Episode 123: Understanding the Effects of Post-Traumatic Stress Disorder (PTSD)

2:15PM Oct 30, 2023

Speakers:

Farris Tuma

Mary Morder

Keywords:

ptsd

people

trauma

symptoms

treatments

traumatic experience

mental health conditions

ada

mental health

increases

including

live

risk

behavior

condition

responses

talking

disorder

mental health professional

traumatic events

Hi, this is Farris Tuma, you're listening to ADA live.

Hello everybody. On behalf of the SE ADA Center, the Burton Blatt Institute at Syracuse University, and the ADA National Network. Welcome to ADA live. I'm Mary Morder and I'm responsible for materials development at the southeast ADA center. listening audience. If you have any questions about the Americans with Disabilities Act, or ADA, you can use the online form anytime at Adalive.org or call the SE ADA Center at 404-541-9001. And all calls are free and confidential. Today we're going to discuss the ways that people with disabilities can be affected by traumatic events or experiences, including post traumatic stress disorder, which is often called PTSD. Because these traumatic events or experiences and PTSD can be difficult to talk about. The information we discuss in this episode may be disturbing for some listeners. According to the National Center for post traumatic stress disorder at the US Department of Veterans Affairs, approximately 6% of adults in the United States experience some form of trauma or PTSD at some point in their lives. However, most people who go through a traumatic event will not develop PTSD. Our guest for this episode is Dr. Farris Tuma. Dr. Tuma is a health science administrator with the National Institute of Mental Health, or n i m h, in Bethesda, Maryland. He also serves as the NIMH point of contact for research on violence and trauma. His formal training is in public health as a research scientist, and he holds a Master's Degree in Health Policy and Management. Welcome to the show today, Dr. Tuma.

Hello, Mary. And thank you.

Thank you. We're glad you're here today. Now, in your role as the health science administrator, you manage a research funding program on the mental health consequences of traumatic stress, including mass trauma and violence involving children, teens and adults. Can you tell us more about your research and its importance,

or I'd be glad to. Perhaps right now, in the midst of the terrible violence that's taking place around the world, it's more important than ever to understand the mental health toll of violence and other traumatic events. What we're trying to accomplish at the National Institute of Mental Health through research that we support and conduct is to understand how best to address vulnerability and resilience in the face of profound trauma and loss. We know for certain that exposure to trauma of many types, whether this is interpersonal violence, war, mass destruction, disasters, or even more routine of accidents and other kinds of traumas, that this increases the risk for mental health challenges, including depression, anxiety, post traumatic stress disorder, and other health conditions. While we know something about what increases risk, and we continue to to study to try to learn more about this to understand how to prevent it, we don't currently know how to prevent these conditions. So consequently, a major thrust of our focus is on improving the best way to identify people who have needs and to improve upon the current treatments that we have to try to bring more relief to people.

Thank you, Dr. Tuma. That's so important and it's it's such a complex issue. You've mentioned that you do research on mental health conditions and a variety of related issues, including traumatic stress disorder. PTSD. Would you please explain for our audience what PTSD is?

