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Association Between the Release of Netflix’s 13 Reasons Why and Suicide Rates in the United States: An Interrupted Time Series Analysis

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Role of media reports in completed and prevented suicide: Werther v. Papageno effects

Thomas Niederkrotenthaler et al. Br J Psychiatry. 2010 Sep.

Abstract

Background: Media reporting of suicide has repeatedly been shown to trigger suicidal behaviour. Few studies have investigated the associations between specific media content and suicide rates. Even less is known about the possible preventive effects of suicide-related media content.

Aims: To test the hypotheses that certain media content is associated with an increase in suicide, suggesting a so-called Werther effect, and that other content is associated with a decrease in suicide, conceptualised as a Papageno effect. Further, to identify classes of media articles with similar reporting profiles and to test for associations between these classes and suicide.

Method: Content analysis and latent class analysis (LCA) of 497 suicide-related print media reports published in Austria between 1 January and 30 June 2005. Ecological study to identify associations between media item content and short-term changes in suicide rates.

Results: Repetitive reporting of the same suicide and the reporting of suicide myths were positively associated with suicide rates. Coverage of individual suicidal ideation not accompanied by suicidal behaviour was negatively associated with suicide rates. The LCA yielded four classes of media reports, of which the mastery of crisis class (articles on individuals who adopted coping strategies other than suicidal behaviour in adverse circumstances) was negatively associated with suicide, whereas the expert opinion class and the epidemiological facts class were positively associated with suicide.

Conclusions: The impact of suicide reporting may not be restricted to harmful effects; rather, coverage of positive coping in adverse circumstances, as covered in media items about suicidal ideation, may have protective effects.

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# data[].attributes.attachment_link.title
Role of media reports in completed and prevented suicide: Werther v. Papageno effects - PubMed

# data[].attributes.attachment_link.description
The impact of suicide reporting may not be restricted to harmful effects; rather, coverage of positive coping in adverse circumstances, as covered in media items about suicidal ideation, may have protective effects.

# data[].attributes.attachment_link.readable_text
Keith Hawton, professor of psychiatry,a Sue Simkin, research assistant,a Jonathan J Deeks, medical statistician,b Susan O'Connor, consultant psychiatrist,c Allison Keen, research assistant,d Douglas G Altman, director,b Greg Philo, research director,e and Christopher Bulstrode, professor of orthopaedics d

Abstract

Objectives

To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

Design

Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.

Setting

49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data.

Subjects

4403 self poisoning patients; questionnaires completed for 1047.

Main outcome measures

Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers.

Results

Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).

Conclusions

Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Introduction

The possibility that media representation of suicide and deliberate self harm may encourage suicidal behaviour in vulnerable individuals has attracted considerable attention,1,2 not least because it is a potentially modifiable factor. Studies of televised news reports of suicides have suggested associations with a short term increased incidence of suicide,3,4 especially if the reports are repeated and the deaths are highly publicised.5 Others have not shown such an effect.6,7 Investigations of the effects of fictional portrayal of suicidal behaviour on television have also produced varying results,8 with some studies indicating a strong influence on suicides9⁻12 or on referrals for deliberate self harm.10 Recent studies in the United Kingdom found either no evidence13 or equivocal effects.14 Most studies in this area have been retrospective so that it has not been possible to investigate whether subjects have seen the media stimulus.1

Advance notice that an episode of the television drama series Casualty would include a serious overdose of paracetamol provided the opportunity to conduct a large scale prospective study of any possible effects on subsequent suicidal behaviour. The box describes the content of the episode, which was shown on 2 November 1996.

Depiction of paracetamol overdose in episode of Casualty

The overdose storyline involved an RAF pilot in his 30s who was having difficulty returning to work after the aircraft he was flying accidentally crashed, killing a colleague. His sense of guilt and fear that he might have epilepsy led to excessive drinking and marital conflict. He was taken to the accident and emergency department after collapsing, and, after a dramatic scene in which he vomited blood, it was discovered that his blood levels of paracetamol were high. Two nurses were shown urgently questioning him about a possible overdose, and when he admitted to taking about 50 paracetamol over two days earlier they looked very concerned.

The dialogue emphasised the danger:

Nurse: "You should have come in earlier. Paracetamol just keeps on working, steadily destroying the liver."

Patient's wife: "What are you saying? It's too late?"

The message was repeated in the final scene of the story:

Doctor: "Your husband is suffering from severe liver damage caused by the paracetamol. It's disturbing his blood's ability to clot. We've got to transfer him to a specialist unit now .... It doesn't look very good."

The episode contained several other storylines, including a female vagrant suffering a severe spinal cord lesion, a young boy being badly burned, a demanding middle aged businessman attending with a minor head injury, and a member of staff being diagnosed with multiple sclerosis.

We aimed to investigate a possible association between the broadcast of the programme and changes in presentation to general hospitals for deliberate self poisoning (including changes in the substances taken). In addition, a questionnaire survey of patients presenting with self poisoning was undertaken to investigate direct links between viewing the episode and decision to take an overdose, choice of drug, and speed of presentation to hospital.

Subjects and methods

Study centres were recruited from the 160 large accident and emergency departments (>35 000 new attendances a year15) in the United Kingdom and from general hospital psychiatric services. Participating centres were asked to provide weekly data on all presentations for overdose during the three weeks before the programme's broadcast (13 October to 2 November) and the three weeks after (3-23 November), giving three measurements before and after the intervention.16 Data were collected either through regular monitoring systems or specific counts for the study. Some psychiatric services could supply data only on patients referred for psychiatric assessment. Information was supplied on sex, age band, and use of paracetamol (if recorded).

