From the Editor

It’s a hit show. Is it dangerous?

Since its launch, 13 Reasons Why has been highly controversial; the storyline of the Netflix series revolves around a teenager’s decision to suicide – which is graphically depicted over three minutes in one episode.

In this week’s Reading, we look at a new Psychiatric Services paper. University of Michigan’s Dr. Victor Hong and his co-authors consider the impact of the show on youth seeking psychiatric care for suicide-related risk. While other studies have analyzed the response in the larger community (including google searches), this study focuses on a vulnerable population. They find: “For certain youths, watching the series correlated with a perceived nonzero elevation in their suicide risk; identification with the main female character and strong affective reactions may be markers of increased risk associated with viewing the show.”

13-reasons-picBig buzz, big problem?

In the other selection, we look at a short essay recently published in JAMA. In “Grief After Suicide,” Dr. Orford discusses the suicide of his brother. The Deakin University intensivist notes that: “As a physician, I have cared for thousands of patients and families in the last hours and days of life. I have listened, watched, and learned.” The loss of his brother, however, continues to have a major effect on his life, three decades later.


Suicide and Culture

“13 Reasons Why: Viewing Patterns and Perceived Impact Among Youths at Risk of Suicide”

Victor Hong, Cynthia J. Ewell Foster, Christina S. Magness, Taylor C. McGuire, Patricia K. Smith, Cheryl A. King

Psychiatric Services, 20 November 2018  Online First

The Netflix series 13 Reasons Why, a recounting of 13 reasons why a high school student chose to die by suicide, was released in March 2017 and has proven both popular and controversial. In 2017, Google searches about the show in the United States exceeded those for any other television or streaming series ( The series has generated significant discussion among parents, teachers, youths, and the suicide prevention community because of its handling of the topic of teen suicide and its graphic depiction of suicide and sexual assault. Some argue that the show glorifies suicide and could negatively influence vulnerable youths, whereas others believe that the series sheds light on important topics, thereby increasing awareness and promoting conversations about the reality of life in high school. Some have recommended that vulnerable youths avoid the series or that Netflix cancel the series. Criticism includes assertions that the producers did not adhere to media guidelines about suicide, citing the evidence regarding suicide contagion. Notably, these concerns exist in the context of the rapid rise in suicide rates for youths in the United States, most significantly among adolescent girls.

In the days following the release of 13 Reasons Why, season 1, suicide-related Internet searches increased markedly, with searches of how to “commit suicide” increasing by 26%. This phenomenon was balanced by an increase of 21% in searches for suicide hotline numbers and an increase of 26% in searches for suicide prevention…

This study was designed to explore exposure, including viewing patterns, to 13 Reasons Why in a sample of youths seeking care at a psychiatric ED for suicide-related risk. The study also examined the perceived impact of the show on participants who reported having watched at least one episode. We expected that vulnerable youths, struggling with suicidal thinking and behavior, would strongly identify with the main female character, Hannah, and that greater identification would be correlated with increased emotional distress and suicide risk. We were also interested in exploring parents’ reactions to the series and the extent to which they were able to provide support to their children post viewing.

victor-hongVictor Hong

So begins a paper by Hong et al.

Here’s what they did:

  • Youths were recruited who were between the ages of 10 and 17, and had presented to a psychiatric ED with a suicide-related concern.
  • Exclusion criteria included psychosis, cognitive impairment, and non-English language.
  • Youth assent and parent or legal guardian consent were obtained from all participants.
  • Different scales were used, including the Reynolds Adolescent Depression Scale (RADS-2) and the Suicidal Ideation Questionnaire-Junior (SIQ-JR). Youth were asked to do a 44-item questionnaire considering “different aspects of youths’ interactions with 13 Reasons Why.” Questions considered quantitative and qualitative items “assessing access to and awareness of the series, number of episodes watched, viewership timeline, reasons for watching (or stopping) the series, how youths viewed the series (e.g., alone, with parents, with siblings, or with friends), and with whom youths discussed the series (e.g., friends, parents, no one, a teacher, or a mental health professional).”
  • Parents also received a survey, similar to the youth questionnaire.
  • Data analyses were done, including both qualitative and quantitative analyses; the former with an iterative grounded theory approach.

