Association Between the Release of Netflix's 13 Reasons Why and Suicide Rates in the United States: An Interrupted Time Series Analysis

Should Physician-Assisted Suicide or Euthanasia be Legalized in the United States? A Medically Informed Perspective

There is a pressing debate in the United States concerning the implied physicians' obligation to do no harm and the status of legalizing physician-assisted suicide (PAS). Key issues that underpin the debate are important to consider. These include: (1) foundational medical beginnings; (2) euthanasia's historical and legal background context; and (3) the key arguments held by those for and against legalization of PAS. This paper reviews the major claims made by proponents for the legalization of PAS and the associated complexities and concerns that help underscore the importance of conscience freedoms. Relief of suffering, respect for patient autonomy, and public policy arguments are discussed in these contexts. We argue here that the emphasis by healthcare providers should be on high quality and compassionate care for those at the end of life's journey who are questioning whether to prematurely end their lives. If medicine loses its chief focus on the quality of caring-even when a cure is not possible-it betrays its objective and purpose. In this backdrop, legalization of PAS harms not only healthcare professionals, but also the medical profession's mission itself. Medicine's foundation is grounded in the concept of never intentionally to inflict harm. Inflicting death by any means is not professional or proper, and is not trustworthy medicine.

Third Molar Comparison in Class I and II Extraction and Non-extraction Orthodontic Treatment: A Retrospective Longitudinal Study

Objective

This study compared third molar angulation and eruption status in Class I and II malocclusions after orthodontic treatment with and without first premolar extractions.

Methods

The sample comprised 93 patients divided into four groups: Group 1, Class I malocclusion treated with first premolar extractions; Group 2, Class I malocclusion treated without extractions; Group 3, Class II malocclusion treated with first premolar extractions; and Group 4, Class II malocclusion treated without extractions. Panoramic radiographs were used to evaluate the third molar mesiodistal angulations at T1 (pretreatment), T2 (posttreatment), and T3 (long-term posttreatment). Third molar eruption status was assessed in dental casts. Intergroup angulations and eruption status comparisons were performed using one-way analysis of variance (ANOVA), followed by Tukey's test and Kruskal-Wallis test, respectively.

Results

Significantly greater mesial angulation and percentage of erupted right maxillary third molars were observed in the Class I extraction group. Significantly greater eruption status of the right mandibular third molars was observed in the Class I and Class II malocclusion extraction groups.

Conclusion

Class I and II malocclusion extraction treatment exhibited more favorable angulations and a greater number of erupted third molars than non-extraction treatment. The non-extraction groups exhibited a greater percentage of unerupted third molars.

Background and Rationale - CDC Guidance for Communities Assessing, Investigating, and Responding to Suicide Clusters, United States, 2024

To assist community leaders in public health, mental health, education, and other fields with developing a community response plan for suicide clusters or for situations that might develop into suicide clusters, in 1988, CDC published Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters (MMWR Suppl 1988;37[No. Suppl 6]:1-12). Since that time, the reporting and investigation of suicide cluster events has increased, and more is known about cluster risk factors, assessment, and identification. This supplement updates and expands CDC guidance for assessing, investigating, and responding to suicide clusters based on current science and public health practice. This report is the first of three in the MMWR supplement that describes an overview of suicide clusters, information about the other reports in this supplement, methods used to develop the supplement guidance, and the intended use of the supplement reports. The second report, CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters - United States 2024, describes the potential methods, data sources and analysis that communities can use to identify and confirm suspected suicide clusters, and better understand the relevant issues. The final report, CDC Guidance for Community Response to Suicide Clusters - United States, 2024, describes how local public health and community leaders can develop a response plan for suicide clusters. The guidance in this supplement is intended as a conceptual framework that can be used by public health practitioners and state and local health departments to develop response plans for assessing and investigating suspected clusters that are tailored to the needs, resources, and cultural characteristics of their communities.

Suicide and Suicide Risk in Adolescents

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Why Suicide? Suicide Propinquity and Adolescent Risk for Suicidal Thoughts and Behaviors

Suicide represents an international public health concern, and for adolescents aged 14 to 18 in the United States, is the third leading cause of death (Centers for Disease Control and Prevention. 2021 Youth Risk Behavior Survey Data. Available at: www.cdc.gov/yrbs . Accessed on August 30, 2023.). In response to this alarming rate, as well as the relative lack of meaningful progress in the prediction and prevention of suicidal thoughts and behaviors (STB) over the past decades (see Franklin et al., 2017), recent reviews of the suicide literature have advocated for the adoption of novel frameworks and theoretical reexamination of the processes that confer risk for suicide. Currently, the majority of suicide theories emphasize distal factors associated with suicide risk, but these factors also generalize to other types of psychopathology and do not answer the fundamental question of "why suicide?" vs. other maladaptive outcomes. In an effort to address this gap and build off existing theoretical and empirical science from various disciplines, the current theoretical paper will explore the concept of suicide propinquity, the degree of closeness and identification with STB, as a potential moderator of the link between psychological distress and suicide. Specifically, this paper: (1) provides context within the existing theories of suicide, highlighting gaps that might otherwise be explained by propinquity; (2) discusses historical and scientific evidence of suicide phenomena that support the existence of propinquity; (3) explores potential processes of how propinquity may confer risk for STB in adolescence; and (4) suggests future directions for research to examine adolescent suicide from a propinquity perspective.