Clinicians in general hospital psychiatric services were also asked to complete questionnaires after assessment of individual patients during the same period. The questionnaire recorded patients' sex, age, choice of drug (and, for those who took paracetamol compounds, whether they knew these contained paracetamol), time from overdose to presentation at the accident and emergency department, history of taking overdoses, and whether the choice of substance was influenced by anything they had seen on television. Patients were classified as viewers of Casualty if they presented in the baseline period and reported seeing the previous week's episode or if they presented after the broadcast and had seen the episode of 2 November. The latter patients were also asked whether viewing the episode had influenced their decision to take an overdose, their choice of drug, and how quickly they sought help. Fifty two hospitals participated across the United Kingdom (see acknowledgments).

We obtained data on suicides, deaths due to undetermined cause, and accidental deaths involving self poisoning with paracetamol and paracetamol compounds that occurred in England and Wales during 1996 from the Office for National Statistics. Viewing figures for Casualty were supplied by the BBC and converted to rates using population figures for the United Kingdom.17

Statistical analyses

We estimated baseline incidence rates of self harm from the counts for the three weeks before the broadcast. The effect of the episode was estimated by comparing incidence rates for the three weeks after the episode with the baseline rates. Comparisons were initially made within centres and then pooled using Poisson regression models that incorporated repeated measures and allowed for variation between centres in both baseline levels and changes after the broadcast.18 The effects of age, sex, and choice of substance were investigated by adding interaction terms to the models. Comparisons were made between accident and emergency departments and psychiatric services, and according to whether centres had participated in the questionnaire section of the study. Changes in presentation rates after the broadcast are reported as percentage changes with 95% confidence intervals.

Questionnaire responses were pooled across centres for the three week periods before and after the broadcast. Relations between viewing the episode and overdose were estimated by comparing characteristics of viewers presenting before and after the broadcast. Significance was tested with Fisher's exact test or the χ ² test for trend as appropriate. We used stata 19 and EpiInfo20 software for analysis.

Results

Presentation rates before and after Casualty episode

Forty nine hospitals supplied data on presentations for overdose (table ). In the baseline period 2127 patients presented, while 2276 presented in the three weeks after the broadcast. There was a marked increase in the number of self poisoning patients in the week after the broadcast of the Casualty episode compared with the baseline period for both paracetamol and non-paracetamol overdoses (figure).

Table 1

Region

No of hospitals recruited

Mean (range) No of annual new attendances at A&E

No of hospitals providing weekly counts of overdose attendances (No of attendances)

Source of weekly counts (No of A&E:No of psychiatric services)

No of hospitals completing questionnaires for individual overdose cases (No of questionnaires)

Northern and Yorkshire
7
56 580 (36 000-87 090)

6 (362)

4:2

3 (85)

Self poisoning rates were 17% higher in first week after the broadcast, 9% higher in the second week, and returned to the baseline level in the third week (table ). The increase for females was significant in both weeks (20% and 17%), whereas that in males was significant only in the first week (14%). Overdoses of paracetamol and paracetamol compounds increased by 19% (both sexes) in the first week after the broadcast and by 23% in the second week (table ). The increase in non-paracetamol overdoses was smaller, only noted in the first week, and only in females.

Table 2

Weekly No of cases/centre (95% CI) in 3 weeks before broadcast

Percentage change (95% CI) in presentation rates compared with 3 weeks before broadcast; P value of difference

1st week after

2nd week after

3rd week after

Average

Data provided by accident and emergency departments and psychiatric services showed similar increases (relative risk=1.01; 95% confidence interval 0.81 to 1.26). There was little difference between centres that collected questionnaire information and those that did not (relative risk=1.07; 0.93 to 1.23).

Attendances by sex, age, and drug taken in overdose

During the baseline period, 52% of the patients were female; 36% were aged <25, 30% were aged 25-34, and 34% were aged ⩾35; and 38% of overdoses included paracetamol (table ). Females showed a somewhat larger increase in attendance rates than males (relative increase in females compared with males was 12%; −1% to 28%). Those aged 25-34 showed significantly different changes in attendance rates after the broadcast compared with the other age groups: their increase in paracetamol overdoses was greater (P=0.005), and non-paracetamol overdoses declined (P=0.002). The other age groups showed small but similar increases for both types of overdose.

Table 3

Age of patients (years) by type of drug used

Percentage change in presentation rates in 3 weeks after broadcast compared with 3 weeks before

Males

Females

Deaths in England and Wales from paracetamol poisoning

We compared the numbers of deaths from paracetamol poisoning in the three weeks before the broadcast with those in a three week period lagged one week after the broadcast to account for the delay between paracetamol ingestion and death. There was no evidence of increases in mortality after the broadcast (ratio of number of deaths before to number after was 14:15 for suicide, 14:8 for undetermined cause, 6:3 for accidents, and 34:26 combined). Use of a three day lag or no lag gave similar results.

