Depression can present a threat to long-duration space missions, and crews need the ability to manage it effectively. The primary objective of this study is to develop a self-guided interactive multimedia program that is capable of facilitating clinical improvement in persons with depression when used in an entirely self-help format. Software that has been developed through this study enables evidence-based treatment for depression to be made available to astronauts at any time and in any location. It can be used autonomously or in combination with other medical resources.

Original aims of Project

1. Complete development of a training module to recognize and prevent depression.
2. Develop a module for implementing computer-based Problem-Solving Treatment (PST) which is an evidence-based treatment for depression.
3. Evaluate the efficacy of the computer-delivered PST module for depression in a randomized, controlled trial.

Aim 2
The end product is a six-session interactive media program in which users are guided step-by-step through a full course of PST. Each session involves a coach (Dr. Mark Hegel) who appears in numerous video and audio clips to help users proceed through the stages of the treatment. The program was designed to exercise a form of clinical judgment by helping users troubleshoot ways to improve their work on particular problems. The program also tracks nine variables which are utilized to analyze the users work across sessions and problems as well as to give suggestions on how to improve their general problem-solving success. This work has resulted in what appears to be the most sophisticated self-help program ever developed, in terms of media usage and data handling. It includes 247 audio and 160 video files to tailor the PST session to the individual.

Aim 3
This aim was addressed via a randomized clinical trial pilot study which compared the PST program to a 7-week waitlist control condition. Originally, planning was to include 68 persons with minor depression for the study. However, the time required to complete development of the PST intervention program precluded enrolling this number of participants. Therefore, 14 persons were enrolled in a pilot study (7 in the experimental group and 7 in the control group). The mean age of participants was 50 years, and all had completed at least four years of college, making them somewhat analogous to the astronaut population. The primary outcome was depression, as measured via the Hamilton Depression Inventory (HDI). No differences were found between groups on the HDI at pre-test.

We partnered with another NSBRI study (PI: Dr. Gary Strangman) by sharing some participants. Participants were to be evaluated via magnetic resonance imaging (MRI) and near-infrared spectroscopy at three points: pre-treatment, mid-treatment (between sessions 3 and 4) and post-treatment. Unfortunately, MRI malfunctions and scheduling problems caused two of the seven participants assigned to the experimental group to have a 4- 9 week lapse between sessions 3 and 4. Because our studys procedures called for participants who lapse for more than 3 weeks between sessions to be removed from the study, data from these two participants were not included in the final analysis. However, we did, allow them to complete the final three sessions, since they wished to continue and had not caused the lapse of time. Also, one control group participant dropped out, leaving six in that group.

Percent change was compared using Kruskal-Wallis Chi Square at pre- and post-treatment for the experimental group and at pre- and post- of the no-treatment period of seven weeks for the control group. A 52.65 percent reduction in depression was found for the five experimental group participants, whereas an 11.12 percent reduction was found for the control group. The difference in percent change was significant (p<.04), and an extremely high effect size was found (Cohens d=1.73).

It is notable that if data from the two persons who lapsed longer than two weeks is included, the percent change is not significant, which suggests that if the treatment is used as recommended (i.e., with no more than a 3-week lapse between sessions), it is likely to help. If not used as recommended, it is unlikely to help. It is also notable that no subjects ever no-showed for a scheduled PST session with the software.

Impact of Findings
This study did address the original specific aims, although the final number of participants enrolled was fewer than originally planned. The program shows strong promise as a new intervention but requires further validation in a larger sample.

Proposed Research Plan for Coming Year
We plan to conduct a large-scale, randomized trial of the PST programs efficacy. We anticipate that this pilot data and the novelty of the treatment will provide strong support for such an application. If it is found to be efficacious in a larger trial, the program could be validated in a space analog setting and ultimately used on long-duration missions. Additionally, it could provide an immediate public health benefit across the United States.

Earth-based Applications of Research Project
The depression treatment program developed through this project has the potential to help individuals receive an evidence-based treatment for depression who would otherwise not have access to it. Worldwide, depression is now the leading cause of disability, and in wealthier nations such as the U.S., mental health disorders account for four of the ten leading causes of lost productivity. A recent study of over 60,000 employees of large American companies found that 45 percent have high levels of psychological distress but that only 22 percent of them are receiving treatment. The annual cost to the U.S. in unearned income due to mental health disorders is $193 billion. Nonetheless, successful treatment of mental disorders generally returns individuals to functioning that is comparable to those who have no history of mental health problems.

Effective, evidence-based treatments for depression do exist. However, there are major barriers to their widespread dissemination in the U.S. including cost, transportation, availability, logistics, stigma and training. The cost of behavioral health and psychiatric care is often borne directly by consumers and is prohibitive for those with limited income. Moreover, the availability of services is limited, and many Americans lack adequate access to behavioral health professionals.

Logistics of travel and scheduling pose barriers to receiving behavioral health care on Earth as well as in space. Taking the time off from work, arranging childcare and potentially traveling a great distance to appointments all conspire against individuals ability to receive a sufficient dose of behavioral intervention. Additionally, the stigma of asking for mental health carein self-perception and in social and employment consequencescan prevent individuals from asking for help when it is needed on Earth, just as in space.

Finally, many Masters and Doctoral-level behavioral health professionals lack training in evidence-based treatment for depression. Practicing clinicians typically fail to adopt such treatments. Moreover, even when they are aware of the evidence-based guidelines and do attempt to provide them, the treatments are often not delivered effectively.

If ultimately found to be effective, the problem-solving treatment program developed through this project, could help overcome the barriers of cost, availability, logistics, stigma and training, while potentially facilitating major improvements in public mental health. It could be rolled out in a mass scale, making an evidence-based treatment for depression available at any location and at any time.

With simple modifications and revisions, this computer-based depression treatment could be adapted for use in other isolated operational environments, such as polar research stations, submarines, commercial ships, oil rigs and underwater research bases. Furthermore, even greater value could be derived by making similar psychosocial support systems available to the public in settings such as primary care practices, public and mental health centers, schools, social services offices, places of worship, military bases, prisons and eventually at home or at any location through the Internet.

Project Description
NASA Task Book Entry