Systematic Review and Meta-analysis: International Prevalence of Suicidal Ideation and Attempt in Youth

OBJECTIVE

Globally, rates of youth suicide vary considerably. Suicidal thoughts and behaviors (STB) are consistently associated with risk of death by suicide. However, international trends in STB have not yet been compared. To address this gap, an international meta-analysis of epidemiological and school-based studies that report on STB in youth was conducted.

METHOD

Systematic searches were conducted in PubMed and PsycINFO through April 2022. Eligible studies included prevalence of active suicidal ideation (SI) or suicide attempts (SA) in community youth younger than age 22. All studies were coded by 2 authors. Mixed models accounting for shared methods and including hypothesized moderators were conducted using the metafor package in R.

RESULTS

There were 371 effect sizes for SI, 94 for SI with a plan, and 316 for SA, representing 149 regions. Year of data collection ranged from 1981 to 2021. Participants were 6 to 21 years old. The prevalence of SI ranged across regions from 14.3% to 22.6%; the prevalence of SA ranged from 4.6% to 15.8%. Year was not associated with increasing STB prevalence except for studies from the United States, which showed increasing rates of SI and SA since 2007.

CONCLUSION

This is the most comprehensive meta-analysis of STB in youth, providing valuable data about how risk factors most commonly associated with suicide vary internationally and over time. International rates of STB among youth are not improving and may be getting worse in the United States, despite efforts to reduce suicide risk. Most studies did not report rates of SI or SA separately for LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others) youth and youth of color. A better understanding of proximal risk at the individual level will be important to informing future prevention efforts, especially for high-risk groups.

Challenges with using popular entertainment to address mental health: a content analysis of Netflix series 13 Reasons Why controversy in mainstream news coverage

Background

Mental health conditions and psychiatric disorders are among the leading causes of illness, disability, and death among young people around the globe. In the United States, teen suicide has increased by about 30% in the last decade. Raising awareness of warning signs and promoting access to mental health resources can help reduce suicide rates for at-risk youth. However, death by suicide remains a taboo topic for public discourse and societal intervention. An unconventional approach to address taboo topics in society is the use of popular media.

Method

We conducted a quantitative content analysis of mainstream news reporting on the controversial Netflix series 13 Reasons Why Season 1. Using a combination of top-down and bottom-up search strategies, our final sample consisted of 97 articles published between March 31 and May 31, 2017, from 16 media outlets in 3,150 sentences. We systematically examined the news framing in these articles in terms of content and valence, the salience of health/social issue related frames, and their compliance with the WHO guidelines.

Results

Nearly a third of the content directly addressed issues of our interest: 61.6% was about suicide and 38.4% was about depression, bullying, sexual assault, and other related health/social issues; it was more negative (42.8%) than positive (17.4%). The criticism focused on the risk of suicide contagion, glamorizing teen suicide, and the portrayal of parents and educators as indifferent and incompetent. The praise was about the show raising awareness of real and difficult issues young people struggle with in their everyday life and serving as a conversation starter to spur meaningful discussions. Our evaluation of WHO guideline compliance for reporting on suicide yielded mixed results. Although we found recommended practices across all major categories, they were minimal and could be improved.

Conclusion

Despite their well intentions and best efforts, the 13 Reasons Why production team missed several critical opportunities to be better prepared and more effective in creating social impact entertainment and fostering difficult dialogs. There is an urgent need to train news reporters about established health communication guidelines and promote best practices in media reporting on sensitive topics such as suicide.

Responding to Suicide in School Communities: An Examination of Postvention Guidance from Expert Recommendations and Empirical Studies

PURPOSE OF REVIEW

We review the published literature on a school's response after a student dies by suicide ("postvention"). We examine published recommendations based on expert guidance and empirical studies that have evaluated postvention measures.

RECENT FINDINGS

Experts recommend careful communication with family, staff, and students that adheres to published suicide reporting guidelines. Experts also emphasize the importance of identifying and supporting high-risk students. Few robust, controlled studies have identified effective postvention measures. Effective measures tended to occur in group settings (e.g., group therapy), focus on improving grief symptoms, and involve mental health professionals. Postvention has not been robustly studied in the school context. Expert recommendations and a few evidence-backed studies provide the frame for a coherent, school-based postvention response. Further research is needed to strengthen and expand our collective understanding of effective postvention measures in the school context as youth suicide attempts continue to rise.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Screen time and suicidal behaviors among U.S. children 9-11 years old: A prospective cohort study

Suicide is a leading cause of death among adolescents. Emerging literature has described relationships between excessive screen time and suicidal behaviors, though findings have been mixed. The objective of this study is to determine the prospective associations between screen time and suicidal behaviors two-years later in a national (U.S.) cohort of 9-11-year-old-children. We analyzed prospective cohort data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 11,633). Logistic regression analyses were estimated to determine the associations between baseline self-reported screen time (exposure) and suicidal behaviors (outcome) based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5) at two-year-follow-up. Participants reported an average of 4.0 h of total screen time per day at baseline. At two-year-follow-up, 1.38% of the sample reported at least one suicidal behavior. Each additional hour of total screen time was prospectively associated with 1.09 higher odds of suicidal behaviors at 2-year-follow-up (95% CI 1.03-1.14), after adjusting for covariates. For specific screen time modalities, each additional hour of texting (aOR 1.36, 95% CI 1.06-1.74), video chatting (aOR 1.30, 95% CI 1.03-1.65), watching videos (aOR 1.21, 95% CI 1.04-1.39), and playing video games (aOR 1.18, 95% CI 1.01-1.38) was associated with higher odds of subsequent suicidal behaviors. Higher screen time is associated with higher odds of reporting suicidal behaviors at two-year-follow-up. Future research should seek to identify how specific screen time experiences may influence suicidal behaviors.