Here’s what they found:

  • Of the 186 families approached to participate in the study, 90 (48%) provided consent and assent.
  • Demographics: youth tended to be female (71%), Caucasian (91%), and had some College or a College degree (65%); parents tended to be female (80%), Caucasian (90%), and had some College or a College degree (65%). And in terms of symptoms: the mean RADS score was 96.60, with 90% reporting in the clinical range for depression.
  • Exposure: “Most youths who watched any episodes of 13 Reasons Why reported doing so alone (N=37, 84%). Other youths reported watching the series with friends or siblings (N=8, 18%) or with their parents (N=2, 5%). Whereas 80% (N=35) of youth viewers reported talking to their friends about the series, only 34% (N=15) discussed their reactions with a parent and 16% (N=7) did not discuss their reactions with anyone.”
  • Perceptions of the Show’s Impact: “Of the 41 youths who responded to this question, 51% of viewers (N=21) indicated that they believed watching the series increased their own risk of suicide to some degree.” In terms of common emotional responses, see figure below, which drew data from a 5-point Likert scale (1 is very slightly; 5, extremely).
  • Youth Vulnerability and Perceptions of Impact: “Identification with Hannah was significantly correlated with higher suicidal ideation and depressive symptoms… Identification with Clay was not correlated with symptom severity.” And“Overall, youths expressed more positive than negative opinions about the series, but the number of youths who believed that the series glorifies or normalizes suicide was equal to the number who believed the reverse (i.e., the series does not glorify or normalize suicide).”
  • Perceptions of Impact on Help Seeking: Data was mixed: “Eighteen of the youths who watched all or part of the series (42%) indicated that the series had no impact on whether they talked to others about their concerns… However, 12 youths (28%) reported that the series made them less likely to talk to others, whereas 12 others (28%) reported that it made them more likely to talk to others.”


A few thoughts:

  1. This is a good study.
  1. The authors do a solid job of combining both qualitative and quantitative analyses.
  1. “51% of viewers… indicated that they believed watching the series increased their own risk of suicide to some degree.” Ouch. Larger questions remain unanswered: did watching result in more completed suicides? In the second season, the show has warnings; did that change anything for vulnerable youth?
  1. I spoke to Sunnybrook’s Mark Sinyor, a psychiatrist who has done research on suicide and culture. He notes the deep problems with the show’s portrayal of suicide, from the way it is romanticized to the lack of finality of death (she literally lives on). “13 Reasons Why violates numerous recommendations from media guidelines.”
  1. I’ve made this point before, and it’s worth repeating: as stigma fades and as people feel more comfortable talking about mental illness, topics like depression, substance use, and suicide are more openly considered, including in the arts; we have great opportunities as a society to reach people that haven’t been reached before. But there are also potential problems.
  1. How did others react to the show? After the first season streamed, Ayers et al. wrote a research letter to JAMA Internal Medicine, showing a significant increase in google searches for terms like “how to commit suicide.” They found that such terms were searched 19% more in the 19 days after the release of the show’s first season. That letter was discussed in a past Reading, found here:


Suicide and Culture

“Grief After Suicide”

Neil Orford

JAMA, 13 November 2018 Open Access

Thirty years ago, I lost my brother to suicide. A talented athlete, a gifted photographer, a deeply compassionate man. A lonely act as he tried to shake off the demons of psychosis. The end of a 3-year battle with schizophrenia.

A month ago, my closest friends lost their son. Another suicide. A wonderful, charismatic, clever young man with no known mental illness. Another lonely act, in the early hours of an ordinary weekday. A family left piecing together an incomplete jigsaw of ‘why’ through an impenetrable cloud of loss. An endlessly branching map of possible futures extinguished. Different young men with different lives, joined only by the nature of their death, and the devastation in the lives left behind.

neilNeil Orford

So begins a short essay by Dr. Orford. His piece is short – and doesn’t require much of a summary here. It’s also beautifully written.

The Australian intensivist talks about the loss of his friend’s son, and the absence his family has felt.

My friends have already traversed their son’s 21st birthday without him. Cancelled the party they were handing out invitations to on the day he died. The birthdays of his siblings.

He then notes that parallel with his own loss:

My brother has been absent from every milestone since I was 20 years old. He never met my wife, attended my wedding, met my children, celebrated my successes, shared my failures, or attended our father’s funeral. He has been absent from every family photo for three decades. He has always been present in our minds.

He goes on to talk about the importance of being present for those who have lost. “We can cook, clean, pick up kids, run errands. We can help when they need to restore some normality and routine to their lives.”

Then, thinking ahead to his upcoming fiftieth birthday: “I will wish my brother, my friends’ son, were still here, to share all this with us. To know they were never alone.”

A few thoughts:

  1. This is a beautiful essay.
  1. “He has been absent from every family photo for three decades. He has always been present in our minds.” This is a particularly haunting line.
  1. This essay helps remind us of the weight of suicide – and, by extension, the importance of our work.


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