Nick Kanas, MD

Collisions with space debris, equipment malfunctions in the space vehicle, bodily fluid shifts and muscle and bone loss due to microgravity, isolated and confined conditions, and interpersonal conflicts among crew members . . . these are all potential stressors for astronauts during space missions-and they present uniquely 21st century psychiatric and psychological issues. Let’s look at some of the mental health issues involved with manned spaceflight, which will become even more important as less well-screened and trained tourists go into space.

Psychiatric problems during space missions

A number of psychiatric problems have been reported during space missions.

 The most common are adjustment reactions that generally present with symptoms of anxiety or depression. One experienced astronaut who was starting a long-duration on-orbit mission became depressed because of the isolation he felt and his separation from his family. These symptoms resolved as he adjusted to his new environment.

Psychosomatic reactions have also been described. One on-orbit cosmonaut wrote in his diary that he experienced tooth pain following anxious dreams he had of a tooth infection, and he began obsessing that nothing could be done about such an infection should it occur.

Problems related to major mood and thought disorders (eg, bipolar disorder, schizophrenia) have not been reported during space missions. This is probably because potential astronaut candidates are screened for predispositions to these psychiatric conditions. However, these syndromes have been reported in up to 5% of less well-screened people working in space analog environments, such as submarines and Antarctic bases, which might have implications for future space tourists.

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Russian psychologists and flight surgeons have reported the existence of “asthenization,” a type of adjustment reaction related to the concept of neurasthenia.

 Symptoms include fatigue, irritability, emotional lability, attention and concentration difficulties, restlessness, heightened perceptual sensitivity, heart palpitations and blood pressure instability, and sleep and appetite problems. A number of countermeasures have been developed to deal with it, such as increasing the frequency of communication between affected space travelers and family members on Earth, and sending up surprise presents and favorite foods on resupply ships to improve morale. The empirical evidence for asthenization is somewhat equivocal, but there is support for the notion that it may be a culturally specific syndrome.

 More research needs to be done to evaluate its clinical characteristics and frequency during space missions.

Psychoactive medications have been available to crew members during space missions. The formulary on Space Shuttle flights included antianxiety medications, such as diazepam; antipsychotic medications, such as haloperidol; pain medications, such as codeine and morphine; medications for sleep, such as flurazepam and temazepam; stimulants, such as dextroamphetamine; and promethazine for space motion sickness.

 In one study, it was found that 78% of Space Shuttle crew members had taken medications in space, primarily for space motion sickness (30%), headache (20%), insomnia (15%), and back pain (10%).

 Newer psychoactive medications (eg, olanzapine, risperidone, SSRIs) also were included on some flights, and similar medications have been used during Russian space missions.

The pharmacokinetic characteristics of psychoactive drugs can be altered by physiological changes due to microgravity (

Such effects can influence medication dosage and route of administration. Medications that are variably absorbed by the gut, such as chlorpromazine and flurazepam, and medications whose metabolism is influenced by first-pass effects, such as many antidepressants, are especially vulnerable to these changes.

 In addition, when intramuscular medications are required in space, it may be better to give them in the arm rather than in the hip because of upper body fluid shifts.

It is important to monitor mediation use in space. During one Russian space mission, the commander took too many sleeping pills without informing physicians in mission control, and he consequently experienced a number of problems.

My colleagues and I conducted 2 NASA-funded studies of psychological and interpersonal issues affecting crew members and mission control personnel. One study took place on the Russian Mir Space Station, and the other on the International Space Station (ISS).

 A total of 30 astronauts and cosmonauts and 186 American and Russian mission control personnel took part during space missions lasting 4 to 7 months. The findings were similar in both studies. There were no significant changes in level of crew member mood and group interpersonal climate over time. There was significant evidence that suggested the displacement of crew tension outwardly to mission control personnel on Earth. Crew cohesion correlated positively with the supportive leadership role of the mission commander. These findings have recently been replicated in a lunar station analog study in China.

We also looked at cultural issues in our Mir and ISS studies. Crew members scored higher in terms of experience with other cultures compared with mission control personnel. Americans reported significantly more work pressure than Russians in both studies and less tension during the ISS missions. Both national and space agency organizational factors were implicated in these differences.