Towards the Influence of Media on Suicidality: A Systematic Review of Netflix's 'Thirteen Reasons Why'

Online streaming series 'Thirteen Reasons Why' (13RW), released in March 2017, was criticized for its sensationalist portrayal of the main character's suicide, leading some people to voice fears of a global contagion of self-harm behaviors. The current investigation provides a systematic review of original studies analyzing the role of 13RW as an influencing factor for suicide. Articles were identified through a systematic search of Medline, Web of Science, Scopus, PsycInfo, and a manual search of reference lists from inception until the 16 January 2023. Twenty-seven published articles were identified from an initial search of 496 studies. The positive effects of watching 13RW included a reduction in suicide stigma and a greater likelihood to discuss mental health concerns and seek for help. However, several studies reported negative outcomes, including significant increases in the rate of deaths by suicide in adolescents, the number of admissions for suicidal reasons, and the prevalence and severity of suicidal ideation and self-harm behaviors in vulnerable viewers. Still, due to methodological limitations, no causal relationship could be established. Preventive measures are required to alert of the risk and should be particularly addressed to susceptible subjects. Psychoeducational programs should be focused on this kind of phenomena in vulnerable populations.

Pediatric Suspected Suicides and Nonfatal Suicide Attempts Reported to United States Poison Control Centers Before and During the COVID-19 Pandemic

INTRODUCTION

This study investigated the characteristics and compared the trends of pediatric suspected suicide and nonfatal suicide attempts reported to United States (US) poison control centers (PCCs) before and during the first year of the COVID-19 pandemic.

METHODS

An interrupted time series analysis using an ARIMA model was conducted to evaluate the trends of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to the National Poison Data System during March 2020 through February 2021 (pandemic period) compared with March 2017 through February 2020 (pre-pandemic period).

RESULTS

The annual number of cases of suspected suicides and nonfatal suicide attempts increased by 4.5% (6095/136,194) among children 6-19 years old during March 2020 through February 2021 compared with the average annual number during the previous three pre-pandemic years. There were 11,876 fewer cases than expected from March 2020 to February 2021, attributable to a decrease in cases during the initial three pandemic months. The average monthly and average daily number of suspected suicides and nonfatal suicide attempts among children 6-12 years old and 13-19 years old was higher during school months than non-school months and weekdays than weekends during both the pre-pandemic and pandemic periods.

CONCLUSIONS

There was a greater than expected decrease in the number of suspected suicides and nonfatal suicide attempts among children 6-19 years old reported to US PCCs during the early pandemic months, followed by an increase in cases. Recognizing these patterns can help guide an appropriate public health response to similar future crises.

The Association Between Media Exposure to Non Suicidal Self-Injury and Emergency Department Visits for Self-Harm

OBJECTIVE

This study aimed to evaluate the association between media exposure to non suicidal 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.

METHOD

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 exposure to NSSI on March 30, 2018. In addition, self-harm methods were assessed.

RESULTS

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 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.

CONCLUSION

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.

DIVERSITY & INCLUSION STATEMENT

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.

Seasonal suicide trends in adolescents in the US: Did they explain the apparent effect of the Netflix show 13 Reasons Why?

INTRODUCTION

Controversy surrounds the effects of the first season of the Netflix show 13 Reasons Why on adolescent suicide in the United States. This research reexamined the question using more sensitive weekly suicide counts and more sensitive tests for seasonal changes in suicide.

METHODS

Weekly suicide counts for adolescents ages 10-19 and young people ages 20-29 obtained from CDC were analyzed from 2013 to 2018 NVSS Mortality Data using time series methods.

RESULTS

Adolescents ages 10-19 exhibited seasonal changes in suicides that increased from March to April and that also paralleled the school year. The same seasonal pattern was evident in males ages 20-24. There was no evidence of an effect of 13 Reasons in male adolescent suicides in 2017 once seasonality, auto-correlation, and longer term trends were removed.

CONCLUSION

Seasonal changes and secular increases can explain why previous studies observed suicide increases in March and April of 2017 in male adolescents. The association between school year and suicide suggests that stressors associated with schooling increase the risk of suicide in some youth. How to reduce these risks is an important focus for future research as is the need to understand the conditions under which fictional depictions of suicide lead to contagion.

Pediatric poison exposures reported to United States poison centers before and during the COVID-19 pandemic

OBJECTIVE

To assess the association of the COVID-19 pandemic with pediatric poison exposures with a focus on unintentional exposures associated with exploratory behavior among children <6 years old.

METHODS

An interrupted time series analysis was conducted to evaluate the association of the pandemic with poison exposures among youth <20 years old. Exposures reported to US poison centers (PCs) from 1 March 2017 through 28 February 2020 (pre-pandemic) compared with 1 March 2020 through 28 February 2021 (pandemic) were analyzed.