Your PTSD or Post Traumatic Stress Disorder is a condition that develops in some people who have experienced a very shocking, scary or dangerous event. People who experience PTSD may have persistent frightening thoughts, and, and memories. So these are things that they cannot stop thinking about that spontaneously come into their mind. And they experience frequently sleep problems, they feel detached or numb, they may feel on edge and tense and easily startled. PTSD can seriously impair a person's ability to perform sort of daily kind of activities, whether those are at home, taking care of with family and relationships or at work. It's natural, that and normal that people have responses, including strong fear responses during and after a traumatic event. The issue is that for most people, those initial responses and reactions fade with time when they don't fade, and maybe they even get worse over time. This is when we were worried and concerned about conditions like PTSD. The condition itself is characterized by a mixture of responses or symptoms that must last for at least a month to sort of meet the diagnostic criteria. And the symptoms are in a number of areas. So one of these is re experiencing. So this is, as I mentioned, having unwanted thoughts or sometimes it shows up as dreams or nightmares. There's a category of symptoms referred to as avoidance, which just like it sounds, this is the person's desire to be nowhere near or around anything that reminds them of the context in which they had their traumatic experience. Another category of these symptoms and responses is around arousal and reactivity. So again, not hard to imagine what this is, is being easily startled, are having very difficult time concentrating, feeling tense and on edge most of the time. And the last category has to do with cognition and mood symptoms. So these are things that look in many ways like depression, having, in some cases, having trouble remembering the details of their event, having very negative thoughts about oneself how they managed during that trauma during the crisis, and having very little interest or losing interest in things that once they found enjoyable or pleasurable. So a mental health professional who has experience in helping people with PTSD, such as a psychiatrist or a psychologist, can help the person determine whether the symptoms that they're having meet criteria for PTSD, whether it's the right sort of diagnosis, and then help them come up with a plan for treatment.

Thank you so much for all of that information. I had no idea about the different characteristics and you explained it all. So clearly. I know for me and for probably many of our listeners, we most often hear about post traumatic stress disorder affecting people like veterans and first responders such as police officers and firefighters, and people like that. But there's more to it based on what you've told us. Who is most affected by PTSD?

Yeah, this is a great question. Thank you. Sadly, PTSD, and other mental health conditions in the wake of trauma don't discriminate, whether it's after a disaster war, physical assault or an accident. Men, women, children, adolescents can and do experience PTSD. It is true, as you mentioned that the in the early days, if you will, this condition was studied and understood to be a major concern among warfighters. And veterans, but we now know, it's actually a very big population public health concern. And in fact, over the decades, some of the things that we've learned or is it are that women are actually at higher risk overall than men for developing PTSD. In fact, act more than twice as likely, over the course of a lifetime. The risk for the percentage of the of the population, if you will, who is likely to develop PTSD is nearly 10% in women and only about 4% of men. So it is a concern among veterans and other high risk occupational groups, if you will, who are, by definition, have their job in harm's way, they are likely to be exposed to things but it's very, very clear that in the civilian context, there's lots and lots of unfortunate trauma and violence that takes place that puts all of us at risk.

Has the COVID pandemic resulted in an increase in PTSD?

There's no doubt that there has been an increase in mental health needs related to the pandemic in a variety of ways and in a variety of different populations, right. So if we think about people who may have been struggling with a mental health challenge prior to the pandemic, who became let's say, isolated, and or lost income, get imagine this sort of cascade of things piling on of additional stressors that would exacerbate their needs, whether that was depression or anxiety or PTSD or some other concern. Then, of course, there's other categories of people, right, who were may be functioning pretty well and healthy going into the pandemic, healthy from a mental health point of view. But because of the numerous stresses and changes in life, that that this experience imposed on all of us, no doubt that it has led to increased rates of depression and anxiety and substance abuse, and in many cases, PTSD, particularly among some of the frontline workers, we can think about people who were in a position to have all of the unfortunately negative experiences that placed people at high risk in terms of loss of life, and other life stress that they may be going through. So there's no question that there was a across the board increase in mental health concerns. If there's a silver lining in any of this, it goes to the resilience of humans as a species, I think, which is, just as we see after other kinds of disasters and crises, and sometimes even prolonged ones, there will be an increase, there'll be a spike, there'll be a rise in rates of symptoms, and maybe diagnoseable, impairing conditions. But thankfully, there's also a decline generally associated with that. Meaning that some of this is very short lived or temporary in nature, and natural mechanika mechanisms of coping and resilience kick in. And so we would expect what we saw in terms of large increases in reports of depression and anxiety to be coming down in the coming months and years. That said, there's no question that it led to increased needs. And we are in a place that we have not been in as a nation before and maybe arguably, globally in terms of the number of people who could benefit from mental health services who may or may not be in a position to get them.

