What we do and don’t know about teen suicide.
Although the first season of the Netflix show 13 Reasons Why was released several years ago, its questionable portrayal of adolescent suicide continues to make waves in the suicide prevention community. At first glance, it would certainly seem that the show’s portrayal of a high school student who eventually dies by suicide would raise the risk of suicide contagion. After all, the show’s representation of young Hannah Baker, her struggles with a desire to escape her life, and her eventual suicide seems to flout almost every single rule about safe messaging that exists. And of course, these rules exist for a reason—irresponsible portrayal of suicide and suicidality can absolutely increase the risk for contagion.
Yet the extent to which this show actually led to a noticeable increase in rates of adolescent suicide is very much up for debate. Lately, it often feels like we are going in circles with this question. A recent time series analysis found a significant increase in monthly suicide rates in teenagers aged 10 to 17 following the release of the show. Another time series analysis published in May of 2019 in JAMA had the same finding.
Yet more recently, a reanalysis of these data showed no clear link between the show and adolescent suicide rates. How is this possible? Is 13 Reasons Why partially responsible for a rise in adolescent suicide rates? If not, what is and do we really understand what’s going on? What could be leading to such disparate results and a lack of consensus on the true effects of the show on rates of adolescent suicide?
It seems that some of the research suggesting an increase in suicides as a result of 13 Reasons Why failed to take secular trends into account. That is, there was a background story of an already increasing rate of suicides among teenagers in the U.S., so the rise in the time period following the show may have been expected regardless of the show itself.
This is obviously part of what makes determining the effect of anything in public health so difficult. We usually track large populations over long periods of time without much ability to understand whether the trends we are seeing are due to the “cause” we are studying or whether these trends would have emerged this way regardless.
This problem is similar to not asking “what’s the denominator” when looking at a particular state of affairs in public health. That is, we must strive to understand what’s already going on in the background before we can understand the effect of whatever we are studying. This, of course, is easier said than done, as the easiest way to separate secular trends from effects stemming from a particular, studied cause is through a randomized controlled trial, which is not always possible in public health research.
The question still remains: What could be behind the rise in rates of adolescent suicide? Some blame it on technology, particularly social media and smartphones. Yet just because there is a change in the technology teenagers are using and a concomitant rise in suicide doesn’t mean the two are connected. It is true that social media is associated with anxiety and depression, but even this does not explain the increase, as most people with anxiety and depression do not die by suicide.
Some blame it on the economy, and there does seem to be some legitimacy to this claim. But at the same time, some experts such as Jean Twenge have noted that the trends don’t completely line up with economic patterns or traumatic events like school shootings. There’s also a shortage of mental health professionals in most parts of the country and structural issues like lack of access to care, which has only gotten worse.
The reality is there’s still a lot we don’t know. The issue is complex and we don’t really understand suicide well in any population because it’s still a rare event. For now, the best we can do is continue to study the trends alongside other phenomena to see what might be causing this unsettling change. And of course, we should always correct our mistakes if a conclusion we have drawn may turn out to be not the best representation of reality.
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