RESULTS

From March 2017 through February 2021, there were 5,244,684 exposures reported to US PCs involving youth <20 years old. There was a 6.0% decrease in poison exposures among youth <20 years old reported to US PCs from pre-pandemic (annual average) to pandemic periods, and there were 93,336 (95% CI: 92,738-93,937) fewer exposures than expected among these individuals during March 2020 through February 2021. Unintentional poison exposures associated with exploratory behavior among children <6 years old accounted for 91.4% of exposures in this age group, and although there were 17,207 (95% CI: 16,951-17,466) fewer of these exposures than expected during the pandemic period, these exposures initially increased during the first two months of the pandemic before decreasing.

CONCLUSIONS

The COVID-19 pandemic was associated with changes in poison exposure patterns among youth <20 years old, resulting in a decrease in the number of exposures reported to US PCs during the first pandemic year. Exposure patterns changed with progression from the initial months of the pandemic to later months and varied by age group and reason for exposure. Unintentional poison exposures associated with exploratory behavior among children <6 years demonstrated an increase during the initial first two months of the pandemic before decreasing. Understanding these patterns will help guide an appropriate response to similar future public health events.

Emergency department visits for self-harm in adolescents after release of the Netflix series ‘13 Reasons Why’

OBJECTIVE

To determine whether the release of the first season of the Netflix series '13 Reasons Why' was associated with changes in emergency department presentations for self-harm.

METHODS

Healthcare utilization databases were used to identify emergency department and outpatient presentations according to age and sex for residents of Ontario, Canada. Data from 2007 to 2018 were used in autoregressive integrated moving average models for time series forecasting with a pre-specified hypothesis that rates of emergency department presentations for self-harm would increase in the 3-month period following the release of 13 Reasons Why (1 April 2017 to 30 June 2017). Chi-square and t tests were used to identify demographic and health service use differences between those presenting to emergency department with self-harm during this epoch compared to a control period (1 April 2016 to 30 June 2016).

RESULTS

There was a significant estimated excess of 75 self-harm-related emergency department visits (+6.4%) in the 3 months after 13 Reasons Why above what was predicted by the autoregressive integrated moving average model (standard error = 32.4; p = 0.02); adolescents aged 10-19 years had 60 excess visits (standard error = 30.7; p = 0.048), whereas adults demonstrated no significant change. Sex-stratified analyses demonstrated that these findings were largely driven by significant increases in females. There were no differences in demographic or health service use characteristics between those who presented to emergency department with self-harm in April to June 2017 vs April to June 2016.

CONCLUSIONS

This study demonstrated a significant increase in self-harm emergency department visits associated with the release of 13 Reasons Why. It adds to previously published mortality, survey and helpline data collectively demonstrating negative mental health outcomes associated with 13 Reasons Why.

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

BACKGROUND

To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents.

METHODS

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.

RESULTS

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.

LIMITATIONS

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.

CONCLUSIONS

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.

Suicidal Depression in Ancient Egypt

OBJECTIVE

To evaluate the oldest record of a depressed individual contemplating suicide.

METHOD

A directed review of ancient Egyptology literature of translations and discussion regarding a papyrus that is approximately 4,000 years old.

RESULTS

The content of the document is consistent with a man going through a severe depression and is contemplating suicide. However, this does not appear to be a suicide note, but more of an ancient example of 'journaling' or working through the thoughts of suicide and its possible consequences to the man's eternal life in the afterworld.

CONCLUSIONS

Presentation of depression, the reasons for considering suicide, and the process by which an individual works through those thoughts have not varied significantly over the past 4,000 years.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Quantitative Methods to Detect Suicide and Self-Harm Clusters: A Systematic Review

Suicide and self-harm clusters exist in various forms, including point, mass, and echo clusters. The early identification of clusters is important to mitigate contagion and allocate timely interventions. A systematic review was conducted to synthesize existing evidence of quantitative analyses of suicide and self-harm clusters. Electronic databases including Medline, Embase, Web of Science, and Scopus were searched from date of inception to December 2020 for studies that statistically analyzed the presence of suicide or self-harm clusters. Extracted data were narratively synthesized due to heterogeneity among the statistical methods applied. Of 7268 identified studies, 79 were eligible for narrative synthesis. Most studies quantitatively verified the presence of suicide and self-harm clusters based on the scale of the data and type of cluster. A Poisson-based scan statistical model was found to be effective in accurately detecting point and echo clusters. Mass clusters are typically detected by a time-series regression model, although limitations exist. Recently, the statistical analysis of suicide and self-harm clusters has progressed due to advances in quantitative methods and geospatial analytical techniques, most notably spatial scanning software. The application of such techniques to real-time surveillance data could effectively detect emerging clusters and provide timely intervention.

Association Between Exposure to Suicidal Behaviors and Suicide Attempts Among Adolescents: The Moderating Role of Prior Psychiatric Disorders

Theories suggest that adolescents exposed to suicide attempts and/or deaths are at higher risk of attempting suicide, themselves. However, research findings have been mixed, with most studies not accounting for psychiatric vulnerability. We examined past psychiatric diagnosis as a moderator of the association between lifetime exposure to suicide attempts and/or deaths and adolescents' suicide attempts. Adolescents (N = 518; 60% female; 45% White), ages 12-21, reported on prior suicide ideation and attempts, and mood, anxiety, and substance use disorders at baseline. Suicide attempts since baseline and exposure to suicidal behaviors were assessed 4-6 years later. Lifetime exposure to family suicide attempts and/or suicide deaths, but not to suicidal behaviors of peers/friends or others, was associated with a suicide attempt at follow-up among those with prior psychiatric disorders. Psychologically vulnerable adolescents may require additional support after exposure to suicidal behaviors of a family member to reduce their risk of attempting suicide.

