Suicide Attempt Admissions From a Single Children's Hospital Before and After the Introduction of Netflix Series 13 Reasons Why

doi:10.1016/j.jadohealth.2018.08.028

Journal of Adolescent Health

Volume 63, Issue 6, December 2018, Pages 688-693

https://doi.org/10.1016/j.jadohealth.2018.08.028 Get rights and content

Abstract

Purpose

Release of the Netflix series 13 Reasons Why in March 2017 raised concern over associated suicide attempts. This study aimed to identify trends in self-harm admissions to a tertiary children's hospital with special attention paid to the time after series release.

Methods

Records for admitted patients ages 4–18 years from January 2012 to October 2017 were identified based on ICD codes indicating self-harm. Admissions were grouped by month, and the ARMA (Auto Regression and Moving Average) model was used in analysis. Log transformation was used to obtain a constant variance, and seasonal terms were added for adjustment. A “postintervention” level shift, temporary shift, and linear growth term were incorporated as predictors in ARMA models to test for differences using the series premier as the intervention. Terms from the best fitting model (without intervention effects) were fit to preintervention data and forecast predictions were compared to the observed data from the postintervention period.

Results

Seven hundred seventy-five records were included in analysis. There was an increase of .024 in the log of suicide admission counts per month (p < .001). The model that best explained the data was an ARMA (2,2) model with cubic growth curve terms, a post-intervention level shift, and a postintervention linear growth term, indicating an increase in observed over expected admissions following the premiere.

Conclusions

Suicide admission counts increased over the time series. Actual suicide admissions following March 2017 were higher than predicted using the optimal model, suggesting an effect that temporally coincides with the release of 13 Reasons Why.

Section snippets

Methods

Admission records were obtained for TCH, a 314-bed facility that is the primary statewide tertiary referral center for children in Oklahoma with approximately 10,000 admissions per year from all counties in the state. Hospital electronic medical records for patients aged 4–18 years who were admitted between January 2012 and October 2017 were initially identified based on ICD9 and ICD10 billing codes indicating suicide attempt, suicidal ideation, self-harm, or poisoning [(ICD9 = E950-959),

Results

There were 1701 charts identified in the data screen, of which 926 were excluded due to the final diagnoses not being consistent with SHID or SI. This large number of exclusions from the initial data screen is explained primarily by the breadth of search terms that was used to be reasonably sure to identify all potential SHID/SI events given the limitations and variability of identifying charts by diagnoses codes. For example, the code for adverse event from medication was included, but this

Discussion

The results of this study demonstrate strong evidence of an overall increase in SHID/SI admissions from 2012 to 2017, which is congruent with national data on deaths by suicide previously cited. The model that best fit the data from our institution contained a clear ‘intervention’ effect that coincided with the release and popularity of 13 Reasons Why. Similarly, forecasted counts based on preshow trends significantly underestimated actual counts for the period after series release. While no

Acknowledgments

Partial results were presented in abstract/poster form at the Southern Society for Pediatric Research Regional Meeting in New Orleans in February 2018 and the Society of Pediatric Psychology Annual meeting in April of 2018. Dr.’s Cooper, Wallace, and Deleon drafted parts of the initial manuscript. There was no sponsor for this study and no payment was received by any author in production of the manuscript.

