Mental health in space

Mental health in space

Astronauts’ physical health is important, but so is their mental health. Human missions in space have a tendency of being longer and longer and given the upcoming long-term manned missions first to the Moon and later to Mars, there will be an increasing need to ensure that astronauts not only survive their missions, but that they also thrive while missions go on.

Astronauts live in a non-stimulating stressful environment when they are in space. The idea with the current project is on a regular basis and for a few minutes to virtually (Using HQ film and HQ audio) take the individual astronaut out of this stressful environment and put them in a place, which in their mind is safe and implies complete relaxation and joy.

Change the physical presence at the station or habitat to a virtual presence, with as close as possible sense of being in a different place for real.

For many years intense research have been done on earth to develop methods and tools to treat the effects of stress. Virtual Reality for Mental Hygiene (VRMH) is now a proven and well documented technology on earth for positive stimulation of the brain to provide maintenance of the mental health and to produce countermeasures for long term stress situations, anxiety etc.

The consortium is proposing a technology based on an extremely well proven and documented VR system and analysis tool, but further developed and tailored for the individual astronaut to ensure maximum benefit for the time invested. The enhanced system is called VAMB (Virtual Assistance helps Mental Balance)

VAMB is proposed as a tailored and holistic gateway to maintain and improve the astronaut’s mental health, which eventually also will have a positive impact on their physical well-being and performance:
1. I.e. VAMB is adapted to the astronaut’s specific needs by including VR environments tailored to them: family, home, etc.
2. VAMB is the first time, astronauts will maintain their mental health using VR.
3. VAMB will document the effect of the system by capturing several measurements. (Skin response, heart rate variability and questionnaire)

Not until in the recent years the portability, the image quality and the sound quality of the VR units have been improved to a level which now gives an all most 360 deg. live feeling. At the same time the cost of the units has decreased to a very affordable level. This give much higher flexibility for the users and the technology have an extremely high potential for helping to relief mental health issues on a much more global scale than seen in the past.

We are taking care of our astronauts physical health… what happens with their mental health?

Justification for Need of Space Conditions
We have learned over the past 60 years, that humans can survive living on space stations in low Earth orbit (LEO), or spend time exploring the moon for shorter periods, but to colonize the moon or other worlds present unique challenges, not only in terms of surviving, but also in terms of thriving.

Until now, space travel has usually been limited to a few weeks or a few months. In the future, man will be in space for several years at a time. That is another challenge. A challenge that requires us not only to train and take care of the astronauts’ physical health, but also to ensure their mental well-being.

Earth has all the ingredients to protect and sustain life, not only physically, but also psychologically. Exploration missions that leave the Earth’s protective sphere, will have to overcome many challenges, from conditions in space. This includes issues like cosmic radiation and other hazardous environments and provides huge challenges of building and using habitats in space, which forces architects, engineers and users to really think out of the box. Main focus is rightfully on the mission to survive, but to survive on the long run also implies that the psychological health needs to be maintained and intact.

Space exploration is more than seeing what is beyond the horizon. Exploration also helps us to understand more about our planet, our solar system, our universe, and last but not least ourselves. At the very core of human space exploration is the desire to explore the unknown and extend human presence deeper into the solar system. First to the Moon before 2030 and then later to Mars maybe around 2040

Such, long-distance and long-duration space expeditions will in the future give rise to different types of challenging tasks on how to maintain mental health by the crew members. Isolation and confinement during long-time space missions and the fact that crew members are forced to interact with each other in a small space will have significant influence on the mental health of the crew members.

On earth the expeditions and exploration of Antarctica and cave environment have been a useful analog to space expeditions. Studies have shown, that living in such a hostile and confined environments have a significant effect on mental health. The pattern of symptoms could resemble sub-clinical depression, including so-matic symptoms as fatigue, headaches and disturbed sleep patterns as well as psychological symptoms such as impaired cognition, anxiety, anger, and irritability.

There is a need for addressing how psychological and interpersonal distress can be reduced in future long-distance and long-duration space expeditions. One way to achieve this goal is to look at the nature of the human brain and to recognize that the modern human brain is a product of a long evolution, admirably adapted to the life on earth and not to the confinement, isolation and machine environment that will characterize long-distance and long-duration space expeditions in the near future.
The human brain and the different substructures of the brain, reflects the evolutionary period where it was built. Different parts of the brain have different abilities and functions and therefore affects our experiences and how we cope in different situations. Structurally, the human brain has not changed much the last 50.000 years.

