Doctor visits about suicidal thoughts rose with '13 Reasons Why.' Handle Season 2 with care.
On March 31, 2017, Netflix released the series 13 Reasons Why, a program documenting events leading to the suicide of a fictional teen. The series generated enormous debate over whether its graphic content could spur self-harm among vulnerable viewers.
And rightly so. One study demonstrated a 19% increase in Google searches related to suicide after the show’s release, including "how to commit suicide," "commit suicide" and "how to kill yourself." The study suggests that the show might have raised awareness of suicide but could also have led some people to actively contemplate suicide.
With the arrival of Season 2, is there renewed cause for concern?
We believe so, based on our study of millions of doctors’ visits by 14- to 20-year-olds during the weeks before and after the release of Season 1 on March 31, 2017.
Using electronic health record data from AthenaHealth, an information technology company that supports more than 4,500 physician practices nationally, we analyzed the proportion of doctor visits that were for suicidal ideation. We hypothesized that visits for suicidal ideation would increase in the months following the release of 13 Reasons Why (we compared January-March 2017 with April-June 2017). We also studied the identical periods in 2016 because a similar increase in doctor visits after March 31, 2016, wouldn’t be expected to occur.
The proportion of visits involving suicidal ideation was stable between January and March 2017 (about 0.19% of all visits). Following the release of 13 Reasons Why, the proportion of visits involving suicidal ideation increased sharply to 0.27% of visits in April and 0.29% of visits in May — a more than 40% relative increase. A similar pattern wasn’t observed in 2016.
These findings are worrisome. To be sure, the observed increase in doctors’ visits for suicidal ideation could reflect an increase in the number of teens seeking help as a result of viewing the show.
Even so, when the increase is taken together with the documented jump in online searches for ways to commit suicide, the alternative explanation of contagion in suicidal thinking is impossible to ignore. Unfortunately, national mortality statistics lag by several years, so we don’t know whether actual suicides increased after the show’s 2017 release.
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The World Health Organization has recognized the importance of careful depictions of suicide by the media and has published suicide prevention guidelines that specifically oppose realistic portrayals of suicide.
To its credit, Netflix has responded to these and other concerns of health professionals by commissioning research to produce a better understanding of how teens and parents related to the original 13 Reasons Why series — and to inform how Season 2 can be most safely presented.
Among several initiatives, cast members in Season 2 will come out of character at the start of the season to discuss issues of depression, suicidal thinking and how to get help.
That’s good, but it’s not enough. Health care providers, particularly those caring for vulnerable teens, should be aware of the Season 2 release and the impact it might have on suicidal thinking and behavior. Some have recommended that at-risk youth not view the show — which could well be good advice.
Everyone should agree that better data are also critical. We do not yet know whether Season 1 actually increased suicides or suicide attempts. But the current evidence, including our own, offers reason for concern. It justifies a general warning for both disseminators and viewers of shows of this kind: Handle with extreme care.
Anupam B. Jena teaches at Harvard Medical School. Josh Gray directs research at AthenaHealth. Cass R. Sunstein teaches at Harvard Law School. Follow them on Twitter: @AnupamBJena, @JoshGray_hit and @CassSunstein