Questionnaire information

Twenty five hospitals supplied completed questionnaires on 1047 individual patients (table ). Questionnaires were returned for 55% (1047/1917) of patients in the hospitals who supplied weekly attendance or referral counts and questionnaires. Table shows that viewing of Casualty by overdose patients in the baseline period was slightly below official BBC figures for those episodes (average of 16% v 22%). In the week after the broadcast 18% of overdose patients had seen the episode (P=0.18 compared with before the broadcast) while the official BBC figure remained at 22%. Few patients reported that their choice of drug for self poisoning was influenced by television programmes in general (table ). Casualty viewers attending after the episode were slightly more likely to state that general television viewing influenced their choice of drug than those attending before the broadcast (14% v 6%, P=0.10).

Table 4

3 weeks before broadcast

3 weeks after broadcast

3rd week

2nd week

1st week

1st week

2nd week

3rd week

Pure paracetamol tablets*

45 (24)

73 (38)

49 (26)

62 (32)

71 (44)

48 (38)

Pure paracetamol or paracetamol compound*

91 (50)

102 (54)

89 (48)

91 (49)

89 (55)

65 (51)

Saw last episode of Casualty

22 (15)

23 (15)

26 (17)

Saw index episode of Casualty

32 (18)

23 (18)

14 (13)

Opinions among those who watched Casualty:

(n=22)

(n=23)

(n=26)

(n=32)

(n=23)

(n=14)

Of the patients who had seen the index broadcast, 15% reported that viewing the episode had influenced their decision to take an overdose. The same number stated that it had influenced their choice of drug, usually in the direction of taking paracetamol (for example: "I saw what happened to him-he died. Thought I'll try it next time I get into trouble" "Knew what tablets to take"). However, some patients said that they had avoided paracetamol because the episode highlighted the dangers of liver damage (for example: "I didn't want to wake up with liver damage and have a slow death"). Ten percent said viewing the episode had influenced their speed of seeking help after the overdose.

Comparison of viewers before and after the broadcast

In the patients who viewed the index Casualty episode there was a doubling in the number taking pure paracetamol compared with Casualty viewers in the three weeks before the episode (table ). There was little change in the choice of drug among non-viewers. Most patients presented within 12 hours of taking their overdoses, and this did not change among Casualty viewers after broadcast of the index episode. There was also no evidence that viewing the index episode encouraged those without a history of self poisoning to take an overdose or those who had never used paracetamol for self poisoning to do so.

Table 5

Non-viewers

Viewers

3 weeks before broadcast (n=375)

3 weeks after broadcast (n=346)

3 weeks before broadcast (n=71)

3 weeks after broadcast (n=69)

Percentage change (95% CI) in 3 weeks after broadcast compared with 3 weeks before; P value of difference*

6-12

23 (12)

22 (13)

2 (6)

5 (13)

χ ² test, P=0.3

Discussion

Portrayal of a paracetamol overdose in a popular television drama seems to have been followed by significant increases in presentations to general hospitals because of self poisoning. Increases of 17% and 9% were noted in the first and second weeks after the broadcast, and presentations returned to pre-broadcast levels in the third week. Increases were found for both paracetamol and non-paracetamol overdoses. There was no evidence of an impact on deaths from paracetamol poisoning, but this is not surprising as mortality from paracetamol overdose is relatively low.21

The increase in self poisoning rates was largest in 25-34 year olds, the age group that included the man who took the overdose in the index episode. Females were more likely to be Casualty viewers and showed somewhat greater increases than males. Of the patients who completed questionnaires after the broadcast, 63% of Casualty viewers were female compared with 52% of non-viewers. The proportion of females among viewers mirrors national rates (61%).

Casualty viewers might be more aware of paracetamol as a dangerous means of overdose because of their general interest in medical matters.22 However, after the broadcast the proportion of patients who were Casualty viewers and used paracetamol for self poisoning doubled-an important finding strongly suggesting that viewing the episode had influenced the choice of substance.

Methodological issues

Several methodological considerations should be noted in interpreting the increase in overdoses after the index Casualty episode. It seems unlikely that awareness of the study hypothesis could have influenced data collection since much of the data were based on routinely collected information. Also, the three centres with established monitoring systems (Bristol, Derby, and Oxford) noted increases in total overdoses in the period after the broadcast, and increases in paracetamol overdoses were noted in Derby and Oxford (Bristol did not report data on overdose substances).

Although there was extra media attention to paracetamol poisoning around the time of the broadcast, a review of television programmes, newspapers, and magazines revealed no specific focus on paracetamol within a few days of the actual broadcast, so it seems unlikely that other publicity could have triggered the increase. An overdose depicted in the television soap Brookside on 8 November (six days after the index Casualty episode) did not specify the substance taken and had an audience of only about a third that of Casualty.

It is possible that viewing the index Casualty episode encouraged people who subsequently took overdoses to go to hospital, especially those who took paracetamol. However, the lack of difference between the viewers and non-viewers in the delay before presentation makes this unlikely.

The questionnaire data add considerably to the strength of the findings. Questionnaires were completed for only about half of the overdose patients in participating centres, but this seems a reasonable figure as many patients in this population self discharge, some cannot be seen by the psychiatric service because of early discharge or delays, and others refuse to answer research questionnaires.23⁻25 Among those responding, nearly a fifth of those who presented in the week after the index Casualty episode reported having seen it, and a fifth of these said that it had influenced their decision to take an overdose. Of those who had seen the episode, 17% said that it had influenced their choice of drug, usually in the direction of taking paracetamol but sometimes the opposite. This illustrates the complex nature of media influences on suicidal behaviour.