The less evolved part of the human brain, the reptilian brain, is concerned with territory, food, reproduction and survival. The more evolved mammalian brain is concerned with living in groups, hierarchy, status and caring. The most evolved part of the human brain is concerned with extended care-giving, attachment and thinking.

These different parts of the brain are linked to our three major emotional regulation systems.
• the threat system,
• the drive system and
• the soothing system,

Each of the emotional regulation systems are associated with distinct feeling-states, motivations, behaviors, neurotically and neurochemistry. Healthy functioning requires adaptive use of all three systems in appropriate measure. Dysfunction come about because of limited flexibility, or over-use of one system to the detriment of others.

The threat system. . . When the threat system dominates our minds, we have a mindset focused on seeking protection from dangers and are motivated for survival. Our emotions are about fear and anxiety, and our physiology is characterized by elevated arousal/stress, and the behavior is dominated by struggle, flight or submission.

The drive system . . .The system has two purposes:
1) to motivate us to achieve desired objects and goals, and
2) to reward us when we have achieved what we wanted.

It is the basis for the development of desire and aspiration. When this system is active, we are motivated to compete or work together to achieve a common goal. Our emotions are positive and motivated, and our physiology is awakened with behavior dominated by focus on the goals. Prolonged over activation of the drive system can lead to stress and burnout.

The soothing system. . .This emotion control system is closely linked to the experience of safety and attachment to people and a places where one belongs and feels comfortable and reassured. When the system is active, we are motivated to care for ourselves and others. The system helps us to find peace, be relaxed and open to others.

It can reduce and regulate the activity of both the threat and drive systems. The emotional experiences that man gets when the soothing system is activated are about satisfaction and peacefulness. The stress related activity in our nervous system is reduced as there is an activation of the parasympathetic nervous system and we calm down. This reduces our alertness, which helps to reduce any activity in the threat system. This reduction means that we no longer feel stressed, unsafe, vulnerable, or threatened.

The three emotional regulation systems are connected to the human autonomic nervous system. The treat system and drive system are mainly connected to the sympathetic nervous system and the soothing system is mainly connected to the parasympathetic nervous system.

The sympathetic nervous system is responsible for the fight or flight response. In the first moment after a stressor occurs it stimulates the hypothalami pituitary adrenal axis (HPA axis). The HPA axis is responsible for the neuroendocrine adaptation component of the stress response. The response is characterized by secretion of cortisol, adrenaline, and nor adrenaline. It increases pulse, breathing and cardiovascular efficiency, dilates the bronchioles and pupils. It also divides fat into fatty acid and glycerol, breakdowns glycogen stored in liver to glucose, causes outflow of blood from limbs to muscles, heart, and brain, and stops digestion.

All this to prepare the body for a fight or flight response. At a certain blood concentration of cortisol, adrenaline, and nor adrenalin, this protection response is achieved, and there is negative feedback to the HPA axis and systemic homeostasis returns.

Emotional Stimulation of the nervous system using VR (illustration by Washington post)

The parasympathetic nervous system is responsible for the body’s rest and digestion response in which the body is relaxed, resting, or feeding. The parasympathetic nervous system decreases respiration and heart rate and increases digestion. It basically undo the work of sympathetic division after a stressful situation.

Our sympathetic nervous system is designed to help us to survive in life-threatening emergencies but if we spend too long in this heightened stat of sympathetic activation, there will be negative consequences on our health. We will become exhausted, unsettled, experience cognitive decline, experience poor sleep and the immune system will be compromised. In the long run this repeated exposure to stressors and activation of the sympathetic nervous system, will also cause that the organism habituates to the stressor with repeated and sustained HPA activation.

Therefore, it is important to support a healthy balance between sympathetic and parasympathetic activation. One way to achieve this, is through the activation of the soothing system and thereby activation of the parasympathetic nervous system. Our soothing system can be activated in various ways e.g., through positive interaction with other humans, slow-breathing, mindfulness, yoga, body awareness therapy, positive self-talk/letter writing and visualization exercises.

