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‘13 Reasons Why’ increases suicide awareness, suicidal ideation

The popular Netflix show “13 Reasons Why” raised awareness of teenage suicide but also elevated suicidal ideation, according to research published in JAMA Internal Medicine.

The finding suggests a need for more suicide screening and prevention efforts in primary care, researchers wrote.

“The Netflix series “13 Reasons Why” explores the suicide of a fictional teen, and the finale graphically shows the suicide over a 3-minute scene,” John W. Ayers, PhD, MA, from San Diego State University, and colleagues wrote. “The series has generated widespread interest (> 600,000 news reports), including debate about its public health implications. For some viewers, the series glamorizes the victim and the suicide act in a way that promotes suicide, while other viewers hope the series raises suicide awareness. To advance the debate, we examined how internet searches for suicide changed, both in volume and content, after the series’ release.”

Ayers and colleagues used Google Trends to evaluate internet search trends in the United States for the term “suicide” between the premier of “13 Reasons Why” on March 31 through April 18. Researchers excluded searches that also mentioned “squad” to account for the movie “Suicide Squad.” They also collected data for the top 25 terms and the next five most related to those terms, excluding duplicate, unrelated or unclear terms, such as “suicide slide” and “suicide bridge,” respectively.

Suicide queries were scaled from 0 to 100 after being divided by the total number of searches. The researchers compared internet search volumes after the release of “13 Reasons Why” with expected search volumes if the series had never been release. They used Hyndman and Khandakar’s autoregressive integrated moving average algorithm and daily trends from Jan. 15 to March 30 to estimate expected volumes.

For the 19 days after the premier of “13 Reasons Why,” all suicide queries were 19% higher than expected search volumes, equating to 900,000 to 1.5 million more searches. The researchers found that suicide queries were significantly higher than expected for 12 of the 19 days studied, ranging from 15% (April 15) to 44% (April 18). A majority (n = 17) of the top 20 related queries were greater than expected and focused on suicidal ideation. Specifically, searches for “how to commit suicide” (26%), “commit suicide” (18%) and “how to kill yourself” were significantly higher. There was also an increase in queries for suicide hotlines, including “suicide hotline number” (21%) and “suicide hotline” (12%), as well as public awareness indicative searches, such as “suicide prevention” (23%) or “teen suicide” (34%).

“‘13 Reasons Why’” elevated suicide awareness, but it is concerning that searches indicating suicidal ideation also rose,” Ayers and colleagues concluded. “It is unclear whether any query preceded an actual suicide attempt. However, suicide search trends are correlated with actual suicides, media coverage of suicides concur with increased suicide attempts, and searches for precise suicide methods increased after the series’ release.”

“The deleterious effects of shows such as “13 Reasons Why” could possibly be curtailed by following the World Health Organization’s media guidelines for preventing suicide, such as removing scenes showing suicide, or addressed by including suicide hotline numbers in each episode,” they added. “These strategies could be retrofitted to the released episodes, included in the planned second season, or applied to other programs. Moreover, programs might undergo testing to evaluate any effect on public health outcomes before release to minimize societal harms.”

Further research aimed at assessing changes in suicide attempts or calls to national suicide hotlines will clarify these findings, the researchers wrote.

In an accompanying editorial, Kimberly H. McManama O’Brien, PhD, from Boston Children’s Hospital, and colleagues wrote that it is encouraging that this study showed an increase in suicide prevention–related searches. Thus, physician preparedness needs to be improved to identify and intervene with youth at risk for suicide, they added.

“Primary care settings offer a key venue for population-wide screening, prevention and early intervention for suicide risk,” they wrote.

“Changing this situation requires development and testing of new medical office systems that increase frequency and quality of screenings, assist clinicians in managing positive results, do not interfere with clinic flow and are effective in reducing patient risk,” they concluded. “Screening, Brief Intervention, and Referral to Treatment is an evidence-based approach which has been shown to increase clinician screening and counseling rates, and impact patient behavior. ... Screening youth for suicidal thoughts during a primary care visit is one viable way to identify youth at risk and connect them to needed care. Beyond the doctor’s office, parents, relatives, friends and school personnel must be attentive to the signs of troubled youth (eg, changes in behavior, worsening school performance, avoiding friends), show interest and concern in their challenges, and seek professional help when needed.” – by Alaina Tedesco

Disclosure: Ayers reports he owns an equity stake in Directing Medicine LLC and HealthWatcher Inc. Please see the study for a list of all other authors’ relevant financial disclosures. McManama O’Brien and colleagues report no relevant financial disclosures.