From the Editor

“Hemingway Dead of Shotgun Wound; Wife Says He Was Cleaning Weapon.” So reads the headline from the front page of The New York Times reporting the death of author Ernest Hemingway. It quotes Frank Hewitt, the Blaine County Sheriff, who comments that the death “looks like an accident… There is no evidence of foul play.”

It is well known that writer Ernest Hemingway died by suicide – the sheriff didn’t want to say it. As we as a society discuss mental illness more and more, how do we discuss topics like suicide? For years, of course, we didn’t – or, if we did, reporting was often insensitive.

In last month’s Canadian Journal of Psychiatry, Sunnybrook Hospital’s Mark Sinyor and his co-authors, including other psychiatrists and journalists, suggest guidelines for the reporting of suicide. The effort provides an update of a past report, and includes recommendations for social media.


In this Reading we look at the guidelines, and consider the opportunities and problems of the Twitter era.


Reporting and Suicide

Media Guidelines for Reporting on Suicide: 2017 Update of the Canadian Psychiatric Association Policy Paper

Mark Sinyor, Ayal Schaffer, Marnin J. Heisel, André Picard, Gavin Adamson, Christian P. Cheung, Laurence Y. Katz, Rakesh Jetly, Jitender Sareen

The Canadian Journal of Psychiatry, March 2018

mark-sinyorDr. Mark Sinyor

Scientific evidence from numerous natural experiments worldwide demonstrates that media reporting of suicide can sometimes result in contagion, with increased suicide rates across a population. The association has satisfied the criteria of consistency, strength, temporality, specificity, and coherence required to conclude that there is a causal relationship. The research evidence indicates that, in general, more suicide deaths occur following repetitive reporting of suicide. This relationship is widely known as the Werther Effect, a reference to a 1774 novella published by Goethe describing the death by suicide of a young man who was rejected by the young woman he loved. This suicide contagion effect is thought to be mediated by social learning, whereby a vulnerable person identifies with people depicted in the media and may be more apt to copy their suicidal behaviour and subsequently die by suicide. The effect may be particularly pronounced for youth, a group that can be more susceptible to social learning, and in cases where the media report relates to a celebrity, whose behaviour people may be more prone to emulate. In contrast, the effect does not seem to occur if the person who died by suicide was a criminal. Although the best evidence in this area comes from large, population-based, natural experiments, where it is challenging to prove exposure to media reports, findings from psychological autopsy studies, reviews of suicide notes, and interviews with people who have attempted suicide show that many have or were exposed to suicide-related media content, which influenced suicidal behaviour. More recently, Niederkrotenthaler et al. postulated a corollary effect to the Werther Effect called the Papageno Effect, whereby media reporting emphasizing a positive outcome of a suicidal crisis may be associated with lower subsequent suicide rates. This was based on a latent class analysis examining media and suicide reporting in Austria. The authors found that articles stressing ‘mastery of crisis,’ in which people contemplating suicide employed adaptive coping strategies rather than suicidal behaviour, were associated with a subsequent decrease in the rates of suicide. The ‘active ingredients’ of reporting that mediate contagion of suicide and adaptive behaviour are not fully understood; however, there is general consensus on putatively harmful and protective aspects of media reporting, and these form the basis for media guidelines.

Guidelines for responsible media reporting of suicide have been developed across numerous countries and jurisdictions worldwide. Several guidelines have been produced in Canada, including those from the Canadian Psychiatric Association, the Canadian Association for Suicide Prevention (CASP), and the Mindset guidelines developed by journalists themselves. Media guidelines have demonstrable impact on the quality of reporting on suicide and, in some cases, have been associated with lower suicide rates. It is estimated that guidelines can prevent more than 1% of suicide deaths; such a reduction in Canada would translate to the prevention of more than 40 deaths per year across the country. Canadian studies examining media reporting—in general and per the guidelines above—are limited. A recent study examining adherence to Mindset’s 14 specific recommendations in the aftermath of a celebrity suicide found that most recommendations were followed (range of adherence was 65% to 99% of articles), except for the recommendation to tell people considering suicide how they can get help (present in only 27% of articles).

So begins the new guidelines. The authors make several core recommendations:

  1. Health reporters, not crime reporters, are best positioned to cover suicides.

The authors write simply: “The notion that suicide is a crime rather than the result of a mental disorder is archaic.”

  1. Reports should generally avoid details of suicide methods, especially when unusual or novel methods are involved.

“There is growing evidence that media reporting on novel methods of suicide has led to dramatic increases in suicide deaths by these methods and in overall suicide rates in various areas of the world.”

  1. Emergency resource links should be included in all articles that deal with suicide.

Noting that guidelines “universally” advise this, they also add: “Online platforms afford an opportunity to go a step further. Reports themselves can be accompanied by embedded links to crisis services to facilitate access, thereby decreasing barriers to help-seeking.”

They also make suggestions with regard to “largely uncharted territory” of social media:

  1. A novel collaboration between Canadian mental health professionals and social media organizations.

They recommend “the CPA and mental health professionals should organize meetings, symposia, and forums to address the topic of suicide collaboratively with social media stakeholders.”

  1. Social media organizations should consider the degree to which they might be used as a platform for suicide prevention.

“Specific efforts may include 1) providing information and resources to people who make suicide-related queries or posts, 2) including “panic buttons” that allow for rapid access to crisis services/hotlines, 3) providing mechanisms for users to report if they are concerned about someone with the possibility for rapid intervention, and 4) moderating forums that frequently include suicide-related postings and making sure to remove inappropriate posts.”


A few thoughts:

  1. These guidelines are very thoughtful.
  1. Though not without controversy, the comments on the contagion aspect to suicide are fascinating. The Werther Effect makes the importance of this project obvious. It also raises larger questions about the psychiatric illness, our behaviour, and our culture. Suicide may be the result of illness (Hemingway had struggled with bipolar disorder for years) but it is ultimately a behaviour, and thus coloured by other factors including, yes, the suicide of others.
  1. Social media is changing the world of journalism. And there are implications for what and how people hear about mental illness and, of course, suicide. Consider, for example, a blogger’s decision to go to “Suicide Forest” near Tokyo and post pictures of a person who had suicided. The blogging made international headlines. You can find an article about it here: Note that the original video was viewed six million times. Social media makes it easy to share life’s experiences – with an iPhone and a Facebook account, we can tell people about our birthdays, our dinner outings, and our favourite books. But it’s also easy to report in a way that is uninfluenced by media standards or even good taste. Whereas traditional media has a filter – an editorial process that oversaw the writing and printing of articles – social media is unfiltered.
  1. The rise of social media isn’t all bad. As Sinyor et al. argue, there is also the potential to observe problems and deploy solutions in real time. After all, the person who is busy chronicling his life on Facebook or who is tweeting about her day-to-day activities on Twitter may be giving clues of increased suicidal thoughts. Sidney Kennedy and Trehani M. Fonseka, both of St. Michael’s Hospital, write on research being done in this area. “Early in 2018, the Public Health Agency of Canada announced a pilot project with Advanced Symbolics, an Ottawa-based AI company which successfully predicted Brexit, Trump’s presidency and results of the 2015 Canadian election. The project will research and predict regional suicide rates by examining patterns in Canadian social media posts including suicide-related content, although user identity will not be collected.” The full article can be found here:
  1. Nearly six decades ago, Hemingway died “of a gunshot wound.” Today, how would we hear about it? Perhaps through social media – for better and for worse.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.