Further, specific stimulation of our senses, in particular our tactile and proprioceptive, but also our visual and auditive senses, have been found to activate the parasympathetic nervous system [RD-5],[RD-6]. Hence, the use of VR is an excellent tool for the activation of the parasympathetic nervous system and therefor use of VAMB will have a stabilizing effect on the nervous system in general and promote both mental and physical health of the astronaut.

Earth Benefits
The experiences and the measurement results from VAMB will feed directly into the science community who are working on improving VRMH to help one of modern society’s biggest problems – Stress. Both for the maintenance of the mental health, but also for the benefit of all people with psychological health issues like mild or severe stress, anxiety, PTSD, ADHD etc. etc.

The effectiveness of VR for treating mental conditions was reported for the first time in 1995 [RD-16]. Since then, the interest in using it for psychotherapy has increased over the years. Current data demonstrate that VR can produce significant behavior change in real-life situations and support its application in different treatment processes. Turning it into a potential tool to enhance care of a wide range of cognitive and affective disorders. Actually, VR interventions are also available to treat a variety of psychological disorders and behavioral issues; anxiety, schizophrenia, substance-related or addictive disorders (drug, internet gaming, eating, alcohol), post-traumatic stress disorder… While there is still a need for additional immersive scenarios to target more disorders, VR has shown the potential to transform the assessment, understanding and treatment of mental health problems.

Evolution of clinical application papers on the benefits of VR for mental health

After more than 25 years of research, the effectiveness of VR, especially for Exposure Therapy (ET) supported by virtual reality (VRET), is weell-established. VRET technologies exceed imaginative exposure by adding a sense of presence. Independent meta-analyses so far, have concluded that these interventions lead to a significant decrease of anxiety and mental health symptoms. There are also studies that determined the safety and efficacy of VRET in PTSD patients that have not responded to previous treatment and in enhancing the treatment of fear of COVID-19 and associated anxiety disorder. Additionally, during a VRET session, wearable devices allowed the assessment and monitoring of bio-signals (heart rate or galvanic skin response) in real time. Due to these advantages, VRET is one of the most powerful treatment modalities’ that overcome the limitations of conventional therapy.

To date, sufficient evidence has accumulated to support the benefits of VR for a variety of assessment purposes in mental health. VR elicits similar psychological and physiological reactions to real-world environments, extending the reach of current assessments beyond the lab or clinic. Empirical evidence indicates that the use of VR allows, in case of achieving a high immersion in the scene, the reduction of painful and anxious sensations in a very effective way.

Indeed, VR has demonstrated to be particularly useful for repeating the exposure to feared situations as many times as necessary, preventing panic attacks and reducing the risk of reinforcing the existing fear, which is helpful to treat phobias.

Superior capabilities for experimental manipulation and controlled exposure improve methodological rigor, as well as enable more accurate and individualized assessment in the field of mental health. Moreover, VR is considered a reliable tool that can help to manage low-intensity depression symptoms using evidence-based Cognitive Behaviour Therapy (CBT) techniques: Behavioral Activation, Social Skills Training and Physical Activity, Cognitive Restructuring and Positive Affect Training. There is also evidence that demonstrates the effectiveness of VR as an exposure therapy to reduce the desire or impulse associated with food and normalize eating patterns.

VR experiences reveal important insights that improve the understanding of mental health conditions and inform clinicians how to approach the process with each patient. VR tools applied to the evaluation and intervention of neurodevelopmental disorders (NDD) have shown to improve behaviour and cognitive function. It also appears to be a good adjuvant tool for obsessive compulsive disorder (OCD) patients.

The opportunities and challenges of VR are important to harness this technology to improve mental health outcomes. Advances in hardware, software, and research evidence have progressed in recent years; thus, the reliability and validity of VR environments to improve social functioning, cognition, and symptomatology of different mental conditions has been demonstrated.

VR environments have proven to be a valuable tool for public health and mental health. Including VR applications in psychotherapy offers a series of advantages. VR covers the possibility of adjusting virtual environments to each patient’s specific needs, controlling the parameters to modulate the environments that patients are immersed in. Moreover, VR enables the therapist to expose the patient to conditions that might be unsafe or only accessible at high cost in the outside world, and to improve confidentiality by avoiding spectators. Furthermore, therapists consider VR exposure to be less aversive than in-vivo therapy. Presumably, the same applies to patients. For instance, another study showed that only 3% of 150 participants suffering from specific phobia refused VR exposure, while 27% refused in-vivo therapy.

