by Alex Masurovsky
A recent study suggests that the Netflix series 13 Reasons Why, which seems to have been written in part to challenge the culture of silence and stigma surrounding suicide, may have actually played a part in raising the suicide rate in the month following the release of the series online.
Based on the 2007 novel by Jay Asher, 13 Reasons Why follows the lives of several American high school students after the suicide of a female classmate. She has left behind cassette tapes recorded shortly before her death as a sort of suicide note detailing her psychological pain. The people from her life – former friends, sexual partners, “frenemies,” admirers – are left to decipher the tapes and deal with the aftermath.
The study, which spans various research groups including the National Institute of Mental Health (NIMH), analyzed data on suicides in the US, freely available for download from a mortality database on the Centers for Disease Control and Prevention (CDC’s) website . The researchers used correlational methods to determine if the release of 13 Reasons Why may have had an impact on the suicide rate , joining a continuing dialogue around suicide, mental health and the responsibilities of the media.
The researchers looked at data from a five-year period surrounding the release of the series on Netflix on March 31, 2017, so as to include a large chunk of contemporary time to serve as a baseline. They found a significant increase in the suicide rate for boys ages 10-17 in April 2017, the first month the series was available for streaming on Netflix. This “28.9% step increase”  was found after controlling for a general increase in suicide rates and seasonal fluctuations. The national homicide rate served as a control, as previous research suggests that it is influenced by some of the same environmental factors (e.g., an economic recession) that also impact the suicide rate.
While a correlational study cannot prove that the series caused a raise in the suicide rate, it hints at the possibility. The chilling implications of a that possibility are made clear by a line in the study report which translates the apathetic, statistical term “suicide rate” into a number of human lives lost: “We estimate that the series’ release was associated with approximately 195 additional suicide deaths in 2017 for 10- to 17-year-olds.” 
When I read the press release for this study on the NIMH’s website , my first thought was: is this clickbait? The NIMH is a large and reputable scientific organization, not a tabloid news hub. Even in the competitive world of online news, one hopes a source such as this is more inclined to cautious scientific statements than sensationalism.
My generation’s parents lived much of their lives in a pre-internet world, a world where TV deaths were bloodless and elegant. They feared the corrupting influence of our godless first-person shooter video games and gory, violent films – what they might do to our supple neocortices, our young ventral tagmentae. We, of course, assumed their fears were akin to concerns about the radiation dangers from microwave ovens.
So when I heard about this study, I had to look into it further.
Bridge et al.  cite previous research touting both the helpful and harmful powers of the media: to raise awareness of suicide risk and encourage people to seek help , as well as to increase the possibility of self-harm in those already at risk, known as “suicide contagion.” Also known as the “Werther Effect” (named for a character in the Goethe novel The Sorrows of Young Werther), suicide contagion describes the well-established phenomenon that a publicized suicide can influence other at-risk people to attempt suicide as well (sometimes referred to as a “copy-cat suicide”) . After the release of Goethe’s novel in the 18th century, there were reports of people shooting themselves in the same manner as the title character Werther, resulting in the banning of the book  and perhaps beginning the discussion of the responsibilities of the media and artists in depicting suicide.
Young people are especially at risk, particularly when they identify with the characters or see explicit depictions of suicide methods on-screen . There are research-based guidelines that exist for the media [e.g. 8] which the authors claim went largely unheeded by Netflix. One warning is displayed before the first episode of the season.
There is some real evidence that media generally can have an effect on suicide risk, in the form of suicide contagion. This raises two important questions: is the media responsible for taking action to prevent suicide contagion, or does the responsibility lie with viewers? And did this particular study find strong evidence that this particular series increased the suicide rate?
A closer look at the methods
The primary methods used in this study were a quasi-Poisson regression and Holt-Winters forecasting models. Any questions?
“As far as the methods of analysis are concerned, I think they are reasonable,” says Luke Tudge, a statistics lecturer at Humboldt-Univeristät in Berlin. “I redid the plot for a slightly broader time period running up to the release [of the series] using a quicker, simpler model of the time trend. A good check is whether the conclusion holds if we change the methods of analysis slightly. And it seems they do, more or less” .
