I recently sent an essay to TAPS Magazine, which is going to be published in its upcoming edition; and I decided to recognize National Survivors of Suicide Day by sharing an excerpt from the essay here on the Grief after Suicide Blog. In the excerpt (you may download it here), I begin with this statement:

I believe the love we feel for a person who has died and the pain of grief we feel are directly and profoundly connected: When people die, our immense love for them is, in a way, the source of our pain.

Then I say that realizing the "pain following the loss of a loved one is a natural phenomenon ... can empower you to give yourself permission to express your pain." I call expressing your pain "a healthy response to the death of a beloved person," implying that such expressions are connected to the loving relationship between you and the now-deceased person. In fact, I declare, "the pain of grief can provide the 'fuel' for profoundly heartfelt discoveries ... [about] the meaning in your loss." I close the excerpt with a list of questions that I hope might help people cope with their pain, followed by this conclusion:

The pain of grief can be terrible, and there is often no sure way to stop pain from unfolding in real time. But finding safe ways to process your pain can help you see beyond it even as it has you in its grip. And reflecting on the connection between your pain and your love for the person who died can help you uncover meaning in your life that comes directly from the relationship you had -- and still have -- with your loved one.

By Franklin Cook

A recent summary report,* "Impact of Suicide on People Exposed to a Fatality," raises an alarm about negative effects some people bereaved by suicide suffer from their loss that go beyond their experience of grief. The report is available, below, to read or download. It delineates research evidence that substantiates two troubling facts:

First, that the bereaved are at a higher risk for suicide:

"Clear and overwhelming evidence [shows] that exposure to the suicide of another person, particularly of a close intimate, elevates the risk of ... death by suicide in the population of people exposed."

Second, that the suicide bereaved are at a higher risk for other negative outcomes:

"The elevated risk for suicidality is not the only adverse effect of exposure to suicide. Many studies have also found elevated rates of psychiatric disorders (particularly depression), social difficulties, and continuing grief reactions in the suicide bereaved when compared with other types of loss survivors or population-level norms."

Even though research on the effects of suicide loss is sparse (which will be the subject of a post later in this series), the report concludes that the United States should "move ahead nationally to strengthen programs, services, resources, and systems to help suicide loss survivors and others affected by a fatality."

As I wrote in my last post regarding the recently released DSM-V revision eliminating the bereavement exclusion for depression, "this dialogue and debate will be ongoing." Hopefully, the discussion will be constructive and solution-oriented, and I'd like to contribute to it -- in that spirit -- whenever possible, so I am responding to the invitation of Donna Schuurman, Executive Director of the Dougy Center, to share "When Does a Broken Heart Become a Mental Disorder?" with readers of the Grief after Suicide blog.

The document, created only a week ago by an ad hoc group at a meeting of the International Work Group on Death, Dying and Bereavement, protests what Schuurman calls (in her comments to the American Association of Suicidology listserv, where she posted it) "the trend to pathologize grief" by outlining the three main points in the argument against eliminating the bereavement exclusion (namely, grief is not depression; antidepressants are already overprescribed; and most antidepressants are prescribed by primary care practitioners who, it is feared, will misprescribe them to bereaved people).

Below is an excerpt from my response to Donna on the AAS listserv, which summarizes both the argument in favor of the exclusion and my point of view about the matter, lists a couple of resources I have found to be helpful, and takes a run at framing the debate in the larger context of what I allude to as problems related to the "DSM 'industry'":

I very much appreciate Sidney Zisook's blog post at Scientific American, "Getting Past the Grief over Grief," in which he tells of discussions he had with a colleague who lost his son to suicide almost a year ago about the removal of the bereavement exclusion from the criteria for diagnosing depression in the recently approved DSM V .

Like many who have debated this issue for the past several years (for an overview of the debate about the bereavement exclusion and links to comprehensive background information, see this blog post), Zisook's colleague was worried that not keeping bereavement as an "exclusion" from a depression diagnosis indicated that, in Zisook's words, psychiatrists' "goal was to diagnose every grieving person with major depressive disorder." In his colleague's words,

"How dare they label me with depression, as though I should have been over my grief months ago? How dare they imply I should take medications to drown my sorrow?"

Zisook's reply is a straightfoward summary of the argument that psychiatrists have no such goal in mind and, on the contrary, are not interested in indiscriminately labeling and medicating bereaved people. The change was made to the DSM, he says:

To make sure clinicians and patients understand that major depression can occur in someone who is bereaved, just as it can occur in someone who is going through a divorce, facing a sudden disability or terminal illness, or struggling with serious financial troubles. There are no known clinically meaningful differences in the severity, course or treatment response of major depressive episodes that occur after the death of a loved one compared to those occurring in any other context. According to the best research available, any very stressful life event can trigger a major depressive episode in a vulnerable person; [and] regardless of the context in which it occurs, prompt recognition and appropriate treatment can be life-promoting and even life-saving. (Emphasis added.)

The American Psychiatric Association has opened a final period of public comment on the draft criteria for the new version of the Diagnostic and Statistical Manual (DSM-5). The DSM -- the catalog of mental illnesses in the United States -- serves as the ultimate authority regarding which constellations of symptoms are designated as bona fide illnesses and, therefore, are proper objects of professional treatment. Public comment can be submitted through June 15 on the DSM-5 Development website.

I recommend an article in MedPage Today, "DSM-5: What's In, What's Out" as an excellent summary of all the criteria still subject to further comment and revision before the new manual is released in May 2013.

Several of the proposed revisions are of special interest to grief support practitioners:

In the case of eliminating the bereavement exclusion for diagnosing a Major Depressive Episode, which MedPage Today notes has been "one of the most controversial proposals in DSM-5,"* the APA workgroup is now proposing that the exclusion be retained but that a prominent notice be added to the diagnostic criteria, differentiating symptoms of normal grief from those that might need clinical intervention:

Note: The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

In addition, it is proposed that Persistent Complex Bereavement-Related Disorder -- which refers to an experience of grief that is prolonged or severe but cannot be diagnosed as including a Major Depressive Episode -- be placed in Section III of the DSM-5, which highlights conditions that merit further research before being included as diagnosable mental illnesses.