To the Editor:

We read with interested the article by Celen and Şimsek, which described the prevalence of post-traumatic stress disorder (PTSD) in paramedics following the COVID-19 pandemic.Reference Celen and Şimsek ¹

Qualifying trauma exposure for the diagnosis of PTSD requires direct or witnessed exposure to a threat to life/limb or indirect exposure via a loved one’s direct exposure. ² Although the care of patients is not typically considered a qualifying trauma exposure, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) makes an exception for first responders who experience repeated or extreme exposure to aversive details of a traumatic event; therefore, paramedics can be diagnosed with PTSD if they are, for example, asked to collect human remains. However, because naturally occurring medical illness, including COVID-19, is not trauma, exposure to patients with COVID-19 would not be considered a qualifying trauma. ² Because paramedics cannot be diagnosed with PTSD on the basis of their exposure to the distress of patients with COVID-19, the prevalence of PTSD in these paramedics cannot be reported or even considered.

If the authors seek to report the prevalence of stressor-related symptoms in paramedics caring for patients with COVID-19, the term “unspecified trauma- and stressor-related disorder” from the DSM-5 can be used.² This category applies to individuals who have “symptoms characteristic of a trauma-and stressor-related disorder that cause clinically significant distress or impairment” but do not meet criteria for other trauma- or stressor-related disorders (p. 290). ²

However, whether direct exposure to COVID-19 infection should be considered a qualifying trauma and whether caring for highly distressed patients is a qualifying exposure has not yet been evaluated. Front-line health care workers (HCWs) were found to have substantial psychiatric illness and distress during the pandemic, and in a future pandemic they would benefit from interventions discussed in the manuscript by Celen and Şimsek, including mental health monitoring and psychological assistance.Reference Celen and Şimsek ^{1 ,} Reference Kamra, Dhaliwal and Li ³ PTSD, in contrast to distress, requires specific treatment, which includes medications and counseling. To prevent negative outcomes of untreated PTSD, ^{Reference Bernal, Haro and Bernert4,} Reference Roberts, Liu and Lawn ⁵ it is essential to determine whether symptoms represent distress or trauma-related psychopathology.

Comparing syndromes following different types of stressors (immediate threat to life or limb vs. medical illness) and exposures (direct vs. indirect via the distress of patients) can aid in this determination. Similar symptom profiles emerging with caring for highly distressed COVID patients (indirect exposure to stressor) and with direct exposure to viral infection compared with direct personal trauma exposure would support inclusion of medical illness and patient care as qualifying trauma exposures, and distinct symptom profiles would support their exclusion from the definition of trauma in PTSD criteria. The prevalence of PTSD in HCWs following COVID-19 could be reported only with empirical data supporting the expansion of the definition of trauma in PTSD criteria to include medical illness and the care of distressed COVID-19 patients.