of our reviews we selected the Worry and Sadness program created by Dr. Gavin Andrews and his team in Australia. A fortunate synergy at UCLA occurred in that the same program has been incorporated into UCLA Depression Grand Challenge – a major and ambitious undertaking to address and eliminate the burden of depression by the end of this century. This gives us the opportunity to join with other campus efforts to bring about this treatment to the broader campus community. As part of that effort the creators produced a special and updated version of the Worry and Sadness program for US audiences and we have access to that version.

• Treatment Conditions: half the sample will be randomized to the self-guided condition that will “treat” themselves on the Worry and Sadness program. The program consists of 6 weekly sessions of approximately 45 minutes each. Participants in that condition will receive weekly text and email reminders about sessions and homework practice as well as feedback on their progress. They can complete their sessions and a place and time of their choosing. Half the sample will be randomized to the videoconferencing condition. Participants of that condition will receive 6 weekly “in-person” sessions delivered by advance therapists in the UCLA Clinical Psychology doctoral program and supervised by the principal investigator and matched for time and content to the Worry and Sadness Program.

• Assessment Protocol Creation: We have created an extensive yet efficient assessment protocols to provide us subjective and objective data on major outcomes related to anxiety, depression, stress, and factors related to those conditions.

• IRB Protocol Creation: We have obtained UCLA IRB (institutional review board) approval. We have also created and submitted an IRB protocol at NASA for review and approval.

• Team and NASA Teleconferences: We have had biweekly teleconferences with members of our team at UCLA (Co-Investigator Dr. Craske) and those located elsewhere (Co-I Peggy Wu and consultant and former astronaut Mike Foale) have provided their expertise and feedback to the formulation of our study content and procedures. We have also had monthly teleconferences with members of NASA BHP team to update them on our progress.

• Coordination with research group at Stonybrook: We were asked by NASA BHP to coordinate, where possible, our work with another group of researchers who are working on similar research (Dr. Adam Gonzalez team at Stonybrook Univ). Where possible we are sharing assessment protocol suggestions to create similar avenues of assessing outcome data.

Our final research product will comprise several components. The main deliverable will be data from a randomized controlled trial (RCT) examining the efficacy, feasibility, and acceptability of asynchronous behavioral techniques in comparison to traditionally delivered psychotherapy (i.e., in-person) focusing on a behavioral health condition of relevance to spaceflight (e.g., stress, sleep/fatigue, conflict). The behavioral health techniques examined will be evidence-based (e.g., cognitive-behavioral therapy--CBT) and will not consist of new or unvalidated treatments. The RCT will be conducted at the UCLA Psychology Clinic with high functioning and healthy (i.e., no psychiatric or medical disorders) participants who report current symptomatology (e.g., stress, low-level anxiety, or depressive symptoms). The techniques examined in the RCT will be selected, in part, by conducting a comprehensive review of current standards of behavioral health practice for spaceflight, including consultation with behavioral health clinicians at NASA Johnson Space Center (JSC) and subject matter experts. We will also conduct a systematic review of the literature of behavioral health approaches, (e.g., computer-guided, bibliotherapy, smart phone apps) suitable for use in an asynchronous communication environment, in comparison to traditional psychotherapy. Based on information from our reviews and data from the RCT, we will formulate a “best practice guidelines” for addressing behavioral health issues of relevance to exploration missions where communication delays are a concern. The best practice guidelines will comprise behavioral health training and treatment that address pre-mission, mission, and post-mission phases of exploration class missions.