It's encouraging to know that, that human beings are so resilient. And that, you know, it can decrease what time

it is. One of the remarkable things that I have just been fascinated by for as long as I've been in this field, which is more than two decades at this point is that we are vulnerable. There's no question that we're vulnerable, but the fact that the vast majority of people who can experience and absorb really horrific kinds of things, and to be clear, they're changed. Coming out on the other side of it, like their life is not the same. But the ability or the the resistance to developing the kind of non remitting impairing additions that that some people experience is just remarkable that the fact that the vast majority of people then will be changed by it, but will not be totally impaired or unable to function by it going forward is a remarkable thing.

And it is, thank you for that. That's, that's important information. You mentioned, we've already talked about this a bit that PTSD can happen to anybody at any age and including children and teenagers and adults. Does it affect these different age groups in different ways?

Oh, another good question. Yes, there's some similarities. So children and teens can have some of the same stream reactions that we've been talking about and symptoms that we've been talking about and adults, including things like physical complaints like stomach aches, and headaches, as well as problems with sleep, trouble concentrating loss, loss of interest and things. But it's important to point out that in many cases, the signs or the symptoms in children and adolescents show up a little bit differently. So for example, in very young children, um, we're talking about less than five years of age, the kinds of things that a trained mental health professional would be looking for, and we would want parents and families to be aware of are things like changes in the child's behavior like becoming very, very clingy and fearful, having unusual tantrums or being more irritable or disruptive or difficult than than they might normally be? Subtly reverting to behaviors that they had previously outgrown. Whether that's things like, Tom sucking, or having bedwetting accidents at night, showing a lot of fear and not wanting to be alone. And those sorts of things. These are important signs in very young children. Thinking about older children and teenagers and adolescents, they're likely to look a lot like the signs and symptoms in adults, except that they show up in different contexts. So you might see, for example, fairly dramatic changes in school performance and attendance issues and behavior issues at school might see this sort of withdrawing from family and importantly, in the teenage group from friends. And, again, it's not uncommon to see sort of disruptive or sort of angry behavior in this age group. Again, a good mental health professional who has experience in helping people who have experienced trauma can help determine whether the kinds of problems that somebody the behaviors and problems that somebody is showing are the kind of thing that that really should be addressed in a treatment context and setting or if it's the kind of changes in behaviors that can be likely will resolve and can be managed with some good support with friends and family,

that that's very good information for families and parents in particular. Thank you for sharing that. We've touched on this question a little bit, but maybe you can give us a broader answer is PTSD associated with other medical conditions?

Yeah, unfortunately, someone living with PTSD, and no other mental health concerns is really the exception. The norm, and it's much more common to see co occurring conditions, for example, major depressive disorder, substance use, and a range of anxiety disorders, including things like panic, but also just generalized anxiety. This is especially true if the PTSD which was brought about by a traumatic experience goes untreated. We know that with the passage of time, because of the symptoms and the responses that that PTSD creates in people. It's extremely common to see depression and anxiety and substance abuse. So all the more reason to, to be concerned about and inform people about the the importance of early detection and treatment.

Thank you, that is important. And it's so difficult for people sometimes to find treatment or to be able to afford it. Why do some people but not everyone who's exposed to trauma or even extreme trauma, develop PTSD? Why do some have it and some don't?

