After efficacy studies are complete, a potential next step would be larger-scale effectiveness studies to further identify in which sub-populations and user settings (home, clinic, etc.) it is most useful. With slight modifications, in addition to use in other operational environments like submarines, Antarctic research stations, commercial ships, and oil rigs. The program could be used with those who work in operationally-demanding professions (e.g., law enforcement, firefighters, emergency first responders, surgeons, and other high-stress professions).

Ultimately, the program may have benefit in helping to prevent mental health disorders in the future by providing easy access to stress management skills that may help mitigate the onset of mental health disorders. SMART-OP has the potential for widespread dissemination via Internet to provide stress-management training to individuals worldwide.

Program Design: We designed a 6-session training program and began production. The 6-session format was based on a review of stress management literature indicating that amount of time needed for proper effect sizes. The program is designed to introduce users to skills in each of the three domains (referenced above) during each "computer session," and then practice those exercises with aid of usb flashdrive at home and in-between sessions. We completed a SMART-OP Design Document.

Program Content: We evaluated third party software for relaxation and biofeedback training exercises and chose two programs that will be incorporated to teach those skills in SMART-OP. The chosen programs will be adapted for use in SMART-OP and utilize a game-like interface to train users how to relax and have been used successfully with other military personnel. We evaluated and chose a third party software for compartmentalization and cognitive flexibility training exercises that will train the user to attend to multiple tasks while being distracted by visual and auditory stimuli. We created a test bank of stress-related questions for use in a knowledge challenge task. We wrote cognitive restructuring exercises and introduction and briefing scripts for the SMART-OP coach. We contacted long-duration astronauts and support staff, and US military personnel to ask for participation in videos and interviews, and filmed three interviews. We also interviewed various experts using structured interview based on stressful scenarios. The SMART-OP content document was incorporated into Astronaut Candidate (ASCAN) training by NASA behavioral health support team. We made the SMART-OP content document into a how to manual and stand alone publication and submitted it for publication.

Content evaluation: The program was presented at an annual meeting of the Behavioral Health and Performance group and at an International Conference on Research in Space Analog Environments. We've had discussions with astronauts and US Navy and Marine personnel to review our work and approach. We reviewed the program's content with Dr. Donald Meichenbaum, Stress Inoculation Training creator and made modifications based on their feedback. We received unanimous feedback that SMART-OP will ultimately be most useful if it is incorporated into standard pre-flight/mission training and the importance that the program gets good support from those in authority to ensure proper "buy-in." The design of the program appears to be engaging and has received positive comments for its look and feel.

Drs. Rose, Cartreine and Buckey presented the aims of the research project to members of the US Naval Center for Combat & Operational Stress Control (NCCOSC) team in San Diego, CA. We formalized a cooperation agreement with researchers at NCCOSC to conduct our efficacy trial (YR 3 and 4) with a sample of US Naval pilots. In June our team will be presenting information about our SMART manual to a group of 10 Naval personnel to get qualitative feedback on our approach.

Our team is currently developing the design document that details the look and structure of the stress management countermeasure. Multimedia production has begun on the stress management assessment and detection module and scripts for the introductory greeting of the program are under development. Design aspects for incorporating the stress management program into the existing VSS are being addressed with team members and multi-media professionals.

Ongoing regular communication via teleconferences and in person meetings with key investigators and collaborators occur to help plan and monitor progress towards team goals.

The first objective of this project is to develop a self-directed, autonomous, interactive multimedia program to train crewmembers how to recognize, assess, prevent and manage stress and anxiety on extended spaceflights. The countermeasure would be used in preflight training, with booster sessions on interventions available in orbit as needed. In this model of implementation, the skills learned prior to a mission would help to inoculate fliers to severe stress reactions thereby enhancing flight-task performance and crew health, safety and efficiency. The countermeasure will comprise empirically supported stress and anxiety-management strategies. This prevention and intervention countermeasure will complement the ongoing NSBRI stress-detection projects, directed and fit seamlessly with Drs. Carter and Buckey's computer-based psychosocial support system, the Virtual Space Station.

Beyond the development of the autonomous, computer-based stress and anxiety-management countermeasure, this project has two additional specific aims -- to evaluate the efficacy of the program with an analog astronaut sample of Navy pilots in a randomized controlled trial with a comparison group and to revise the countermeasure as needed, based on data from the efficacy trial and qualitative feedback from a sample of astronauts who evaluate the program for usability and acceptability.