Review of: Niederkrotenthaler T et al, JAMA Psychiatry 2019. doi: 10.1001/jamapsychiatry.2019.0922

Several studies have examined whether Netflix’s 13 Reasons Why is good or bad for teens. Results have been mixed. In the CCPR March/April 2019 issue, we reported a study finding that most suicidal ideation decreased after watching the first season of the series (Zimmerman A et al, J Am Acad Child Adolesc Psychiatry 2018;57(8):610–613). But other findings include increases in suicide-related hospitalizations and self-harm. Now a new article has been published looking at actual suicide data.

Investigators examined CDC-collected suicide data before and after the show’s release in April 2017. Monthly data across 19 years (1999–2017) was used to estimate expected suicide counts. Twitter and Instagram posts, a proxy for viewership data, estimated that social media attention from the show was highest in April 2017 and trivial after June 2017. As such, only these 3 months following the show’s release were explored. Suicide counts and methods were compared across these age groups: 10–19 years, 20–29 years, and 30 years or older.

Among the show’s target audience (ages 10–19), suicide counts were about 15% higher than expected in the 3 months following the series premiere. No excess suicide mortality was found in other age groups. Excess suicides were higher among girls versus boys (22% vs 12%). The 27% increase in hanging suicide was particularly high compared to other methods (such as cutting, which was the method used in the show).

Study strengths include analysis of suicide counts instead of proxies (eg, hospitalizations, symptoms, and attitudes), suicide methods, and various age groups. The time series analysis also accounted for trends, temporal fluctuations, and seasonal fluctuations in suicides. Because this is an observational study at a population level, it is unknown whether those who committed suicide watched the series. Netflix also added content warnings to the show in May 2017. It is unknown what effect, if any, this has had on results.

CCPR Take
Since the first season, the show has shifted its tone from authentic teen experience to a mashup of who-done-it mystery and #MeToo shoutouts. While this show may promote dialogue about teen depression and suicide and about help-seeking behaviors, we must ask: At what cost? This study identifies an association between release of 13 Reasons Why and an increase in youth suicides. The timing, age specificity, and gender specificity of the associations, at least for the first season, is consistent with potential suicide contagion by media. This study suggests an association, not causation. Nonetheless, it highlights the importance that media portrayals of suicide follow best practices to reduce possible unintended consequences. It also suggests caution may be warranted with exposing vulnerable teens to certain kinds of media.