Quantifying Changes in the Language Used Around Mental Health on Twitter Over 10 Years: Observational Study

BACKGROUND

Mental health challenges are thought to affect approximately 10% of the global population each year, with many of those affected going untreated because of the stigma and limited access to services. As social media lowers the barrier for joining difficult conversations and finding supportive groups, Twitter is an open source of language data describing the changing experience of a stigmatized group.

OBJECTIVE

By measuring changes in the conversation around mental health on Twitter, we aim to quantify the hypothesized increase in discussions and awareness of the topic as well as the corresponding reduction in stigma around mental health.

METHODS

We explored trends in words and phrases related to mental health through a collection of 1-, 2-, and 3-grams parsed from a data stream of approximately 10% of all English tweets from 2010 to 2021. We examined temporal dynamics of mental health language and measured levels of positivity of the messages. Finally, we used the ratio of original tweets to retweets to quantify the fraction of appearances of mental health language that was due to social amplification.

RESULTS

We found that the popularity of the phrase mental health increased by nearly two orders of magnitude between 2012 and 2018. We observed that mentions of mental health spiked annually and reliably because of mental health awareness campaigns as well as unpredictably in response to mass shootings, celebrities dying by suicide, and popular fictional television stories portraying suicide. We found that the level of positivity of messages containing mental health, while stable through the growth period, has declined recently. Finally, we observed that since 2015, mentions of mental health have become increasingly due to retweets, suggesting that the stigma associated with the discussion of mental health on Twitter has diminished with time.

CONCLUSIONS

These results provide useful texture regarding the growing conversation around mental health on Twitter and suggest that more awareness and acceptance has been brought to the topic compared with past years.

Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults

In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.

The Historical Significance of Titicut Follies in Psychiatric Treatment: An Anti-Censorship Perspective

Works of art and information judged as obscene can be censored or banned. This brief review evaluates the costs and benefits of censorship and the banning of artwork and information. In the history of psychology, Frederick Wiseman's film Titicut Follies epitomizes the disadvantages of concealing art content. Despite protecting the privacy of patients, the ban of Titicut Follies delayed the reform of psychiatric treatment practices and hospitals. The decision to censor or ban artistic and scientific information can result in the loss of knowledge and potential improvements to social, political, and economic institution practices.

["And what does that feel like? It feels like nothing. Like a deep, endless, always blank nothing" - A Psychodynamic Interpretation of "13 reasons why"]

The 2017 Netflix series "13 reasons why" also caused a mass media sensation as well as a sensation in the psychiatric and psychotherapeutic world. The series follows protagonist Hannah Baker over the course of 13 episodes, uncovering the 13 distinct plots ultimately resulting in Hanna's suicide by means of audio cassettes she had recorded shortly before taking her own life. Utilising reflective, relational film psychoanalysis according to Hamburger (2018), the topics suicidality, guilt, power and powerlessness, autonomy, identity crisis and aggression can be elaborated on. As empirical studies establish diametrical conclusions whether this TV series exhibits "preventing" or rather "promoting" effects regarding suicidality, this ought to be addressed in the field of psychotherapy. A patient mentalizing the protagonist as well as one's own affective impulses in relation to the series together with the therapist makes transfer of the patient-therapist-relationship to the level of real world relationship possible, whilst also stimulating the (patient's) ability to mentalize in general.

13 Reasons Why: Perceptions and Correlates of Media Influence in Psychiatrically Hospitalized Adolescents

OBJECTIVE

The Netflix series 13 Reasons Why (13RW) has sparked controversy due to graphic depictions of youth suicide, bullying, and sexual assault. However, further research is needed examining experiences of the show among youth with psychiatric illness. This exploratory, mixed-methods study examines adolescents' perceptions of 13RW and associations among viewership, suicide-related media influence processes, and self-injurious thoughts and behaviors (SITBs).

METHOD

Participants were 242 adolescents hospitalized in a psychiatric inpatient facility; 60.7% female, 30.2% male, 9.1% other genders; ages 11 to 18; and 74.3% White, 7.5% Black, and 21.8% Hispanic. Participants completed measures of series viewership, media message processing, and SITBs. Participants who watched completed open-ended questions regarding beliefs and opinions about the series.

RESULTS

In all, 50.4% of participants watched 13RW, with girls (63.3%) more likely to have watched than boys (26.0%). More than half (55.9%) of youth expressed negative reactions to the show, while approximately one-third (33.8%) expressed positive reactions. Having watched the series was associated with greater likelihood of past-year non-suicidal self-injury (NSSI), but not with suicidal ideation or past-year suicide attempts. Youth's interpretation of media messages in 13RW, including greater identification with and perceived likeability of the main character, were associated with suicidal ideation and past-year NSSI.

CONCLUSIONS

Findings suggest high rates of 13RW viewership among psychiatrically hospitalized youth, particularly girls, and provide insight into factors that may affect youths' vulnerability to suicide-related media effects.