Conclusions

Our findings about short term changes in presentations for self harm are in keeping with those of an earlier study in adolescents in the United States,10 and raise serious concerns about the facilitating effect on suicidal behaviour of media portrayals of self poisoning or self injury. This is especially so for popular soap programmes. In addition to being associated with an increase in self harming behaviour, media portrayals seem to influence the choice of method, which is particularly dangerous if it concerns a method such as paracetamol overdose.

Those responsible for writing and producing such programmes must take this seriously. It is questionable whether methods of self harm should be portrayed. Media producers should consider how their clearly influential role could be used to encourage help seeking in those at risk and hence contribute to prevention of this major health problem. Joint production of consensus guidelines about this matter by media staff, researchers, and clinicians would be an important step in the right direction.

Acknowledgments

We thank Barbara Machin for her contribution to the study, the BBC for supplying detailed audience viewing figures, and the Office for National Statistics for supplying mortality data.

Footnotes

Funding: This study was funded by the Nuffield Trust. KH and SS were also supported by Anglia and Oxford NHS Executive Research and Development Committee.

Competing interests: None declared.

References

2. Gunnell D. Reporting suicide. The effect of media coverage on patterns of self harm. BMJ. 1994;308:1446-1447. [ Google Scholar]

6. Wasserman IM. Imitation and suicide: a re-examination of the Werther effect. Am Sociol Rev. 1984;49:427-436. [ Google Scholar]

16. Bero L, Grilli R, Grimshaw J, Oxman A, eds. The Cochrane Effective Practice and Organisation of Care Group (EPOC) module of the Cochrane database of systematic reviews. In: Cochrane Collaboration. Cochrane Library. Issue 3. Oxford: Update Software, 1998.

24. Hughes T, Hampshaw S, Renvoize E, Storer D. General hospital services for those who carry out deliberate self-harm. Psychiatr Bull. 1998;22:88-91. [ Google Scholar]

Articles from The BMJ are provided here courtesy of BMJ Publishing Group

# data[].attributes.attachment_link.title
Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

# data[].attributes.attachment_link.description
Keith Hawton, professor of psychiatry,a Sue Simkin, research assistant,a Jonathan J Deeks, medical statistician,b Susan O'Connor, consultant psychiatrist,c Allison Keen, research assistant,d Douglas G Altman, director,b Greg Philo, research director,e and Christopher Bulstrode, professor of orthopaedics d To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

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Thoughts of suicide can be abundant and frequent for some. These thoughts easily disrupt the lives of not only the suicidal person but the world around said person. It may, however, be possible to tell someone is suicidal before it's too late. Participants of committee on the Pathophysiology and Prevention of Adult and Adolescent Suicide of the Institute of Medicine's held two workshops, Risk Factors for Suicide, March 14, 2001 and Suicide Prevention and Intervention, May 14, 2001, to discuss the topic of suicide. The two workshops were designed to allow invited presenters to share with the committee and other workshop participants their particular expertise in suicide, and to discuss and examine the existing knowledge base.

Risk Factors for Suicide: Summary of a Workshop summarizes the first workshop whose participants were selected to represent the areas of epidemiology and measurement, socio-cultural factors, biologic factors, developmental factors and trauma, and psychologic factors. They were asked to present current and relevant knowledge in each of their expertise areas.

# data[].attributes.attachment_link.description
Thoughts of suicide can be abundant and frequent for some. These thoughts easily disrupt the lives of not only the suicidal person but the world around said person. It may, however, be possible to tell someone is suicidal before it's too late.

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Table of Contents

Westview Special Studies in Peace, Conflict, and Conflict Resolution -- General Introduction -- Moral and Philosophical Inquiries -- Introduction -- War and Massacre1 -- Anarchism and World Order -- Contrasting Approaches to Conflict -- Ethological and Psychological Inquiries -- Introduction -- The Lorenzian Theory of Aggression and Peace Research: A Critique -- The Frustration-Aggression Hypothesis -- The Social Learning Theory of Aggression -- Cultural and Anthropological Inquiries -- Introduction -- Anthropology and the Study of Conflict -- Peaceful Societies -- Internal War: A Cross-Cultural Study -- Sociopsychological Inquiries -- Introduction -- Personality Dynamics and Social Conflict -- Psychological Factors in Civil Violence -- Aggressive Behaviors Within Politics, 1948-1962: A Cross-National Study1 -- Sociological Inquiries -- Introduction -- The Nature of Conflict -- Some Social Functions of Violence -- Societal Approaches to the Study of War -- Socioeconomic Inquiries -- Introduction -- The Economic Foundations of Wars: A Soviet View -- Some Thoughts on the Nature of Economic Imperialism -- A Structural Theory of Imperialism -- Decisionmaking Inquiries -- Introduction -- Hypotheses on Misperception -- Crisis, Stress, and Decisionmaking -- Comparative Case Analysis of Crisis Decisions: Korea and Cuba -- International Systemic Inquiries -- Introduction -- National Images and International Systems -- Patterns in International Warfare, 1816-1965 -- Cause, Surprise, and No Escape -- Normative Inquiries -- Introduction -- International Law and the Control of Force -- The Grotian Conception of International Society -- Unravelling the Future of World Order

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The War System: An Interdisciplinary Approach

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This anthology discusses the war system and provides a rigorous social science approach that is sensitive to values. It premises the etiology of war on a complex reality that builds understanding by investigating all major structural and behavioral variables of the human situation.

