When mental illness pushes someone past his or her natural instinct for self-preservation to suicide, the people around are often left with a host of feelings beyond the normal grief that sets in after a sudden death. Among them are guilt that they should have done something to prevent it, anger at the person for leaving them or at others for "causing" the suicide, and shame that a family member has broken a major societal taboo.

"When I started to work as a family therapist, I didn't tell anybody that my brother had taken his life because I thought people would think: 'She couldn't save her own brother, how can she help other people?' " said Karen Dunne Maxim, co-author of "Suicide and Its Aftermath," and the facilitator of a long-running suicide survivor support group. "The other reason I didn't mention it was because I thought people would think there was something strange about my family, even though I knew that wasn't true."

Maxim's teenage brother threw himself in front of a train 28 years ago. At the time, many people described his death as an accident -- "He was crossing the tracks to visit a friend" -- which Maxim said only makes matters worse because it fuels the idea that suicide is too shameful to talk about openly.

Though the stigma around suicide has diminished since then, it has by no means vanished. The effects on co-workers, classmates, siblings, parents, children -- even the mental health professionals who treated the person -- can be varied and severe. At least one study of suicide survivors found they had a more intense feeling of responsibility and rejection, more difficulty making sense of the death and greater overall grief reactions than those whose loved ones had died in other ways.

"I remember going into a school once (where a child had committed suicide) and the janitor saying, 'I used to smile and joke with him every day and that day I didn't,' " Maxim said. "And you hear this from co-workers: 'I was supposed to call her that night and I didn't.'"

According to Dr. Herbert Hendin, a psychiatrist and medical director of the American Foundation for Suicide Prevention, studies have shown a higher incidence of subsequent suicide among surviving family members, although it's not clear whether that is due to residual grief and guilt, or a shared genetic makeup that leaves them more susceptible.

Sometimes, survivors will show symptoms of post-traumatic stress disorder, especially if they were a witness or the first to discover the body.

"If you hear a bullet shot in the next room and go in and your husband has shot his brains out and you have to go and clean up the bed, it's a far different experience" than simply being told of the death and not having to confront the grim details directly, Hendin said.

One of the most difficult tasks facing a family is what to tell the children of a parent who has committed suicide. Mental health professionals say they should be told the truth, making sure to stress that it was the result of a mental illness and that no one is to blame.

Still, even today many families feel they are somehow protecting their children by concealing the circumstances surrounding the death. But that can backfire terribly, Hendin and Maxim said. Children often learn about it elsewhere and then feel they must keep their own knowledge a secret to protect the surviving parent.

The effect of a suicide can even ripple out into the broader community. Clusters of suicides among teenagers have been documented and studied by the Centers for Disease Control and Prevention, which recommends active suicide- prevention measures, especially if the deaths attract media attention.

Surprisingly, much of what is known about the effect of suicide on survivors comes from the collective experience of people who work with them rather than from scientific research. There are few definitive studies in the medical or psychological literature, Hendin said.

But that may be changing. The Foundation for Suicide Prevention is co- sponsoring a workshop early next year at the National Institute of Mental Health to develop an agenda for research specifically on people left behind after suicide.

"We expect this research will contribute to improving our ability to help survivors and minimize some of the worst consequences of their loss," Hendin said.

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