Beyond the correlation, using the homicide rate as a control helps to support the study’s claim that something unusual had to have happened around April 2017 which specifically affected suicide rates but not violent crime in general. The authors also note that another study found an increase in internet searches about suicide in that April , as well as an increase in admissions at a local hospital related to suicide attempts [2, 9].
Pamela Rutledge, director of the Media Psychology Research Center, emphasized in an email to Comes to Mind that the limits of a correlation cannot be overstated. “It’s a relationship, not a cause. It is equally likely that people who are contemplating suicide will watch a show about suicide. Beyond that, life is complicated. Nothing happens without other influences and factors, such as social isolation and depression” .
One particularly perplexing aspect of the study’s correlational finding is that it is specific to boys between the ages of 10-17. Dr. Tudge’s impression was that there was “no obvious explanation why this should be the case” . Dr. Rutledge suggests the lack of gender agreement between the study’s findings and the series “makes the application of behavioral contagion theories questionable” .
The study authors were also surprised, having predicted an increase in suicide rates for young women due to the plot centering around the suicide of a high-school aged girl. Previous studies had indicated that “suicide contagion disproportionately affects those who strongly identify with the person who died by suicide (particularly celebrities)” . However, they note that [SPOILER ALERT] at the end of of Season 1, a young male character makes a serious attempt at killing himself with a gun, coinciding with “a well-known gender paradox in suicide … with male rates of suicide being higher than female rates and female rates of attempted suicide being higher than male rates across the lifespan” . The researchers only had access to data about deaths from suicide, not suicide attempts.
Responsibilities: you and the media
This correlational study adds to a continuing study of suicidology, the factors that lead to suicide and the ways we can support our fellow human beings.
While questions remain about artistic expression, media outlets can, at a minimum, provide clear and frequent warnings, so that those who are at risk can avoid exposing themselves to potentially harmful content. Such warnings notices can be easily added without show creators having to compromise on content or stylistic elements . This association study adds to a continuing study of suicidology, the factors that lead to suicide and the ways we can support our fellow human beings.
As for actionable steps for take, Dr. Rutledge has a few more words of advice:
“Parents should use shows like this to start open conversations about difficult topics with their kids, rather than freak out. Teens have a lot of emotions that can be hard to control. This is a development fact. Talking helps kids sort them out. Parents should not worry about TV shows ‘causing’ suicide, but should take advantage of the show to establish communications channels.
“If kids do have issues, they need to have an outlet. If kids are seriously depressed, parents need to know. Depression is a serious mental health issue – a problem independent of TV show content” .
In Berlin, you can check out Berliner Krisendienst if you or someone close to you needs to talk to someone with professional mental health training right away. The NIMH in the US also offers a helpline and and information sheet about suicide prevention.
Another comment in the study’s report brought my childhood to mind: “Numerous media outlets failed to adhere to guidelines for suicide reporting after the death of the actor Robin Williams. This resulted in a roughly 10% increase in suicide deaths in the subsequent five months, representing an excess of 1,841 cases” [2, 10].
 CDC WONDER Online Database, released December, 2018: https://wonder.cdc.gov/controller/datarequest/D77
 Bridge JA, Greenhouse JB, Ruch D, et al., J Am Acad Child Adolesc Psychiatry, 2019
 National Institutes of Mental Health Website
 Sisask M, Varnik A, Int J Environ Res Public Health, 2012
 Halgin RP & Whitbourne S. Abnormal Psychology, 2006
 Meyers DG, Social Psychology, 2009
 Gould MS, Ann. N. Y. Acad. Sci., 2001
 National Recommendations for Depicting Suicide. https://theactionalliance.org/messaging/entertainment-messaging/national-recommendations
 Tudge L, personal communication, 2019
 Ayers JW, Althouse BM, Leas EC, Dredze M, Allem JP, JAMA Intern. Med., 2017
 Cooper MT, Jr., Bard D, Wallace R, Gillaspy S, Deleon S. J Adolesc. Health, 2018
 Stack S, J Epidemiol Community Health, 2003
 Pamela Rutledge, personal communication, 2019
Header photo by freestocks.org on Unsplash