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Table of Contents

Part 1: The Media 1. The Role of the Media 2. Historical Trends Part 2: Positive and Negative Themes 3. Stigma, Labelling and Social Exclusion 4. The Positive Depiction of Mental Health Issues Through the Media 5. The Association Between Madness and Violence Part 3: Media Sources 6. The Press 7. Literature 8. Film 9. Television 10. The Internet Conclusion

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Mental Health Issues and the Media: An Introduction for Health Professionals

# data[].attributes.attachment_link.description
Mental Health Issues and the Media provides students and professionals in nursing and allied professions, in psychiatry, psychology and related disciplines, with a theoretically grounded introduction to the ways in which our attitudes are shaped by the media.

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The Netflix series, 13 Reasons Why, has caused a furor. In the show, a high school student who has died by suicide has left 13 tapes, one for each person she believes have contributed in some way to her eventual decision. Each episode relates to an individual tape. The penultimate episode depicts the suicide in a gruesome manner. Some say the series is an accurate and sensitive portrayal of the inner angst of an individual that will help enlighten us as to the motivations behind suicidal behaviour and suicide itself. Such an openness can only be good and may be helpful to others in similar predicaments. Critics, though, have worried that it may glamorise suicide or normalise it as a legitimate option when dealing with interpersonal predicaments-leading to more suicides.

It is well known that suicide can be a contagious phenomenon. "Copycat" suicides are seen in local clusters from time to time. Any possible causes of such contagion should be taken seriously, but the science shows that the role that fiction can play in inspiring suicide is at best unclear. 13 Reasons Why is not the first work of fiction to be embroiled in this type of controversy. Shakespeare's Romeo and Juliet has been accused of glamorising suicide. Johann Wolfgang von Goethe's novel, The Sorrows of Young Werther, released in 1774, describes the pain and heartache experienced by Werther because of his affection for Charlotte, who eventually married Albert, Werther's friend. Unable to cope, Werther decides that one of them must die and ends up shooting himself with Albert's pistol. It was widely believed that von Goethe's work led to a wave of young men deciding to end their lives all over Europe, many of whom were dressed in the same clothing as von Goethe's description of Werther and using similar pistols. Some even had the copies of the novel beside their bodies with the page opened to the page of the suicide scene. The suicide researcher, David Phillips, coined the term, "The Werther Effect," to refer to the phenomenon of copycat suicides. The result of Phillips' research from the 1970's was the recommendation that stories about suicide not be placed on the front page of newspapers.

In Vienna of the 1980's, a spate of subway suicides was combatted by the city's main newspapers' decision to substantially curtail the publicity surrounding these deaths. After a certain date, these suicides were no longer mentioned. This coincided with a progressive fall in the number of subway suicides illustrating the power for good of the media.

Counteracting the Werther Effect, though, is the Papageno Effect, taking its name from the character, Papageno in Mozart's Opera The Magic Flute. Papageno tries to hang himself after he's convinced that he will never win over his love, Papagena. He is persuaded, though, by 3 child-spirits not to end his life.

Research has shown that excessive media coverage of suicides of celebrity figures actually has led to an increase in suicide attempts and ideation. Women in their 30's were more at risk of suicide after Marilyn Monroe's death in 1962. Suicide experts King-wa Fu and Paul Yip examined the impacts of the deaths of 3 Asian celebrities on suicide using a time series analysis comparing the deaths in the weeks before and after the suicide. They found a substantial rise in the number of suicides in the first, second and third weeks after the death of each celebrity in Hong Kong, South Korea and Taiwan compared to a reference period. This was even more the case with people of the same gender as the celebrities.

However, the research evidence in relation to fictional portrayals of suicide in TV and film is more complicated. Pirkis and colleagues reviewed the literature regarding film and television drama portrayals of suicide. The group was unable to offer conclusive answers to questions surrounding the impact of fictional suicides on actual suicidal outcomes in the general population.

Studies attempting to assess the effect of broadcasting an episode of the British soap, Eastenders, on March 2nd, 1986 have been conducted. This episode featured an attempted overdose by a female character in her 30's. The studies attempted to assess the attendance at emergency departments in the UK before and after the episode. Some of the studies provided evidence for a copycat effect, but some did not. Mixed findings were reported in others. Therefore, it just cannot be concluded whether fictional portrayals of suicidal behaviour on film and television increase its incidence in the population. While it is certainly true that over-the-top media representations of suicide of celebrity-type figures will have a copycat effect, it does appear that the public at large are able to distinguish fact from fiction.

Nevertheless, we should be aware of the Werther and Papageno Effects. It is difficult to see how the fictional portrayal of suicide in an explicit manner could have a positive effect in any way unless, of course, the downsides of suicide in terms of its effect on relatives and friends are also strongly portrayed. From a deterrent perspective, the gruesome nature of the suicide itself may be a positive feature, and the same could be said of the adverse effects on the survivors. However, the message that suicide can have simple, or a simple set, of causes, or that suicide represents some type of solution, is unfortunate. There is never one reason why, or even thirteen.

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The Netflix series, 13 Reasons Why, has caused a furor. In the show, a high school student who has died by suicide has left 13 tapes, one for each person she believes have contributed in some way to her eventual decision. Each episode relates to an individual tape.

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Werther vs. Papageno —

A Netflix series fueled heated debates about the risk of copycat suicides in fiction.

Enlarge / Back in 2017, the first season of the Netflix series 13 Reasons Why sparked controversy about suicide contagion. Four years later, a new UCLA study offers guidance for Hollywood on how to best handle such topics going forward.