The bounds of suicide talk: Implications for qualitative suicide research

Following the implementation of a provincial suicide prevention gatekeeper training initiative in western Canada between 2015 and 2018, we conducted a focused ethnography designed to capture the post-initiative context within one small community. Analyses of our field observations and interviews with community members suggest suicide prevention work is represented in multiple informal or coordinated actions to generate innovative pathways to provoke open conversations about suicide. Simultaneously, suicide talk is constrained and managed to limit vulnerability and exposure and adhere to community privacy norms. Further, parameters around suicide talk may be employed in efforts to construct the community and mental health care in livable ways. As the research process paralleled existing representations of suicide prevention work in the community, this paper explores our entanglement in the bounds of suicide talk during phases of recruitment, data collection and knowledge translation activities.

Investigating Viewership of Season 3 of "13 Reasons Why" and the Mental Wellness of Adolescents: Partially Randomized Preference Trial

BACKGROUND

A conflicting body of research suggests that additional investigation is needed to understand how globally watched television shows featuring social and mental health issues, such as 13 Reasons Why, might affect adolescents' mental wellness.

OBJECTIVE

This study aims to investigate adolescents' viewership of the third season of the Netflix drama 13 Reasons Why (13RW-3) and their engagement with show-related content, paying special attention to mental health outcomes and conversational partners.

METHODS

A panel-based research platform operated by the National Opinion Research Center at the University of Chicago recruited 157 adolescents aged 13 to 17 years from its nationally representative pool of participants. Participants answered questions about how they discussed and learned about social and mental health issues portrayed in 13RW-3 (eg, masculine role pressure and sexual assault) and questions about mental wellness (eg, mental health self-efficacy and depression). After the participants completed the survey (T1), they were directed to either watch 13RW-3 as it aired for the first time (intervention group) or not watch 13RW-3 (control group). Approximately one month later (T2), all the participants were asked to complete the postsurvey. Additional survey questions about conversational partners, information seeking because of watching the show, and use of show-related content were included in the intervention postsurvey.

RESULTS

Our sample (N=157) was 52.2% (n=82) female and 54.8% (n=86) White, with a mean age of 14.99 (SD 1.4) years. At T2, viewers of 13RW-3 spoke about suicide significantly more frequently than nonviewers (P=.007). From T1 to T2, viewers increasingly discussed issues explored by 13RW-3 (P=.002), especially suicide, mental health, and bullying. Adolescent viewers were most likely to speak with friends, and parents were the second most commonly named. Two variables emerged as consistent moderators of conversational choices-having depressive symptoms and being impacted by sexual assault. There was no association between conversational frequency and information seeking around social and mental health issues, and neither mental health self-efficacy scores nor masculine role pressure scores significantly differed between viewers and nonviewers at T2.

CONCLUSIONS

Viewing 13RW-3, a globally watched television show featuring social and mental health issues, led to adolescent conversations and information searches about topics explored by the show. Depressive symptoms and the impact of sexual assault moderated several relationships, guiding participants toward engaging with certain issues and seeking out specific conversational partners. As 13RW-3's stories drove conversations-and story-driven conversations can raise awareness, reduce stigma, shift attitudes, normalize certain behaviors, and strengthen supportive relationships-potential wellness implications for television shows featuring social and mental health issues are considerable.

Applying Behavioral Economics to Improve Adolescent and Young Adult Health: A Developmentally-Sensitive Approach

Each day, adolescents and young adults (AYAs) choose to engage in behaviors that impact their current and future health. Behavioral economics represents an innovative lens through which to explore decision-making among AYAs. Behavioral economics outlines a diverse set of phenomena that influence decision-making and can be leveraged to develop interventions that may support behavior change. Up to this point, behavioral economic interventions have predominantly been studied in adults. This article provides an integrative review of how behavioral economic phenomena can be leveraged to motivate health-related behavior change among AYAs. We contextualize these phenomena in the physical and social environments unique to AYAs and the neurodevelopmental changes they undergo, highlighting opportunities to intervene in AYA-specific contexts. Our review of the literature suggests behavioral economic phenomena leveraging social choice are particularly promising for AYA health. Behavioral economic interventions that take advantage of AYA learning and development have the potential to positively impact youth health and well-being over the lifespan.

Can synthetic controls improve causal inference in interrupted time series evaluations of public health interventions?

Interrupted time series designs are a valuable quasi-experimental approach for evaluating public health interventions. Interrupted time series extends a single group pre-post comparison by using multiple time points to control for underlying trends. But history bias-confounding by unexpected events occurring at the same time of the intervention-threatens the validity of this design and limits causal inference. Synthetic control methodology, a popular data-driven technique for deriving a control series from a pool of unexposed populations, is increasingly recommended. In this paper, we evaluate if and when synthetic controls can strengthen an interrupted time series design. First, we summarize the main observational study designs used in evaluative research, highlighting their respective uses, strengths, biases and design extensions for addressing these biases. Second, we outline when the use of synthetic controls can strengthen interrupted time series studies and when their combined use may be problematic. Third, we provide recommendations for using synthetic controls in interrupted time series and, using a real-world example, we illustrate the potential pitfalls of using a data-driven approach to identify a suitable control series. Finally, we emphasize the importance of theoretical approaches for informing study design and argue that synthetic control methods are not always well suited for generating a counterfactual that minimizes critical threats to interrupted time series studies. Advances in synthetic control methods bring new opportunities to conduct rigorous research in evaluating public health interventions. However, incorporating synthetic controls in interrupted time series studies may not always nullify important threats to validity nor improve causal inference.