Oh, yeah. So this is arguably one of the most important and challenging questions that we're trying to answer through research. Essentially, it is the holy grail of trauma and PTSD is to understand this vulnerability and resilience cocktail. And while we don't have a perfect answer, we do know about many of the factors that play a part in this. So some of the things that can increase one's risk for developing PTSD after a traumatic event have to do with things that somebody brings to that experience, meaning some of these factors exist before the trauma happened. Some of these factors are defined by the nature of the traumatic experience, and then what happens after the traumatic experience. So some examples would be having been exposed to previous traumatic experiences, particularly during childhood, we know is something that increases risk. We know that being hurt, or seeing people hurt or killed, dramatically changes the risk for PTSD. We know how the person responds in the moment of going through a traumatic experience again, whether that's an assault, a disaster, a very bad car accident, the experience of feeling intense, horror, helplessness, and extreme fear increases the risk for PTSD. We know after trauma, having little or no social support increases the risk for developing mental health conditions after trauma. We also know that other stressors, which is unfortunately often accompanies extreme traumatic events, so something happens, but it affects other aspects of the community or your life. Dealing with these other stressors increases the risk. And then I guess, lastly, the other big one would be having a personal or family history of mental illness or substance abuse increases the risk. The flip side of that is that we also know something about protective factors or resilience. Some of these things include the ability and the motivation of someone to seek out support from a family member from a support group, from a therapist, this act and this desire, this ability to want to do that seems to be a major influence on one's recovery after traumatic experiences. We're all different individuals, you know, I'll try to deal with things myself inside my head. And over the years, I'm learning slowly, that that may not always be the best strategy. Sometimes it's better to ask for help, or just to tell somebody what you're feeling. We know that that makes a big difference. We know that having a coping strategy, if you went into a traumatic experience, and you already knew how to handle stress, or you had healthy ways of handling that this is an important protective factor, feeling prepared. So if something bad happens to you, again, that you have the ability to go through it, and and persevere, all of these things can help protect against developing PTSD and depression and other post traumatic problems. But that really short answer is, we don't have a good solution. We don't have a good risk prediction tool at an individual level to tell us why two people exposed to the exact same horrific experience, one might come through with some acute problems that resolved within a couple of weeks, and the other might go on to developing an impairing condition. It's a major thrust of the research that we're doing.

Well, that leads right into my next question, which, you know, you gave us some important information about coping strategies and maybe going to a support group and some people may benefit from reaching out and talking about their traumatic experience with other people. Those are all good ways to try to deal with the trauma based upon your research you've done in your years of expertise. Are there some actual treatments that are most effective for PTSD?

Yeah, so there's some good news here. This is not all bad news situations. I mentioned. The fact that 80 to 90% of people who live through a traumatic experience won't develop PTSD. That's good news. And for the percentage that do go on to develop an impairing condition like this, there are treatments that are helpful. I'll say that it's important for anyone With PTSD symptoms to work with a mental health professional who has experience in treating PTSD, the main treatments are psychotherapy, or talk therapy and medications or a combination of them. And this is where again, talking with a mental health professional to figure out what might work best for each person is important because one of the things that we know about PTSD is that it shows up, and it affects people differently. So it's not, you know, a uniform disorder that looks the same in every individual. But nevertheless, there are treatments and this sort of two categories. I mentioned psychotherapy or talk therapy. This includes a variety of techniques to help people identify and change, troubling emotions that they experience some cases reframing their thinking and thoughts, and to frankly, change their behaviors in response to when they feel stressed out. And our feeling may be triggered by something that's happened. These kinds of treatments can take place, one on one, or in a group setting. And they can last really anywhere from three or four weeks out to 12 weeks or even longer. There's a lot of research going on during trying to figure out how to compress these treatments to make them essentially more manageable and easier to go through. Generally, these are thought of as cognitive behavioral treatments, meaning that they include aspects of thinking and behavior, right, that are problematic for the person who has PTSD. In many cases, they involve something called exposure therapy, and cognitive restructuring. So these help people learn to manage their fear, for example, in exposure therapy, by gradually exposing them in a safe controlled way to reminders of the trauma that they experienced, having prepared that person with strategies for how to cope with that, and how to manage the emotional and physiological sensations that they might have in response to thinking about reading about talking about, or in some cases visiting a situation in which they were exposed to something traumatic. So that's a very useful and fairly effective treatment that a lot of people find beneficial. Another component of these effective treatments is this idea of helping people to make sense of what they went through, there's often this disconnect between, you know, the world is makes no sense was this all my fault. Sometimes people remember the event differently than it actually happened. So here you have cognitive restructuring as a component of therapy, which is to help the person see what their role or responsibility was and wasn't and to put their behavior in response in that context, and to think more positively about what they did or didn't do. This is often done in concert with teaching people coping skills for when they feel the intense reactions and emotions that they feel. And they have to practice this over time. So this is a sort of talk therapy. Beyond that there are also medications. There are two that are approved by the FDA specifically for PTSD, although they are used in other mental health conditions. And these are basically antidepressants that help people manage some of the symptoms of PTSD, such as sadness, and worry, and sometimes anger. There's other medications that psychiatrists and doctors can use to help manage other symptoms having to do with things like sleep, and nightmares. And often, as I mentioned, it's the combination of these that works best. And again, it's important to know that each person is different and their constellation of problems, the thing that's most disturbing to them or distressing to them is going to be different from patient to patient. And the best way to get at that, unfortunately, it takes time and effort is to work with a mental health provider who can discuss the options in all likelihood end up working with the patient to try one or more combinations of medications and psychotherapy. But the good news is helpful for many, many people. We don't have a cure, necessarily, but we certainly have treatments that help people lose their diagnosis, meaning that they may still have some symptoms, if you will, but they're not to the degree where it's impairing and they're unable to function and and carry on a healthy happy life.