Netflix

When 13 Reasons Why debuted on Netflix on March 31, 2017, it was initially met with mostly rave reviews from critics and viewers alike. Viewers appreciated the show's frank and sensitive handling of such complex topics as suicide, bullying, rape, and depression. Within weeks, however, mental health professionals began voicing strong objections to the YA-targeted show's treatment of suicide in particular—these professionals believed the depiction could trigger suicidal thoughts or actions in vulnerable teens.

It's well known that high-profile suicides can sometimes influence copycats, but the issue is less clear when it comes to fictional stories. Throughout the last four years, multiple, often contradictory studies on that very topic have since appeared. Some of the studies show negative impacts, while others show beneficial effects in young people who watched 13 Reasons Why.

The series aired its fourth and final season last year, but 13 Reasons Why continues to inspire research on the potential impact (positive or negative) of fictional stories on teen mental health. A new study available today from researchers affiliated with UCLA's Center for Scholars and Storytellers focuses specifically on the show's third season, and it shows that series like 13 Reasons Why can have a positive impact on teen mental health as long as the issues are depicted accurately and with empathy.

The report also recommends that appropriate supplementary resources be provided to viewers—which is a major challenge, since most viewers don't engage with such resources even when they are available. But whether it's a streaming series or accompanying readings, the researchers at UCLA's Center for Scholars and Storytellers strongly believe that the media tweens and teens consume plays a crucial role in their development, as it does with any other young demographic.

"I went into the film business because I believe content can change the world," said Yalda Uhls, a former film executive who went on to earn a PhD in child development and now leads this three-year-old research center. "We're working to harness the power of entertainment media for tweens, teens, and young adults, and to support social and emotional learning. There's a long history of doing this for preschool audiences, like Sesame Street and PBS Kids. I felt there was a gap there. The tween and teen years are just as important a developmental period as early childhood."

(Spoilers for 13 Reasons Why below.)

The Netflix series at the center of all this is based on the 2007 YA novel Thirteen Reasons Why by Jay Asher, in which a high school student named Clay struggles in the aftermath of his friend Hannah's suicide. (Asher was moved to write the book after a close relative attempted suicide.) Hannah has left behind seven double-sided cassettes, identifying 13 people she blames for driving her to such a desperate act. It's her way of confronting her tormenters from beyond the grave.

There is the boy who humiliates her after their first date; the girl who spreads rumors about Hannah to hide her own same-sex inclinations; a student who betrays her trust; the bullying jock, Bryce, who rapes Hannah; and the high school guidance counselor who turns a blind eye to Bryce's chronic bullying and rape-y behavior, just to name a few. (Hannah was not Bryce's only victim.) The tapes are mailed out to each person on the list in succession. Hannah's story is told in flashbacks, with present-day events narrated from Clay's point of view.

Asher's novel remained on The New York Times bestseller list for more than three years despite mixed critical reviews, and it ultimately garnered a number of awards. But the story also generated a fair amount of controversy because of its frank depictions of bullying, sexual assault, and suicide. From 2010 through 2019, it was the third most-banned book in the US. The release of the Netflix series only brought renewed attention.

Enlarge / Katherine Langford starred as Hannah Baker, a teen who commits suicide, in the first two seasons of 13 Reasons Why.

Netflix

Apart from a few small deviations, the streaming series hews pretty closely to Asher's novel. There is one key difference, however. In the novel, Hannah kills herself by swallowing a handful of pills. By contrast, the TV series originally included an intense, graphic scene where Hannah slits her wrists in the bathtub. Full disclosure: I was a fan of the first season, and I found that scene to be beautifully rendered and emotionally powerful, albeit extremely difficult to watch. (The two are not mutually exclusive.) So I was frankly surprised when the backlash began. In retrospect, I shouldn't have been.

The backlash begins

By standard Hollywood metrics, 13 Reasons Why was a success. The response, and viewership, was sufficiently strong to spawn three subsequent seasons (which were far less well received). Katherine Langford, who played Hannah, was nominated for a Golden Globe. The series even won a Mental Health America Media Award in 2018 "for elevating the dialogue across the country between parents, students, and mental health advocates on the epidemic of teen suicide, depression, and bullying."

Among those who were not fans was Washington Post television critic Hank Stuever, who compared the show to one of ABC's old afterschool specials. He also objected to the basic storyline. "[It] strikes me as remarkably, even dangerously naive in its understanding of suicide," he wrote. As the weeks wore on, voices like Stuever's began to dominate the conversation.

The backlash centered on the risk of suicide contagion (or copycat suicides) among teens. Suicide contagion is a phenomenon in which exposure to suicide within a family, among friends, or through the media may be associated with an increase in suicidal behavior. Many expressed concerns that the show glamorized suicide, and these critics thought the bathtub scene in particular violated current journalistic guidelines for responsible reporting on suicide.

In April 2017, the National Association of School Psychologists released a statement warning about the potential adverse effects of the series, and the organization also sent a letter to school mental health professionals—the first time it has undertaken such an action. The Society of Clinical Child and Adolescent Psychology (SCCAP) released a similar statement and also criticized the depiction of ineffectual mental health professionals—notably, high school guidance counselor Kevin Porter (Derek Luke), who fails Hannah when she seeks his help after her rape by Bryce.