Systematic review and meta-analyses of suicidal outcomes following fictional portrayals of suicide and suicide attempt in entertainment media

BACKGROUND

Guidelines to encourage responsible reporting of suicide in news media are a key component of suicide prevention strategies. Recent guidelines have been developed on portrayal of suicide in entertainment media although the relationship between these portrayals and subsequent suicidal behaviour has received considerably less attention in research.

METHODS

We conducted a systematic review and meta-analysis to examine the association between portrayals of suicide and suicide attempt in entertainment media and suicidal behaviour in the population. We searched PubMed, Scopus, Embase, PsycInfo, Web of Science and Google Scholar until April 20, 2021. We included studies adopting interrupted time series or single/multiple arm pre-post designs. Separate analyses were undertaken for studies of suicide and suicide attempts. We synthesized studies at moderate risk of bias and included studies at serious risk in a sensitivity analysis. Using a random-effects meta-analysis, we synthesized studies at moderate risk of bias and included studies at serious risk in a sensitivity analysis. Study registration: PROSPERO (CRD42020221333).

FINDINGS

Twelve studies met our inclusion criteria. Six studies were about suicide. Two of these were at moderate risk of bias and both examined the effects of the Netflix series 13 Reasons Why. The pooled rate ratio (RR) for these studies was 1·18 (95% CI 1·09 to 1·27, p<0·001). Heterogeneity was low (I² = 29%). Six studies focused on suicide attempts, and two of them were at moderate risk of bias. The pooled RR for these two studies was 1·33 (95% CI 0·84 to 2·09, p = 0·22). Heterogeneity was high (I² = 92%). Enhanced funnel plots indicated likely publication bias for studies of suicide and possible bias for studies of attempted suicide.

INTERPRETATION

Portrayals of suicide in entertainment media may increase suicides and attempted suicide in the population. More studies that limit the potential sources of bias are needed to fully understand the circumstances under which fictional portrayals may influence suicidal behaviour.

FUNDING

None.

Longitudinal studies support the safety and ethics of virtual reality suicide as a research method

Many have expressed concerns about the safety and ethics of conducting suicide research, especially intense suicide research methods that expose participants to graphic depictions of suicidality. We conducted two studies to evaluate the effects of one such method called virtual reality (VR) suicide. Study 1 tested the effects of VR suicide exposure over the course of one month in participants with (n = 56) and without a history of suicidality (n = 50). Study 2 exposed some participants to VR suicide scenarios (n = 79) and others to control scenarios (n = 80). Participants were invited to complete a follow-up assessment after an average of 2 years. For both studies, the presence of suicidality post exposure was the primary outcome, with closely related constructs (e.g., capability for suicide, agitation) as secondary outcomes. Study 1 found no pre-post increases in suicidality or related variables, but revealed several significant decreases associated with small to medium effect sizes in suicide-related constructs. In Study 2, VR suicide exposure did not cause any significant increases in suicidality or related variables. Together with prior research, these findings suggest that methods involving intense suicide stimuli appear safe and consistent with utilitarian ethics.

The Werther effect of celebrity suicides: Evidence from South Korea

Since 2003 Korea has experienced the highest suicide rate among OECD countries. One of the societal risk factors that triggers suicide is the contagious nature of suicide. This paper empirically examines the effect of celebrity suicide reports on subsequent copycat suicides, using daily suicide data and information of highly publicized suicide stories in Korea from 2005 to 2018. The findings from the Poisson regression model suggest that the number of public suicides soars after media reports on celebrity suicides. On average, the number of suicides in the population increased by 16.4% within just one day after the reports. Further analysis reveals that female and younger subgroups are more likely to be affected by celebrity suicides. Moreover, the public reacts more strongly to suicide incidents of celebrities of the same gender and even imitates the methods of suicide used by celebrities. This paper highlights the significance of careful and responsible media coverage of suicide stories to prevent copycat suicide. For policymakers, it is crucial to implement regulations not only for traditional media but also for new media where younger people can freely access unfiltered information.

Impact of Web-Based Sharing and Viewing of Self-Harm-Related Videos and Photographs on Young People: Systematic Review

BACKGROUND

Given recent moves to remove or blur self-harm imagery or content on the web, it is important to understand the impact of posting, viewing, and reposting self-harm images on young people.

OBJECTIVE

The aim of this study is to systematically review research related to the emotional and behavioral impact on children and young people who view or share web-based self-harm-related videos or images.

METHODS

We searched databases (including Embase, PsychINFO, and MEDLINE) from January 1991 to February 2019. Search terms were categorized into internet use, images nonspecific and specific to the internet, and self-harm and suicide. Stepwise screening against specified criteria and data extraction were completed by two independent reviewers. Eligible articles were quality assessed, and a narrative synthesis was conducted.

RESULTS

A total of 19 independent studies (20 articles) were included. Of these, 4 studies focused on images, 10 (11 articles) on videos, and 5 on both. There were 4 quantitative, 9 qualitative, and 7 mixed methods articles. In total, 11 articles were rated as high quality. There has been an increase in graphic self-harm imagery over time. Potentially harmful content congregated on platforms with little moderation, anonymity, and easy search functions for images. A range of reactions and intentions were reported in relation to posting or viewing images of self-harm: from empathy, a sense of solidarity, and the use of images to give or receive help to potentially harmful ones suggesting new methods, normalization, and exacerbation of self-harm. Viewing images as an alternative to self-harm or a creative outlet were regarded in 2 studies as positive impacts. Reactions of anger, hostility, and ambivalence have been reported. There was some evidence of the role of imitation and reinforcement, driven partly by the number of comments and wound severity, but this was not supported by time series analyses.