Considering all, VR is a tool that provides a greater flexibility (in terms of intervention time), considerable cost effectiveness, significant patients’ acceptance (less drop-outs and an improved adherence to treatment) and an increased ability to tailor interventions to individual preferences and characteristics. These properties of the VR, could greatly increase access to psychological therapies.

Over 5% of European citizens suffer from phobias or anxiety disorder. Left untreated, these mental disorders can progress and severely limit daily life, participation in society, and eventually lead to isolation, depression and substance abuse.

One method of anxiety and phobia treatment is the use of imaginative techniques, in which the patients use their imagination to place themselves in a anxiety-triggering situation. However, the effectivity of this technique is highly dependent on the imaginative capacity of the patient: if a patient cannot (or deep down does not want to) create an accurate mental representation of the feared situation, the treatment will not be successful. Moreover, relying solely on the imagination means that there is no sensory stimulation like auditive or visual input, further reducing the effectivity of the treatment. Lastly, with imaginative techniques, the therapist has no direct connection to the experience the patient is having, leaving the therapist in the dark and not able to control the therapy. These factors result in a low sense of progress for the patient, which subsequently means high dropping rates.

Next, the use of exposure therapy to treat mental conditions has demonstrated to be very effective. However, it is currently not widely used by professionals as it often requires extensive logistics to execute such a therapy, which means a heavy workload for the treating therapist (ET is most effective after 15+ weekly sessions) as well as high costs for the healthcare payer. In addition, patients often get anxiety by just thinking about their future ET sessions, resulting in a number of patients quitting prematurely.

As current treatment techniques have high dropping rates and/or come with high costs and high strain on the mental health sector, the majority of people suffering from phobias or anxiety disorder are therefore underserved in their need for an appropriate therapy. The strain on the European Mental Health systems therefore increases, and subsequently the strain on the therapists within these systems.

VR-based ET solutions overcome these challenges as here the fear stimuli are presented to the patient in a VR instead of in reality. In current VRET which are performed in the therapists office, patient feedback is collected by observing the patient and asking them how they feel about their progression, and is therefore highly subjective. Therapists have to invest a substantial amount of time in observing and reporting patient response and elaborating on the suitable continuation of the therapy plan. Moreover, the subjective patient feedbacks also results in inaccurate assessment and, consequently, a suboptimal treatment plan.

In addition, the effectivity of VRET is heavily dependent on the sense of presence in the environment. Current VRET solutions offer low quality content, with no possibility for interaction with the virtual environment. This significantly reduces the efficiency of the therapy, and undermines the potential of VRET.

To maintain the mental well-being of astronauts and counteract stress is the ultimate test of VR`s potentials. Astronauts are role models and frontrunners. Therefore, their use of Virtual Reality is one way of getting people to recognize the potential of VR.

VR for mental health care and stress prevention is likely to become an essential tool for stress relief and treatment of other mental health issues. VRHM and thereby VAMB will become key elements to help solving one of UN’s key SDG’s and thereby save communities very very large sums.

Space Benefits
Much has been learned from experiences on the International Space Station about important psychological, interpersonal and psychiatric issues that affect people working on-orbit. This information should be incorporated in the planning for future longterm manned space exploration missions like the Lunar Gateway or later to Mars. VAMB could be a tool to help these issues which are further described in detail in the following.

A number of psychiatric problems have been reported during on-orbit space missions. Most common are adjustment reactions to the novelty of being in space, with symptoms generally including transient anxiety or depression. Psychosomatic reactions also have occurred, where anxiety and other emotional states are experienced physically as somatic symptoms. Problems related to major mood and thought disorders (e.g., manic-depression, schizophrenia) have not been reported during space missions so far, but it is very likely to see these effects as the missions are longer and longer.

The fact that this has not been reported at this point is likely is due to the fact that crew members have been screened psychiatrically for constitutional predispositions to these conditions before launch, so the likelihood of these illnesses developing on-orbit is low.

Possible VAMB Application environments (illustrations from NASA)

Post-mission personality changes and emotional problems have affected some returning Astronauts. These have included anxiety, depression, excessive alcohol use, and marital readjustment difficulties that in some cases have necessitated the use of psychotherapy and psychoactive medications.