Dr. Tuma, thank you for that comprehensive and very detailed answer really gives us a lot of information to share with To our friends and family who may need it. And just to know that there is light at the end of the tunnel out there for people if they can manage to access these treatments and therapies, Adalive listing audience if you have questions about this topic or any other ADA live topics, you can submit your questions online at nada live.org or call the SE ADA Center at 404-541-9001. And now a word from this episode sponsor, the National Institutes of Mental Health.

The National Institute of Mental Health, NIMH, is the lead Federal Agency for Research on mental disorders. NIMH is one of the 27 institutes and centers that make up the National Institutes of Health. NIH, the largest biomedical research agency in the world, and ih is part of the US Department of Health and Human Services. Learn more about the National Institute of Mental Health by visiting their website at www.nimh.nih.gov

Welcome back everyone. I'm Mary Morder with the SEADA Center. Our guest is Dr. Farris Tuma. Dr Tuma is a health scientist and administrator with the National Institute of Mental Health, or NIMH. In Bethesda, Maryland. He manages a program on the mental health consequences of traumatic stress, including mass trauma, and violence involving children, teens and adults. We are talking about Post Traumatic Stress Disorder, or PTSD, what it is, and how PTSD and other traumatic events can affect people differently, depending on their age, gender, and other factors. We also talked about possible treatments that may help manage the effects of PTSD, and improve a person's mental health doctor to how PTSD or other types of trauma affect a person's daily life and functioning.

Or it's a great question. So earlier, we talked about some of the symptoms of PTSD, and here's how they, they can become really impairing and cause difficulty in daily life. So I mentioned that someone suffering dealing with PTSD, is often going to be reminded of their trauma and have thoughts about it when they would rather not have those thoughts. So words, objects, sounds, smells, all these things can trigger both physical and emotional sensations, where someone might feel like they're in danger. Again, even when they know rationally, the danger has passed, their body reacts and feels as if it's happening again, it's not hard to imagine how that can alter somebody's behavior and willingness to go out in the world and do things at a very simplistic level. The very nature of the disorder and its symptoms often leads to changes in social and occupational and family caregiving kind of behaviors. The other symptoms like this avoidance symptoms may cause somebody for example, just to completely change their routines, maybe refuse to get in cars, or to drive a car or even ride in a car. If, for example, they had an experience related to automobiles or being on the road, avoiding crowded places. These kinds of things can obviously lead to social isolation, and difficulty with maintaining important aspects of one's life. The arousal symptoms of PTSD, so being on edge and on guard all the time, can lead to feelings of extreme stress and anger and interfere with the kinds of parts of the parts of daily life like sleeping and eating and concentrating again, basic things that when all of this stuff gets out of whack, it's not hard to imagine why it's harder and harder to carry on with a normal, healthy lifestyle. Cognition and mood symptoms can lead a person to feel detached and isolated from their friends and family members, and not want to be around their friends and family members, because there may be unreasonable expectations from them. And I mentioned early in their conversation, the concern around substance abuse and it's not at all surprising that if somebody's having these kinds of symptoms and feelings, that they might turn to alcohol or other drugs to try to manage these things themselves. This is a major concern and obviously has huge impact on somebody's ability to function if there is misuse and even abuse and addiction, obviously, that's going to make it difficult to maintain a healthy, high functioning lifestyle.

