Abstract
IMPORTANCE: On March 31, 2017, Netflix released the show 13 Reasons Why, sparking immediate criticism from suicide prevention organizations for not following media recommendations for responsible suicide portrayal and for possible suicide contagion by media. To date, little research has been conducted into the associations between the show and suicide counts among its young target audience. OBJECTIVE: To analyze the changes in suicide counts after the release of 13 Reasons Why. DESIGN, SETTING, AND PARTICIPANTS: For this time series analysis, monthly suicide data for the age groups 10 to 19 years, 20 to 29 years, and 30 years or older for both US males and females from January 1, 1999, to December 31, 2017, were extracted from the Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database. Twitter and Instagram posts were used as a proxy to estimate the amount of attention the show received through social media from April 1, 2017, to June 30, 2017. Autoregressive integrated moving average time series models were fitted to the pre-April 2017 period to estimate suicides among the age groups and to identify changes in specific suicide methods used. The models were fitted to the full time series with dummy variables for (1) April 2017 and (2) April 1, 2017, to June 30, 2017. Data were analyzed in December 2018 and January 2019. MAIN OUTCOMES AND MEASURES: Suicide data before and after the release of the show in 2017. RESULTS: Based on social media data, public interest in the show was highest in April 2017 and was negligible after June 2017. For 10- to 19-year-old males and females, increases in the observed values from April to June 2017 were outside the 95% confidence bands of forecasts. Models testing 3-month associated suicide mortality indicated 66 (95% CI, 16.3-115.7) excess suicides among males (12.4% increase; 95% CI, 3.1%-21.8%) and 37 (95% CI, 12.4-61.5) among females (21.7% increase; 95% CI, 7.3%-36.2%). No excess suicide mortality was seen in other age groups. The increase in the hanging suicide method was particularly high (26.9% increase; 95% CI, 15.3%-38.4%). CONCLUSIONS AND RELEVANCE: Caution must be taken in interpreting these findings; however, the suicide increase in youth only and the signal of a potentially larger increase in young females all appear to be consistent with a contagion by media and seem to reinforce the need for collaboration toward improving fictional portrayals of suicide.