"From a public health perspective, the producers of 13 Reasons Why (S1) disregarded established science and the evidence that the approach they were set on taking—depicting suicide in a raw and graphic way—would set a blueprint for a vulnerable subgroup, especially those who identified with the main character," said John Ackerman, a psychologist specializing in suicide prevention at Nationwide Children's Hospital in Columbus, Ohio.

Ackerman is quick to emphasize that he is not anti-Netflix. "I am not someone who overstates media effects," he told Ars. "Media, gaming, and social media can be part of the solution if done well. However, the science was strong enough at the time to know there was strong potential for harm. There was virtually unanimous condemnation of this series by the suicide prevention and mental health community. Why? Because they knew what the producers did not—all attention to a problem is not created equal, and modeling suicide as a solution to distress and bullying is dangerous."

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How 13 Reasons Why sparked years of suicide-contagion research

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A Netflix series fueled heated debates about the risk of copycat suicides in fiction.

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In that crucible called high school, the avenging angel and the suicide victim: Dylan Minnette and Katherine Langford in "13 Reasons Why." Credit... Beth Dubber/Netflix

A note to adults in the audience: "13 Reasons Why" is not Netflix's next "Stranger Things."

Based on Jay Asher's 2007 novel of the same title, the series, available Friday, should be of interest mainly to the same age group that put the book on the children's and young-adult best-seller lists. It's unlikely to cross over to their parents.

In tone and style, it resembles a more serious, grimmer cousin of Freeform (formerly ABC Family) series like "Pretty Little Liars" and "Twisted." Like them, it literalizes the idea that teenage life is a mystery, one that adults can't hope to solve.

Young viewers may find the combination of thriller and morbid teenage melodrama in "13 Reasons Why" addictive, though parents should be aware that it contains startlingly naturalistic depictions of rape and suicide.

The rest of us won't have as much patience for the show's excessively convoluted, repetitive and unlikely story, or for the narrative gimmick reflected in its title.

The action begins a few weeks after the death of Hannah Baker (Katherine Langford), a junior at a suburban high school. Clay (Dylan Minnette), a socially awkward classmate who had a crush on her, receives a shoe box full of vintage cassette tapes (Maxell 60s, if you're a nostalgist).

They contain Hannah's descriptions of 13 traumatic events that led to her decision to kill herself, each addressed to the schoolmate or adult who caused that particular trauma. She's left instructions that the box be passed from one tormentor to another, and Clay is late in the list, so most of the other people she accuses have already heard the tapes before he receives them.

The novel began the same way but took place in one night, as Clay listened to the tapes while visiting the scenes of Hannah's downfall. The TV show's developer, the screenwriter Brian Yorkey, has expanded the story to 13 hourlong episodes by beefing up the present-day portion of the narrative (which continually shifts between the past as seen by Hannah and the present as experienced by Clay).

Clay now becomes a detective and avenging angel, confronting other students in a campaign to get to the truth and, in the process, repair Hannah's reputation. The show also makes more room for adults (goosing the drama by having Hannah's parents file a lawsuit against the school), which means that the largely anonymous cast can be supplemented with more familiar and accomplished performers like Brian d'Arcy James, Steven Weber, Keiko Agena and Kate Walsh.

You can understand why the book would, almost inevitably, become a 13-episode series, but the inflation has several unfortunate consequences. Reading a young-adult novel in one sitting, it's easier to suspend your disbelief regarding Hannah's copious misfortunes, which include broken friendships, a fatal auto accident and sexual violence.

Ms. Langford stars as a teenage suicide victim who left behind a box of explanatory tapes. Credit... Beth Dubber/Netflix

We're meant to see that there's an emotional and practical order to these events - Hannah's diminished standing and waning self-confidence lead to new incidents of bullying or abandonment. But the show doesn't make her downward progress convincing. It too often feels artificial, like a very long public service announcement.

Another problem is a storytelling contrivance that quickly becomes irritating. To parcel out the surprises and stretch the drama, the Netflix Clay, unlike the novel's Clay, chooses not to listen to the tapes in one sitting - as any normal teenager would, and as the other fictional teenagers in the show do.

Instead he listens to the recordings one at a time, and keeps confronting the other characters - quizzing them, arguing with them, fighting with them - without knowing the whole story, or his own role in it, even though he could find out with just a few hours of binge listening. It makes no sense as anything but a plot device, and you'll find yourself, like Clay's antagonists, yelling at him to listen to the rest of tapes already.

If you stick with "13 Reasons Why" - and the watchful, smart performance by Mr. Minnette ("Scandal," "Awake") is one reason to make the effort - it builds up some cumulative force. In the last four episodes, two directed by Jessica Yu, one by Carl Franklin and one by Kyle Patrick Alvarez, it achieves a momentum and gravity somewhat equal to its subject matter. (It also throws in a groaner of a pretext for a possible second season.)

You might find yourself skeptical, though, despite the undeniable veracity of some of the show's depictions of high school angst. The overall message - one that probably appeals to teenagers - is that it's possible to figure out why someone takes her own life, and therefore to guard against it happening to others. But the beleaguered school counselor played by Derek Luke may have it right when he tells Clay, you can just never tell.

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Review: '13 Reasons Why' She Killed Herself, Drawn Out on Netflix (Published 2017)

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A note to adults in the audience: "13 Reasons Why" is not Netflix's next "Stranger Things." Based on Jay Asher's 2007 novel of the same title, the series, available Friday, should be of interest mainly to the same age group that put the book on the children's and young-adult best-seller lists.