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Longitudinal study of 1445 twin individuals with elevated depressive/anxiety symptoms in late adolescence or young adulthood (age range: 19–30), assessed in Swedish surveys completed in 2005. Through linkage to nationwide registries, individuals were prospectively followed from 2006 to 2018. The outcome included consecutive annual days of SA, which were analyzed using group-based trajectory modeling. Multinomial logistic regression estimating odds ratios (OR) with 95 % confidence intervals (CI) was used to examine associations of age, sex, and educational level with the resulting SA trajectories.
Four distinct SA trajectories were identified in the total sample: ‘high-increasing’ (6 %), ‘low-increasing’ (12 %), ‘high-decreasing’ (13 %), and ‘low-constant’ (69 %). Increasing age was associated with higher odds of belonging to the low-increasing trajectory (OR = 1.07, 95 % CI = 1.02–1.12). Women had higher odds of belonging to the low-increasing trajectory (OR = 1.67, 95 % CI = 1.10–2.53), compared with men. Higher education was associated with lower odds of belonging to high-increasing (OR = 0.34, 95 % CI = 0.22–0.54) and high-decreasing (OR = 0.59, 95 % CI = 0.43–0.81) trajectories, compared with lower education. Few differences were observed in analyses stratified by occupational sector.
Information on potential confounders (e.g., psychiatric comorbidity, work-environment factors) was not available.
Among young adults with prior depression/anxiety, close to every fifth showed rising SA trajectories over time. This calls for targeted strategies to improve public mental health already at young ages.
The Association Between Media-Based Exposure to Nonsuicidal Self-Injury and Emergency Department Visits for Self-Harm
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This study aimed to evaluate the association between media-based exposure to nonsuicidal self-injury (NSSI) and emergency department (ED) visits due to self-harm in Korea, specifically before and after the initial broadcast of the song Barcode, which has an explicit focus on NSSI.
We used the national emergency department information system to obtain data related to ED visits due to self-harm between January 1, 2014, and December 31, 2018. Using interrupted time series regression analysis, we assessed the monthly ED visits due to self-harm before and after the media-based exposure to NSSI on March 30, 2018. In addition, self-harm methods were assessed.
A total of 35,928,834 visits to ED were identified, of which 115,647 were due to self-harm. ED visits due to self-harm showed a significant step increase in the 10- to 14-year-old (β = 0.883, p = .001), 15- to 19-year-old (β = 2.941, p < .001), 20- to 24-year-old (β = 1.997, p = 0.002), and 25- to 29-year-old (β = 1.438, p = .029) age groups, before and after the media-based exposure to NSSI. The most pronounced increase was observed in male participants aged 20 to 24 years (β = 1.790, p = .012) and female participants aged 15 to 19 years (β = 5.158, p < .001). Self-harm by cutting has increased significantly in participants aged 10 to 29 years, and self-harm by poisoning has also increased significantly in participants aged 10 to 19 and 25 to 29 years.
ED visits due to self-harm increased significantly, especially in adolescents and young adults, following the exposure to NSSI. Responsible media reporting on NSSI and appropriate guidelines would help prevent a further increase in self-harm.
We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.
Exploring Place-Based Differences in Suicide and Suicide-Related Outcomes Among North Carolina Adolescents and Young Adults
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Citation Excerpt :
In addition, our time period included the transition from ICD-9 to ICD-10 codes. To ensure homogeneity of codes, we included ICD-10 codes that incorporated poisoning to provide a representative sample of self-injury, suicide ideation, and suicide attempt [17]. These ICD-10 codes mostly closely align with ICD-9 codes to ensure a longer time period and representative sample but likely overestimate self-injury.
Suicide is an ongoing public health crisis among youth and adolescents, and few studies have investigated the spatial patterning in the United States among this subpopulation. Potential precursors to suicide in this vulnerable group are also on the rise, including nonfatal self-injury.
This study uses emergency department data, death certificates, and violent death reporting system data for North Carolina from 2009 to 2018 to investigate spatial clusters of self-injury and suicide.
Findings show that the demographic characteristics of individuals committing fatal and nonfatal self-injury are quite different. Self-injury and completed suicides exhibited different geographical patterns. Area-level measures like micropolitan status and measures of racial and income segregation predicted the presence of high-risk suicide clusters. Suicides among Native Americans and veteran status/military personnel also were associated with higher risk suicide clusters.
Future interventions should target these specific high-risk locations for immediate reductions in adolescent and youth suicides.
Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics
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Citation Excerpt :
Since the release of 13 Reasons Why, multiple studies have confirmed that initial concerns were valid. In a single children's hospital, suicide admissions for patients aged 4–18 were higher than predicted after March 2017 (Cooper et al., 2018). In another single hospital, adolescents 11–18 years of age hospitalized on a psychiatric unit demonstrated that watching the series was associated with an increased likelihood for non-suicidal self-injury (NSSI) (Nesi et al., 2022).
To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents.
Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame.
Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10–17 years, Black race, and female sex. There were no significant findings, overall, for females 6–9 years, but in-patient visits for depression increased in May 2017 for Black females 6–9 years. Males 6–9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors.
Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest.
The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.
Effects of media stories of hope and recovery on suicidal ideation and help-seeking attitudes and intentions: systematic review and meta-analysis
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Another key implication of our study is the issue of harm. There are several examples of well intentioned media messages that have caused more harm than good.25,26,31–34 In contrast to this, stories of hope and recovery do not appear to show harmful effects among those who are vulnerable from the general population and could have some benefits.
There is strong evidence that suicides increase after media stories about suicides by celebrities, particularly those that highlight the suicide method (the Werther effect). Much less is known about the Papageno effect—the protective effects of media stories of hope and recovery from suicidal crises. A synthesis of the retrievable evidence is lacking. We aim to summarise findings from randomised controlled trials about the effects of stories of hope and recovery on individuals with some degree of vulnerability to suicide.
For this systematic review and individual participant data meta-analysis, we searched PubMed (including MEDLINE), Scopus, Embase, PsycInfo, Web of Science, and Google Scholar published from inception to Sept 6, 2021, without language restrictions. We included trials that reported suicidal ideation (the primary outcome) or help-seeking attitudes or intentions (the secondary outcome) and tested a media narrative of hope and recovery. Studies were excluded if they did not feature a clearly positive story of hope and recovery, or had a control group exposed to suicide-related stimulus material. We contacted the lead or senior authors of all original studies to obtain participant-level data for this study. The primary analysis was restricted to individuals with some vulnerability to suicide. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomised trials. The study is registered with PROSPERO, number CRD42020221341.
Our search yielded 7347 records. 3920 records were screened by title and abstract, and 25 full-text records assessed for eligibility. There were eight eligible studies with 2350 participants for which individual participant data were sought. For suicidal ideation, six studies met the inclusion criteria for the primary analysis. Follow-up responses were available for 569 (90%) of 633 participants who were randomised with high vulnerability (345 [55%] allocated to the intervention group and 288 [45%] to the control group). The pooled standardised mean difference (SMD) indicated a small reduction in suicidal ideation of –0·22 (95% CI –0·39 to –0·04, p=0·017; six studies) in the intervention group. For help-seeking attitudes and intentions, four studies met the inclusion criteria and follow-up data were available for 362 (86%) of 420 participants (247 [59%] allocated to the intervention group and 173 [41%] to the control group). The pooled SMD showed no evidence of a difference between the groups (SMD=0·14, 95% CI –0·15 to 0·43, p=0·35; four studies). Low levels of cross-study heterogeneity effects were observed for both analyses (I²=5% [suicidal ideation] and I²=36% [help-seeking attitudes and intentions]). We found no evidence of publication bias.
Media narratives of hope and recovery from suicidal crises appear to have a beneficial effect on suicidal ideation in individuals with some vulnerability, but there is insufficient evidence regarding help-seeking attitudes and intentions. These findings provide new evidence about narratives for suicide prevention.
None.
Suicide and Suicide Attempts During Adolescence
2022, Comprehensive Clinical Psychology, Second Edition
Suicide is a leading cause of adolescent death worldwide. This article summarizes many of the factors that contribute to adolescent death by suicide and suicide attempts. The first portion of this article discusses factors associated with death by suicide and attempted suicide. The second portion of the article describes the clinical evaluation and treatment of adolescents who attempt suicide, with a focus on the use of evidence-based practices. The article concludes with a discussion of future research directions and clinical applications of adolescent suicide research.

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: Conflicts of interest: The authors have no conflicts of interest relevant to this article to disclose.

: Financial disclosure: The authors have no financial relationships relevant to this article to disclose.

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Original articleSuicide Attempt Admissions From a Single Children's Hospital Before and After the Introduction of Netflix Series 13 Reasons Why

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgments

Psychiatr Clin N Am

“13 Reasons Why” Netflix series: Considerations for educators.

‘13 Reasons Why’ depicts a graphic suicide. Experts say there's a problem with that

Media contagion and suicide among the young

Am Behav Sci

Why teen mental health experts are focused on ‘13 Reasons Why’

Suicidal disclosures among friends: Using social network data to understand suicide contagion

J Health Soc Behav

Center for Disease Control and Prevention: National Suicide Statistics

Suicide rates for teens aged 15–19 Years, by sex – United States, 1975–2015

Trends in the prevalence of suicide-related behavior, national YRBS: 1991–2014

A year in bingeing

Ted Sarandos blasts NBC's Netflix rating info: 'Remarkably Inaccurate'

Original article
Suicide Attempt Admissions From a Single Children's Hospital Before and After the Introduction of Netflix Series 13 Reasons Why