Persistent, Impairing Grief After Suicide of a Loved One

Intake assessments by psychiatrists and other mental health professionals are expected to include questions about suicidality. However, despite its greater prevalence and its clinical relevance, clinicians are much less likely to query the experience of having lost someone close to suicide (ie, suicide bereavement). Yet, in the United States alone, about 180,000 people lose a loved one to suicide each year. Suicide-loss survivors often struggle profoundly in the wake of their loss and are at risk for a number of serious mental health consequences. In the words of Edwin Shneidman (1973), “in the case of suicide, the largest public health problem is… the alleviation of effects of stress in survivor-victims of suicidal deaths, whose lives are forever changed, and who, over a period of years, number in the millions…. survivors often struggle with difficult questions and intense emotions.” Shneidman’s astute observations predated more recent attention and scientific inquiry into a condition of intense, persistent, and disabling grief that is now making its way into ICD-11 and quite likely into DSM-5.1. This condition (variously named complicated grief, persistent complex bereavement disorder, or prolonged grief disorder) is estimated to affect about 10% of individuals who have lost an important person and perhaps as many as 20% after a suicide death.

ICD-11 provides a simple guideline for a clinical diagnosis of prolonged grief disorder. The guideline requires the persistence of intense yearning, longing, or preoccupation with thoughts of the deceased, with additional evidence of persistent grief-related emotional pain (eg, sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, emotional numbness). The level of grief intensity should clearly exceed expected social, cultural, or religious norms and cause significant impairment in functioning. We hope our colleagues will find this guideline to be the missing piece in allowing them to identify bereaved people in need of treatment. We believe it is possible, if not likely, that DSM-5.1 will finalize a criteria version that will harmonize with ICD-11.

This condition is important to recognize and treat. It has been associated with intense suffering and substantial medical and psychiatric morbidity, and tends to persist for years, if not indefinitely, in the absence of formal interventions. Focused treatment can have a profound effect. We use a simple heuristic model in our work with bereavement. In our model, we envision acute grief as the initial response to bereavement, with symptoms the same as those identified by the ICD-11 guideline. Over time, bereaved people usually adapt to the loss by accepting the finality and consequences of the loss, including a changed relationship to the deceased, and by re-envisioning the future with possibilities for happiness. Grief doesn’t totally disappear but rather becomes integrated into the bereaved person’s heart, mind, and ongoing life. However, a minority of bereaved people are caught up in counter-factual ruminations (eg, what should or could have happened?), excessive avoidance of reminders, or excessive difficulty regulating painful emotions, which interfere with adapting to the loss. In the case of suicide, common impediments to adapting include feeling especially isolated and silenced, questioning why, believing that the person did not need to die in this way, feelings of responsibility, and feeling blamed or judged or rejected. People who experience persistent impairing grief as described by ICD-11 show a high rate of response to a short-term treatment called complicated grief therapy (CGT.) This treatment is also feasible and effective for individuals struggling with suicide bereavement. You can read more about CGT at www.complicatedgrief.columbia.edu or explore our digital program for bereaved parents at https://parents.griefsteps.columbia.edu/.

Financial disclosure:Dr Shear is under contract with Guilford Press to write a book on grief. Dr Zisook has no relevant personal financial relationships to report.