In 2007, a woman named Lisa Nowak drove 900 miles to the Orlando airport, bringing a knife, a mallet, rubber tubing, and a BB gun. At the airport, she wore a black wig and followed Air Force Captain Colleen Shipman in the parking lot. After Shipman declined to give her a ride, Nowak began crying and then tried to pepper spray Shipman, according to police reports.

Nowak was subsequently arrested and charged with attempted murder. Police said she had planned to harm Shipman over an apparent love triangle. The case drew international headlines and, over the next two years, media outlets followed whether Nowak would pursue an insanity defense in court.

Why did this attack receive so much coverage?

Nowak was an astronaut.

This bizarre incident called attention to NASA's medical practices and the role of mental health in space flight. Just months earlier, Nowak had flown on the shuttle Discovery to the International Space Station, where she controlled robotic instruments during spacewalks. Now, she awaited criminal trial, reportedly diagnosed with a brief psychotic disorder and major depression, among other conditions.

Dr. Patricia Santy, a psychiatrist who worked as a NASA flight surgeon, publicly criticized the agency, saying “NASA tends to deny behavioral issues are a big problem for astronauts.” NASA’s Johnson Space Center conducted an internal review of its medical assessments, recommending additional mental health screenings for astronauts.

It’s been ten years since the Nowak debacle, and NASA hasn’t forgotten about mental health. Last year, scientists working for the Human Research Program at NASA released their latest evidence report on the mental health risks of space flight.

The 123-page document provides an in-depth look at the psychological demands placed on people in space. For example, crew members endure major disruptions to human physiology, including sleep changes, radiation exposure, and gravity shifts. They live in confined environments with limited social interactions and at long distances from home. Meanwhile, their work is high-stakes and under intense public scrutiny.

Medical research at NASA has provided clues about the prevalence of mental health problems during space flight. Across 89 shuttle missions from 1981 to 1998, US astronauts had over 1,800 in-flight medical events; less than 2 percent of these were related to behavioral health, largely stemming from “anxiety and annoyance.” By comparison, space adaptation syndrome—a set of gravity-related symptoms including motion sickness, headaches, and facial stuffiness—represented over 40 percent of all medical events.

Nonetheless, NASA’s evidence report suggests past space missions may have ended early as a result of behavioral problems. The Soviet Soyuz 21 mission to the Salyut 5 station was halted in 1976 after crew members reported smelling a strong odor; the origin of the odor was never found and a shared delusion has been proposed as the underlying cause. In 1985, depression may have factored into the abrupt end to the Soviet Soyuz T14-Salyut 7 mission.

The psychological state of crew members has also led to some close calls, according to the NASA report. In the 1980s, a Chinese payload specialist on the shuttle Challenger became distressed when his experiment failed and he briefly threatened not to return to Earth. In 2001, US astronaut Henry Hartsfield Jr. spoke about an incident during a prior mission: “We had one payload specialist that became obsessed with the hatch. ‘You mean all I got to do is turn that handle and the hatch opens and all the air goes out?’ It was kind of scary…so we began to lock the hatch.”

Space flight isn’t necessarily bad for mental health. In fact, research suggests space travel can be salutogenic—an experience that promotes health and wellbeing. For example, seeing Earth from afar can foster spirituality and unity among crew members. A 2006 survey of 39 astronauts and cosmonauts found “space travel is a meaningful experience whose effects endure for some time postflight.”

Still, NASA has focused on reducing the risks of any mental health issues during space flight. Astronaut candidates must complete hours of psychiatric screening during the selection process. The agency employs teams of mental health providers, including psychiatrists and psychologists, to support personnel during space missions. Every two weeks, crew members on the International Space Station partake in psychological conferences with medical staff.

In addition to screening for mental health problems, the agency aims to promote wellbeing through psychosocial supports. The Family Support Office serves as a resource to astronaut families, hosting educational events and providing informational updates. Internet access, hobbies, and care packages can give crew members a sense of connection to home.

For years, astronauts have also turned to pharmaceuticals to cope with the stresses of space flight. According to a 1999 study of debriefings from 79 space shuttle missions, 94 percent of astronaut flights included the use of medication; most of the medications were used for sleep disturbances or motion sickness. More recently, a study published in 2014 found 78 percent of crew members took sleeping pills during shuttle missions.

But as NASA’s evidence report points out, there’s still so much uncertainty around mental health and space exploration. For example, astronauts might want to hide mental health issues during screenings in order to avoid professional consequences. Scant research exists on the use of psychiatric medications in microgravity environments. As missions become longer in duration and distance, the psychological effects of extended space travel remain poorly understood.

The lingering question is what happens when all these psychological supports fail. In other words, how do you manage a mental health crisis in space?

The NASA report indicates that space agencies have prepared for this possibility. The International Space Station has antipsychotics, antidepressants, and anxiolytic drugs in its medicine kit. And a “physical restraint system is available” if it were to become necessary.

So far, NASA says there have been no behavioral emergencies during US space flights. But as we extend our reach into space, it’s likely a matter of when, not if, something like this will occur. Private organizations, such as Space X, have announced plans to launch their own crews into space. NASA has set its sights on longer, more strenuous human-based missions to asteroids and Mars.

In 2009, Lisa Nowak, the astronaut who carried out the Orlando airport attack, pleaded guilty to lesser charges of battery and burglary, avoiding trial. At a court hearing, Nowak told the judge, “The counseling has been completed and I am not suffering from any debilitation at this time.”

If the Nowak incident tells us anything, it’s that astronauts are all too human.