The COVID-19 pandemic covered 223 countries, 136,291,755 individuals with confirmed infection and 2,941,128 deaths as of April 13, 2021 (1). Globally the case mortality rate from COVID-19 is 10.4 deaths per 100,000 inhabitants but it varies widely by region and country, with as high as 84.9 in Belgium, 67.5 in Andorra, and 64.3 in the United Kingdom (2). Age is the main risk factor for complications and death as a result of COVID-19; the disease death rate varies from 0.2% for individuals aged 10–39 years to 21.9% in people over 80 years. Death rate also increases in patients with pre-existing comorbid conditions, such as history of metastatic solid tumor (57%), myocardial infarction (47%), cerebrovascular disease (39%), congestive heart failure (37%), hemiplegia (34%), malignant neoplasm (27%), diabetes (20%), dementia (20%), chronic pulmonary disease (16%), hyperlipidemia (11%), and hypertension [8.4%; (3–5)]. Given the high COVID-19 mortality, the severe disease may be life-threatening and as such may be considered a traumatic event, especially for individuals at high risk of complications and death (6–8).

People who are exposed to traumatic events can develop post-traumatic stress disorder (PTSD). PTSD is a serious mental disorder that can develop in persons exposed not only to actual or threatened death, who directly experienced the traumatic event(s), but also in those who witnessed such an event personally, learned that the accidental or violent event occurred to a close family member, or friend or experienced repeated or extreme exposure to aversive details of the traumatic event personally. Such an event is criterion A for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5; (9)]. PTSD causes severe distress or impairment in psychosocial functioning and is marked by four main types of symptoms that last for at least a month, being, respectively, the criteria B, C, D, and E for the disorder: (i) intrusions associated with the traumatic event, e.g., involuntary distressing event-related memories, dreams, and flashbacks, or physiological reactions to cues that resemble the traumatic event; (ii) avoidance of event-related stimuli, i.e., internal (memories, thoughts, and feelings) or external (people, places, situations) reminders; (iii) negative alterations in event-related cognitions, and/or mood, e.g., inability to remember an important aspect of the event, distorted cognitions about the event leading to blaming himself or herself or others and/or persistent negative emotional state and inability to experience positive emotions, diminished activities, and/or detachment from others; and (iv) event-related increased arousal and reactivity, e.g., difficulty sleeping and concentrating, reckless or self-destructive behavior, and being easily irritated and angered (9). PTSD individuals are 2–5 times more at-risk of suicidal ideation, suicide attempt, and deaths by suicide (10). Previous research indicates that about 80% of individuals with PTSD have at least one other comorbid disorder, in particular: depressive and anxiety disorders, as well as substance use disorder (11, 12).

Given the exceptional epidemic situation we are facing now, can we define groups at high risk of developing pandemic-related PTSD? What steps can mental health specialists take to prepare for it? In the following paper we will briefly address these issues.

We believe that mental health professionals in pandemic countries should be prepared for an increase in the PTSD prevalence in three specific groups during COVID-19 pandemic and later: (i) individuals who have had severe COVID-19 and who feared imminent death from the disease; (ii) family members of these severely touched patients or patients who have died as a result of the disease; and (iii) frontline healthcare workers (HCWs) witnessing COVID-19 patients' sudden deaths, or life-threatening situations.

A systematic approach to services to prevent, diagnose, and treat PTSD in risk groups is needed (34). First of all, mental health experts should be aware of the risk of developing PTSD in severe COVID-19 survivors who feared imminent death from the disease, their family members and family members of patients who have died as a result of the pandemic, as well as frontline HCWs witnessing patients' sudden deaths, or life-threatening situations. Information about PTSD and its symptoms should be made available to all HCWs and to mental health patients and their families during and in the months following the pandemic.

Second, we postulate that the three groups at risk described above should be routinely screened for PTSD in the months following the onset of the disease as the usual window of PTSD onset lies between 1 and 6 months after a traumatic event. Screening should be done in primary medical and pediatric care if resources are immediately available for timely follow-up by mental health professionals with specific expertise in PTSD assessment, and—in optimal circumstances—treatment of this disorder. Screening should distinguish between other mental health problems vs. PTSD. Measurement should begin with screening first for traumatic events, i.e., directly experiencing or witnessing death or imminent threat of death due to the pandemic (or other concurrent or previous incidents) being criterion A of the disorder according to DSM-5. PTSD symptoms should be screened only if potentially traumatic events are identified. For example, non-symptomatic individuals who test positive for COVID-19 are not at risk and should not be screened for PTSD, although they may develop other mental disorders such as depressive or anxiety disorder (35). Co-occurrence of PTSD and other disorders [see (7, 8)] is associated with high levels of distress, burden and reduced quality of life (11, 12), thus special clinical attention should be paid to individuals with PTSD experiencing additional mental health problems.

Bereaved surviving close ones who died unexpectedly as a result of the pandemic should be screened not only for PTSD but also for prolonged grief disorder, for example with the Prolonged Grief Disorder-13-Revised scale (36). PGD measurement should be carried out 12 months after the loss, as—according to DSM-5-TR—this is the time after which the persistence of severe grief symptoms, if they interfere with the psychosocial functioning, indicates the presence of this disorder (37).

Third, mental health services should prepare to provide evidence-based therapeutic interventions for individuals with PTSD such as prolonged exposure therapy, and cognitive processing therapy (38). It would be worth training clinicians in various countries in delivering these evidence-based interventions online, as well as to test their effectiveness in individuals with pandemic-related PTSD. Moreover, mental health professionals should be encouraged to: (i) share their experiences on the adjustments to be made in order to tailor these interventions to the current situation, e.g., necessity to provide interventions online and to acknowledge the specificity of the clinical picture of symptoms in severe COVID-19 survivors and their families (including the bereaved), and HCWs; (ii) define frameworks to effectively implement evidence-based interventions in mental health services in various countries (in particular in low income countries); and (iii) prepare accessible and easy-to-follow online trainings for professionals from various countries on evidence-based therapeutic interventions for PTSD.

Finally, studies indicate that the severity of PTSD symptoms in parents is associated with an increase in behavioral and emotional problems in their children (39, 40). Therefore, one should be prepared to prevent such cascading effects of the pandemic by considering psychological support for children of parents who have developed PTSD due to the pandemic. Again, one of the challenges would be providing support for children and their families through online services.

The issue of the full prevalence of pandemic-related PTSD remains a matter of future research as symptoms may develop up to 6 months after the traumatic event. Research showing the full scope of pandemic-related PTSD prevalence will be possible only a few months after the end of the outbreak. Former studies indicated a large prevalence of PTSD in survivors of the earlier coronavirus epidemic (SARS), especially in HCWs, therefore we suggest that mental health professionals should prepare for the frequent occurrence of PTSD in this high risk groups. Families of survivors of severe diseases with high mortality and those who died from the pandemic, as well as frontline HCWs who were not infected but have witnessed numerous deaths and life-threatening situations—although not included in such systematic studies as survivors—may also experience traumatic stress during the outbreak and develop PTSD. Notwithstanding, we suggest that health care policies should consider routine screening for the presence of PTSD symptoms in the three groups at risk described in this paper, together with preventive and treatment strategies of PTSD, and related risks such as suicide.

MS wrote the first draft of the manuscript. All authors edited it, wrote parts of the reviewed manuscript, and accepted its final form.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.