13 Things Pediatricians Should Know (and Do) About 13 Reasons Why

In 2017, Netflix released the television show 13 Reasons Why. The show revolves around a teen-aged girl that kills herself. In lieu of a suicide note, she leaves behind a series of cassette tapes that tell the story of why she took her own life, with each person who receives the tapes identified as 1 of the 13 reasons. In the final episode, there is a flashback to the girl graphically committing suicide on screen by cutting her wrists in the bathtub.

Because of the success of the first season, Netflix announced a second season will premier in the spring of 2018. As per Netflix format, the entire season becomes available for viewing at the same time, and the first season remains available indefinitely.

In the show, the teenager who kills herself is immortalized in the audio tapes, which serve as entrées for flashbacks of the story leading up to her death. As soon as the show was released, mental health advocates, including providers and educators, expressed concern that this fictional portrayal of suicide may lead to an increase in teenagers killing themselves.^1,2 

Fictional works have inspired “copycat” suicides or suicide “contagion” before. In the 18th century, The Sorrows of Young Werther led to a spate of young men dressed as the main character of the novel killing themselves with the same method as the protagonist, often with the book at their sides. One month after a British TV show aired an episode about an antifreeze ingestion suicide, there were more antifreeze ingestion suicides reported to the London poison control.³ 

On the basis of research in which authors show which types of media portrayals are most associated with copycat suicides, the World Health Organization⁴ has published guidelines for how media should discuss suicide. Much of the criticism of 13 Reasons Why involves the fact that this fictionalization of suicide violates many of these guidelines because (1) the show depicts suicide graphically, (2) suicide is portrayed as the only possible outlet for the character, and (3) it underemphasizes the main character’s mental health and overemphasizes social contributions to her feelings of hopelessness.

Using Google Analytics, Ayers et al⁵ showed that there was a significant increase in online searches for suicide, including searches for how to kill oneself, in the days after 13 Reasons Why debuted. This increase reflected as many as 1.5 million more searches than expected, with a 26% spike in searches for the phrase “how to commit suicide.”⁵ 

In the months after the show’s release, we began to hear stories within our hospital of patients’ interactions with the television show contributing to their presentations, including several children who had created lists of 13 reasons why they wanted to kill themselves. In a few cases, patients were altering their appearance to mimic the deceased main character. We were dismayed to find out that these anecdotes were far from isolated. When we searched our system’s electronic record for documented references to the show in the 6 months after the show’s release, we found that 13 Reasons Why was explicitly documented over 60 times among 31 pediatric patients. More than three-quarters of the references were in medical encounters related to a suicide attempt, and more than half of the time, the parent or patient expressed concern that the show had contributed to the worsening of their mental health symptoms. Although this was an informal analysis of a single health care system, the presence of references to the show among so many encounters related to suicide was alarming.

Although the narrative of the show is fictional, the reality of suicide among teenagers, particularly those with depression, is one pediatricians know well. Earlier this year, the American Academy of Pediatrics updated its guidelines for management of adolescent depression in primary care to now call for universal screening for depression starting at age 12.⁶ The effects we are seeing of shows such as this can be used to highlight the importance of this new recommendation.

The American Academy of Pediatrics also recommends pediatricians discuss safe media use among school-aged children and adolescents.⁷ The expanding types of subject areas kids are exposed to under the guise of entertainment are highlighted with this show, and the importance of pediatricians’ ability to provide counsel that is relevant to their patients is underscored.

Given the on-demand format of Netflix, many of our patients will continue to watch the show. Accordingly, it may be appropriate for providers to ask about the viewing of the show by name. By asking about it explicitly, without judgement, we can challenge patients who have watched the show to find the unrealistic or inaccurate portions of the story and possibly use it as a natural entrée for further mental health discussion.

When we care for a patient with suicidality or depression, we advise their parents to restrict their access to guns and medications. Because there is growing evidence that viewing shows in which suicide is graphically glorified may be a trigger for suicidal behavior, we feel we should explicitly advise these patients against watching shows like 13 Reasons Why that violate known best practices.

We will continue to raise our concern that 13 Reasons Why and shows like it that portray suicide as escape or allow victims to obtain a posthumous hero worship of sorts are irresponsible and dangerous. Key stakeholders, including health care providers, educators, parents, and producers of future content, should consider the possible ramifications of such work, and we support the calls to reconsider airing this or other shows like it.

Advocates of the show argue that it creates an opportunity for a dialogue about mental health. We agree that such a dialogue is essential and that the media can play an important role in supporting this conversation. As outlined above, pediatricians may even be able to seize this popular phenomenon to support some of these discussions. Yet, the facts remain: 13 Reasons Why violates established best practices surrounding portrayal of suicide in the media. There are clear precedents of similar phenomena leading to increases in suicide and online search behavior about suicide. In the days after the show’s release, a spike was seen in searches about how to kill oneself. Moreover, in our hospital, we found pediatric patients referencing the show as part of their presentations for suicidality. Although opportunity for a dialogue about mental health may be an outcome of this show, we ask, at what cost?

As the show’s popularity continues to rise, we encourage pediatricians and stakeholders to familiarize themselves with the known risks of media’s graphic portrayal of suicide and hope this primer helps inform future discussion and actions to keep children safe.