If the mental health had been prioritised to the same level as the physical health this would probably not have been the case.

Some astronauts have had difficulties adjusting to the resultant fame and media demands that followed their missions, and similar problems are likely to occur in the future following high-profile expeditions, such as a trip to the Moon or later to Mars.

Fatigue, irritability, emotional lability, attention and concentration difficulties, and appetite and sleep problems, has been reported to commonly occur in cosmonauts by Russian flight surgeons. Again the use of VAMB could be an effective tool to relief such symptoms if used on a regular basis like the physical health is maintained with exercises on a regular basis.

Research to date into human psychological and sociological effects based on on-orbit near-Earth experiences may have limited generalizability to a long-distance, multi-year space expedition, such as a long-term mission to the moon or to Mars. In the case of Mars, new stressors will be introduced due to the great distances involved in journeying to the Red Planet.

For example, the crew members will be relatively autonomous from terrestrial mission control and will need to plan their work and deal with problems on their own. They are expected to experience significant isolation as the Earth becomes an insignificant bluish-green dot in the heavens, the so-called Earth-out-of-view phenomenon.

From the surface of Mars, there will be two-way communication delays with family and friends back home of up to 44 minutes, as well as low-bandwidth communication channels, adding to the sense of isolation. Having the opportunity to use VAMB would form an excellent opportunity to “escape” from this isolation for a little while.

There are a number of psychosocial and psychiatric issues that may affect crew members during an expeditionary mission to Mars. In terms of selection, only a subset of all astronaut candidates will be willing to be away from family and friends for the two- to three-year mission, so the pool of possible crew members will be restricted and possibly skewed psychologically in ways that cannot be foreseen.
Little is known about the physical and psychological effect of long-duration microgravity and the high radiation that occurs in deep space. In addition, on Mars the crew members will be subjected to a gravity field that is only 38 percent of Earth gravity, and the effect of this situation on their physical and emotional well-being is unknown.

Given the long distances involved, the crew must function autonomously and develop their own work schedules and solve operational emergencies themselves. They must also be able to deal with medical and psychiatric emergencies, such as physical trauma due to accidents as well as suicidal or psychotic thinking due to stress and depression.

There will be a great deal of travel time during the outbound and return phases of the mission, and occupying it meaningfully and flexibly may be a challenge. Hence, the use of VR to maintain the mental wellbeing is a flexible, cheap and easy tool to use.

Furthermore, during on-orbit or lunar missions a number of interventions have been implemented successfully to support crew member psychological well-being. These have included family conferences in real time (i.e., with no appreciable delays), frequent consultations with mission control, and the sending of gifts and favorite foods on resupply ships to enhance morale.

Such actions have helped to provide stimulation and counter the effects of isolation, loneliness, and limited social contact. But with the delays in crew-ground communication and the inability to send needed resupplies in a timely manner due to the vast distances between the habitats on Mars and Earth, the currently used Earth-based support strategies will be seriously constrained, and new strategies will be needed.

Finally, since gazing at the Earth’s beauty has been rated as the major positive factor of being in space, the experience of seeing the Earth as an insignificant dot in the heavens may enhance the sense of isolation and produce increased feelings of homesickness, depression and irritability. VAMB with the correctly selected and personalised 360 deg films would be an excellent tool to provide countermeasures for these issues and ensure the astronaut keeps His/Her focus without jeopardising the mission.

Stress costs the world enormous losses and causes great human suffering on Earth and if we do not act now, this will also be the case during the long stays in Space. The ambition is to show that with the right virtual reality setup we can help astronauts to maintain their mental balance and avoid stress in an extremely stressful situation.

Not only is VR considered as a possible treatment for stress and other mental disorders, but to a large extent also as a great opportunity to prevent stress and maintain the mental health. Space travel is the most extreme test under the most extreme conditions.

Andreas Mogensen (illustration from ESA)

Further, Astronaut are role models for us who must remain on Earth. If the Space Exploration experts and Astronauts recognize the importance of maintaining the Astronauts mental health and avoid stress by using VR. The people on earth will recognize it as a powerful tool to avoid it, and lead to far more widespread use of VRHM for the benefit of mankind.

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