Review of: Bridge JA et al, J Am Acad Child Adolesc Psychiatry 2020;59(2):236–243

Netflix’s 13 Reasons Why (13RW) continues to generate controversy that it may do more harm than good amid the backdrop of an already increasing teen suicide rate, and CCPR has been watching the unfolding research (see Mar/Apr 2019 and Sept/Oct 2019 issues). Last time, we reported an increased suicide rate in 10- to 19-year-old females during the 3 months following the show’s 2017 premiere (Niederkrotenthaler T et al, JAMA Psychiatry 2019;76(9):933–940). Let’s look at a second, similarly designed study.

Investigators examined CDC-collected suicide and homicide data before and after the show’s release in April 2017. Data were assessed across 5 years (2013–2017) and these age groups: 10–17 years, 18–29 years, and 30–64 years.

Among the show’s target audience (ages 10–17), suicide counts were 28.9% higher than expected in the first month following the series premiere. No excess suicide mortality was found in other age groups or in the control outcome, homicide counts. Overall, there were an additional 195 suicide deaths among 10- to 17-year-olds in the 9 months following the premiere. Suicides beyond expected rates were higher in boys than in girls. (Of note, season 1 depicts a male adolescent character making a serious suicide attempt.) Further, the authors used data showing suicide completion; adolescent girls are 3 times more likely to attempt suicide than boys, but boys are 4 times more likely to complete suicide.

We now have two epidemiological studies that found associations between the release of 13RW and increased youth suicides: one finding a higher rate in girls, the other finding a higher rate in boys. Each study supports potential suicide contagion by media, at least for season 1, based on timing and age specificity. Netflix has since taken measures to try to reduce risk such as adding content warnings, removing the season 1 suicide scene, and publishing an online toolkit for clinicians, parents, youth, educators, and media professionals (www.13reasonswhytoolkit.org). The toolkit summarizes research outcomes from 13RW, counsels that at-risk youth should not watch the series, and cautions against teen binge-watching. It also recommends that if teens watch the show, they should do so with a parent or trusted adult and engage in discussions around viewing risk and how to recognize and seek help for negative reactions, if they occur. This is crucial given the recent release of the series’ fourth and final season.

CCPR’s Take
Based on growing research, it seems apparent that 13RW is problematic for at-risk youths. As mental health providers, we need to be aware of this association and provide psychoeducation to youth and families. Our role includes urging parental engagement and advocating for treatment for at-risk youth, while admonishing the media to value life over profits. Criticism from mental health providers about the show’s content and associated risk led to Netflix’s changes, demonstrating the impact of our collective voices. This situation warrants continued surveillance on suicide rates in association with viewing the series, particularly as the final season was just released in June 2020.