Other researchers have studied psychological issues that affect astronauts and cosmonauts. Gushin and colleagues

 found that space crews showed decreases in the scope of their communications and a tendency to filter what they said to outside personnel, and they interacted more with some individuals than others in mission control.

 surveyed 75 astronauts and cosmonauts and 106 mission control personnel and found that both groups rated coordination conflicts between space organizations as the biggest problem that affected their missions. Other issues included miscommunications due to simple misunderstandings, differences in language and work management styles, and communication difficulties between mission control personnel and their support teams.

Eleven cosmonauts were surveyed to gain their perspective on possible psychological problems during an expedition to Mars.

 Issues mentioned included isolation and monotony, distance-related communication delays between the crew and people on Earth, differences in space agency management style, and cultural problems resulting from the international makeup of the crew.

A survey of 576 employees of the European Space Agency was undertaken to look for important cultural issues that could affect performance. A positive link was found between experience with other cultures and ability to work with employees who were from different countries.

Finally, a content analysis of personal journals from 10 ISS astronauts showed that 88% of the entries dealt with the following: work, outside communications, adjustment, group interaction, recreation/leisure, equipment, events, organization/management, sleep, and food.

 The participants reported that their life in space was not as difficult as they had expected prior to launch.

Traveling in space can be a positive experience. Some astronauts and cosmonauts have reported transcendental experiences, religious insights, or a better sense of the unity of mankind as a result of viewing the Earth below and the cosmos beyond.

 In his diary, cosmonaut Valentin Lebedev noted that photographing the Earth from the Salyut 7 Space Station was a restful and stress-reducing experience that seemed to help him cope with the stress he was feeling because of his crewmate.

In a survey of 54 astronauts and cosmonauts who had flown in space, the participants rated the positive excitement they felt about their mission to be one of the main factors that enhanced communication between them and mission control personnel.

 In a follow-up study, my colleagues and I surveyed 39 astronauts and cosmonauts who had flown in space.

 All respondents reported at least some positive change as a result of their experience. Observing the beauty of Earth from space was a significant positive factor for them, and this experience sometimes led to lifestyle alterations after they had returned home.

Based on the findings above, a number of countermeasures are suggested for future space missions. Crew members should be selected who are sensitive to psychosocial issues. They need to be able to monitor their feelings and engage in problem-solving activities around interpersonal difficulties. Crew members (including space tourists) and mission control personnel need to receive pre-launch psychosocial training.

During missions of long duration, both groups should take computer-based psychosocial education refresher courses to remind them of key issues discussed prior to launch. Periodic “bull sessions” should be scheduled to allow crews the opportunity to discuss and deal with stress before it begins to fester. Crew members need to have leisure time and window space available to view or photograph the Earth. Private contact with family and friends on Earth should be facilitated. Finally, post-return re-adaptation debriefings and supportive activities need to be utilized to help crew members and their families readjust to life together on Earth. Psychiatric counseling should be available when indicated, both during and after the mission.

 Two astronauts-Scott Kelly and Mikhail Kornienko-returned to Earth this past March after an historic 340-day mission aboard the International Space Station. During their mission, the American and Russian took part in, among many other things, research about the stress of long-duration spaceflight. We therefore thought that an article on psychiatric issues in space was especially timely, and we thank Dr. Kanas for his insights into the unique psychological, physiological, and pharmacokinetic aspects of space flight. We also honor Commander Kelly and Flight Engineer Kornienko and the courageous men and women who continue to advance the exploration of deep space.

Dr. Kanas is Professor Emeritus (Psychiatry), University of California, San Francisco. He was a NASA-funded Principal Investigator, has over 200 publications, and is the author of Humans in Space: The Psychological Hurdles (Springer, 2015). In 1999, Dr. Kanas received the Aerospace Medical Association Raymond F. Longacre Award for Outstanding Accomplishment in the Psychological and Psychiatric Aspects of Aerospace Medicine, and in 2008, he received the International Academy of Astronautics Life Science Award. He reports no conflicts of interest concerning the subject matter of this article.

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Articles

The many potential stressors for astronauts during space missions present unique and fascinating 21st century psychiatric and psychological issues. 

Nick Kanas, MD

Articles

Psychiatric Issues in Space