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W ith expert handling, high school dramas comfortably earn their place in the TV canon. It’s been 20 years since Buffy, and its central conceit – that adolescence is, literally, a horror show – stands up today, although the teenage experience has shifted to an unfathomable degree since 1997. Similarly, My So-Called Life and Freaks and Geeks continue to be relatable, even though the smartest phone they had to be concerned with was fixed to the kitchen wall. There’s a rich seam of action to be found in the melodrama of school corridors, and Netflix’s latest, 13 Reasons Why, attempts to portray almost every aspect of it.

A grim concoction of misdemeanours … there’s a cumulative horror of all these woeful scenarios happening to one girl. Photograph: Beth Dubber/Netflix

It’s based on a 2007 YA novel by Jay Asher, and the central premise is bleak: a 17-year-old girl, Hannah Baker, has killed herself. She leaves behind 13 sides of cassette tape, on which she has narrated the wrongdoings of those around her. Each side concerns the actions of one of her acquaintances; they are supposed to listen, then pass the tapes to the next person, in order to learn what they’ve done, and so that it never has to happen again. Hannah is a martyr of teen angst. We see her tragedy unfold over two timelines, with flashbacks of how it all came to be, and a present-day story in which Clay (supposedly the nerdy, Star Wars-loving kid, with a jaw carved out of stone) attempts to unravel and then avenge the mystery.

Rather than listen to the tapes all at once, Clay takes his time over it, confronting those whose secrets are revealed as he discovers their part in it. This works to the benefit of the 13-episode structure, but drags it out for the viewer, in part because it becomes repetitive. There is a grim concoction of misdemeanours, from bullying to voyeurism, sexual assault to a fatal car crash, all against a backdrop of sex, drugs and nostalgic mixtapes.

There is plenty to admire and its aims are undoubtedly ambitious. Dylan Minnette, who plays Clay, handles a tough role with sensitivity and resists the urge to overegg it; Clay’s struggle to cope with what has happened is one of the more complex diversions in the story. The portrait of grief that Grey’s Anatomy’s Kate Walsh conjures up as Hannah’s mother is devastating and, at times, hard to watch. While this does not necessarily make it a pleasurable viewing experience, the fact that it’s unflinchingly awful – think Lord of the Flies, The Secret History and Heathers mixed up in a Californian high school – has some power. It’s particularly brave in its depiction of the behaviour of young men, both towards girls and with each other, and if its intended audience comes away with a recognition that this is not normal, and does not have to be normal, that can only be a positive.

Though it is funny, at times, it is largely one-note – and that note is horrifying … Dylan Minnette and Katherine Langford as Clay and Hannah. Photograph: Beth Dubber/Netflix

But it’s unfortunate that a show so concerned with the catastrophic effects of misogyny doesn’t manage to avoid some pitfalls of its own. The decision to depict rape graphically, and not briefly, either, was obviously taken with the intention of insisting we witness its brutality; personally, I found it to tip towards the gratuitous. Likewise a storyline that suggests the love of a sweet boy might have sorted all this out added to an uneasy feeling that stayed with me – that this was more about boys than girls, even though the ruined life of a girl is at its centre. I wonder about its handling of suicide, which again is depicted graphically; one of the adult characters says there’s never really any way of knowing why Hannah did what she did, and I found myself on his side in that, even though I don’t think that is what we’re being led to feel.

It’s also one of those Netflix moments where binge-watching is not beneficial. In the end, the cumulative horror of all these woeful scenarios happening to one girl feels overblown if you watch it in bulk, though I imagine it would have been far more effective in the old way of teasing out the mystery with one instalment a week.

Uneasily, this is a show that seems to be more about boys than girls, even though the ruined life of a girl is at its centre … 13 Reasons Why. Photograph: Beth Dubber/Netflix

Unlike Stranger Things, its appeal is likely to be limited to the age group of those whose lives it depicts; I would be surprised if it lands with adults in the way that it is clearly expected to with teenagers. Though it is funny, at times – “Have you ever heard of the male gaze?” / “We’re not entirely sure what it means, but we think you have it” – it lacks the crossover wit of its forebears (though there are nods to its heritage, with a cameo from Wilson Cruz, My So-Called Life’s Ricky, and some shots reminiscent of Heathers). It’s too tied up in conveying the message that terrible behaviour can have horrible consequences to deal in any subtleties or shades of feeling. It’s largely one-note – and that note is horrifying. “It has to get better,” implores one student towards the end, but given its fairly open ending, an apparent season two setup, it does not seem as if there’s much chance of that happening.

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13 Reasons Why review – sex, drugs and mixtapes in Netflix’s high-school horror show

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This unflinching teen mystery is like Lord of the Flies meets Heathers, and it may have achieved the impossible – being the first Netflix series too bleak to binge

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-Write conclusion
-Edit and check dissertation
-Submit!

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-Write social learning theory, suicide contagion and papageno effect paragraphs

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-Settle back into university
-Finalise chapter plan
-Write introduction

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Iron out gaps in research
Rewatch 13 Reasons Why and consider ways to apply the research to the text

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Head to Thailand!

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Research more into
-Papageno Effect
-Banduras Social Learning Theory

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What extent does televised suicide affect young audiences?

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What extent does televised suicide affect young audiences?

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13 Reasons Why and the Complexity of Suicide

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13 Reasons Why and the Complexity of Suicide

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Exploring participatory culture in the AMV community and the issues that it causes the creative industries

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Exploring participatory culture in the AMV community and the issues that it causes the creative industries