Well, that's all excellent information show that's going to be very helpful for our listeners. Thank you for sharing that. I'm going to turn the conversation a little bit and talk now about something else. Here at the SE ADA Center. We receive a lot of questions from people about their legal rights when they have mental health conditions. Each situation under the Americans with Disabilities Act has to be looked at on an individual case by case basis. But many employees and job applicants with mental health conditions are protected from discrimination by the ADA. And plays in job applicants with disabilities might ask their employer to provide what are known as reasonable accommodations to perform their job. And this would include employees who have mental health condition, what sorts of accommodations might be helpful for these folks?

Thanks, I can think of a couple relatively simple things that could make a big difference in someone's life. First and foremost, would be having some flexibility with regard to schedules. Obviously, we want someone if they have PTSD, or any other chronic mental health problem to be able to get into and stay in treatment. So for example, being able to keep therapy and medical appointments that might need to be scheduled during the work day seems like a pretty important thing to do. So having some flexibility there. Secondly, I think it would be really helpful to allow someone with PTSD, to make some adjustments to their daily schedules, there may be some benefit to being able to take short breaks periodically. You know, we were discussing earlier that some of the challenges in dealing with this disorder and going through treatment have to do with managing responses that somebody's going to feel when they're reminded of something or if they start to have the sensations again, of that fear and helplessness and worry, when those things happen. Hopefully, that person is learning some coping skills and can practice those. So having the ability to take a few minutes, timeout every now and then to use that to practice their coping skills. And to de stress a little bit is probably useful. I think a really practical accommodation would be having some ability to make some adjustments to the physical workplace if somebody's in a physical workplace. So thinking about things like adjusting lighting, or being in a low noise environment, or maybe even rearranging furniture in a way that the person in that room doesn't feel threatened or vulnerable. For example, it's often the idea of not having your back to a door and being able to see who's coming and going. These could end up being very important and comforting, reassuring kinds of things to somebody with, with PTSD. Some of this in the world that we work in today, where a lot of people are teleworking, it's a mixed bag. On the one hand, it allows for some amount of being at home and working in what might be a comfortable environment for the kinds of jobs where one can do that. On the other hand, there's a risk or a downside to that of being isolated in a sense, but I think having some flexibility with scheduling some some physical work environment accommodations, and the possibility for having some breaks throughout the day. These are all be helpful, reasonable things to do.

Those are wonderful suggestions, Dr. Tuma, and we know that most employers are eager to keep their valuable employees working. But there may be some misconceptions out there by certain employers. What are some of the myths and realities about PTSD that employers should be aware of?

One of them that we we've already touched on a little bit is that PTSD only affects war veterans. You know, it's true that the diagnosis was solidified in the post Vietnam era, to essentially replace syndromes such as shell shock, or combat fatigue, with a more contemporary diagnosis that was tied to treatment, but it's really, really clear and important now that we understand that anyone can develop PTSD. It's a condition experienced by millions of children and adults, and can be caused of many kinds of trauma. I think another myth or misunderstanding is that PTSD is a condition that's purely psychological. It's in someone's head, it's not really a medical condition. This is something we now know from very credible and replicated studies for more than two decades now, is that the symptoms of PTSD are actually related in a very clear way to how the brain functions. So parts of our brains involved with memory, fear, learning, emotion regulation, are altered in PTSD, essentially, the accelerator and the brake pedals in our brains that help us regulate our emotions, our physiological functioning can become altered, and the ability to learn how to change those is altered. So people with PTSD have a difficult time relearning, what's a safe environment, what's not a safe environment. All of this is to say that it is clearly not something that's under someone's control. That is just a matter of making up your mind to get over your trauma, we know that the environment and experience can change our brains. The good news is we also know that treatment and therapy can change our brains for the better. I think the last myth that I probably struggle with the most over time is this idea that PTSD causes violent behavior. Sadly, the media has portrayed people with PTSD as being wildly dangerous, or violent. And the reality is, the vast majority of people with any mental health problem, especially if it's being treated are no more likely to be violent than anyone else. We know from lots of studies now that only about three 4% of violent acts, at least in the United States can be attributed to individuals living with a serious mental illness. The reality is that people with mental illness, including PTSD, are many, many times more likely to be the victims of violence, or to harm themselves rather than to harm someone else. So I think it's important that we keep that in mind, that the stereotype and the media portrayals of what it's like to live with this condition are just counterproductive.

Thank you, that's very good information that stereotypes are just rampant everywhere in the disability community. So we're, unfortunately very familiar with that concept. And with that being used against us, in some situations, what other advice do you have for friends and family members, for our listeners, who may be struggling with PTSD, or other mental health issues.

If you or someone you know, may be experiencing Post Traumatic Stress Disorder, the most important thing you can do for yourself or for them is to get to see the right health care provider who can help with the diagnosis and treatment. Some people may need the kind of help literally making the appointment or finding the professional to go and speak with. Some people may need help in getting to their appointments and having support to go through those initial meetings with a health care provider. If a close friend or a relative is diagnosed with PTSD, you can encourage them to follow their treatment plan. If the symptoms don't get better in 5 to 8 weeks, they should have a conversation with their health care provider. In terms of finding health care providers, NIMH on its website, has a number of useful resources and guidance on how to do this, including pointers to resources around the country, and encourage people to look at that and not wander and suffer alone in silence.

That's actually excellent. Thank you for sharing those resources with us and reminding us that there's help out there for the people who need it. We really appreciate your being our guest today. Do you have any other thoughts to share with us?

I guess the last thing I would say is if you or someone you know is struggling and having thoughts of hurting themselves or suicide, which is a concern in this context, that they should please call or text the 988 suicide and crisis Lifeline at 988 or chat at 988 lifeline.org. In a life threatening situation they should call 911. But don't ignore warning signs.

Excellent advice. Thank you, doctor to listeners. Thank you for joining us for this informative discussion. With Dr. Farris Tuma, a health scientist administrator with the National Institute of Mental Health. If you're looking for more information, be sure to check out the ADA live website where this episode will be archived, along with information and resources on Post Traumatic Stress Disorder, mental health and the Americans with Disabilities Act. listeners. Thank you for joining us. You can access all ADA Live episodes with archived audio accessible transcripts and resources on our website at Adalive.org. Listen to the SoundCloud ADA live channel at soundcloud.com/adalive. Download ADA live to your mobile device and your podcast app by searching for ADA live. If you have questions about the Americans with Disabilities Act, use the online form any time at ata live.org or contact your Regional ADA Center at 1-800-949-4232. All calls are free and confidential. Ada live is a program of the southeast ADA Center, the Burton Blatt Institute at Syracuse University, and a collaboration with the disability inclusive employment policy, rehabilitation research and training center. Our producer is Celestia Ohrazda with Cheri Hoffman, me Mary Morder, Marsha Schwanke, Chase Coleman and Barry Whaley. Our music is from Our music is from four wheel city the movement for improvement