CONCLUSIONS

Although the results of this review support concern related to safety and exacerbation of self-harm through viewing images of self-harm, there may be potential for positive impacts in some of those exposed. Future research should evaluate the effectiveness and potential harms of current posting restrictions, incorporate user perspectives, and develop recovery-oriented content. Clinicians assessing distressed young people should ask about internet use, including access to self-harm images, as part of their assessment.

Suicide and the agent-host-environment triad: leveraging surveillance sources to inform prevention

Suicide in the US has increased in the last decade, across virtually every age and demographic group. Parallel increases have occurred in non-fatal self-harm as well. Research on suicide across the world has consistently demonstrated that suicide shares many properties with a communicable disease, including person-to-person transmission and point-source outbreaks. This essay illustrates the communicable nature of suicide through analogy to basic infectious disease principles, including evidence for transmission and vulnerability through the agent-host-environment triad. We describe how mathematical modeling, a suite of epidemiological methods, which the COVID-19 pandemic has brought into renewed focus, can and should be applied to suicide in order to understand the dynamics of transmission and to forecast emerging risk areas. We describe how new and innovative sources of data, including social media and search engine data, can be used to augment traditional suicide surveillance, as well as the opportunities and challenges for modeling suicide as a communicable disease process in an effort to guide clinical and public health suicide prevention efforts.

The association between Twitter content and suicide

OBJECTIVE

A growing body of research has established that specific elements of suicide-related news reporting can be associated with increased or decreased subsequent suicide rates. This has not been systematically investigated for social media. The aim of this study was to identify associations between specific social media content and suicide deaths.

METHODS

Suicide-related tweets (n = 787) geolocated to Toronto, Canada and originating from the highest level influencers over a 1-year period (July 2015 to June 2016) were coded for general, putatively harmful and putatively protective content. Multivariable logistic regression was used to examine whether tweet characteristics were associated with increases or decreases in suicide deaths in Toronto in the 7 days after posting, compared with a 7-day control window.

RESULTS

Elements independently associated with increased subsequent suicide counts were tweets about the suicide of a local newspaper reporter (OR = 5.27, 95% CI = [1.27, 21.99]), 'other' social causes of suicide (e.g. cultural, relational, legal problems; OR = 2.39, 95% CI = [1.17, 4.86]), advocacy efforts (OR = 2.34, 95% CI = [1.48, 3.70]) and suicide death (OR = 1.52, 95% CI = [1.07, 2.15]). Elements most strongly independently associated with decreased subsequent suicides were tweets about murder suicides (OR = 0.02, 95% CI = [0.002, 0.17]) and suicide in first responders (OR = 0.17, 95% CI = [0.05, 0.52]).

CONCLUSIONS

These findings largely comport with the theory of suicide contagion and associations observed with traditional news media. They specifically suggest that tweets describing suicide deaths and/or sensationalized news stories may be harmful while those that present suicide as undesirable, tragic and/or preventable may be helpful. These results suggest that social media is both an important exposure and potential avenue for intervention.

TikTok, Tide Pods and Tiger King: health implications of trends taking over pediatric populations

PURPOSE OF REVIEW

With children and adolescents constantly connected to their devices in an ever-changing technological landscape, new and emerging trends in entertainment media have created potential health implications for pediatric patients. The purpose of this review is to provide pediatricians with explanations of specific trends on streaming services, the popular new mobile application TikTok, recent widespread 'Internet Challenges' that include pediatric participants, and new technologies. These emerging trends can pose potential harms to the health and wellbeing of children and adolescents.

RECENT FINDINGS

Recent reports and news articles have discussed popular technological trends and the adverse effects that can occur. Although technology provides access to information and social connection for youth, it also creates platforms where children can be exposed to disturbing content, peer pressure, cyberbullying, and encouragement to participate in activities that could cause potential physical harm or even death.

SUMMARY

Pediatricians need to be aware of trends to best understand the implications of these technologies, especially in clinical practice. Pediatricians play an important role in educating parents and patients about the risks of these trends, in facilitating conversations about related topics including self-esteem, cyberbullying and peer pressure to promote healthy internet use, and providing necessary resources.

Public awareness of the National Suicide Prevention Lifeline following the release of a hip-hop song

OBJECTIVE

In light of the current national mental health crisis, we use Google Trends, Twitter and data obtained from the National Suicide Prevention Lifeline to evaluate the effect of '1-800-273-8255' on public awareness for the National Suicide Prevention Lifeline.

DESIGN

Cross-sectional analysis.

MAIN OUTCOME MEASURES

We extracted data from Google Trends and Twitter for terms related to suicide following the release of Logic's song, '1-800-273-8255'. We then used a forecasting autoregressive integrated moving algorithm model to determine the greater than expected search interest.

RESULTS

Google searches for 'Suicide Hotline' increased 49% more than expected the day after Logic's song was released and sustained increase of queries resulted in an average relative search volume of 59.5%-9.1% higher than the mean forecasted value of 50.4% for the 28 days following the release. Tweets that engaged with the account '@800 273talk' on Twitter increased by 10 450% more than expected the day after the song was released and increased by a mean of 1497% greater than expected the week after the songs released.

CONCLUSION

Findings from our study suggest that the entertainment industry can play an important role in increasing awareness of hotline numbers. Logic's song provides an example of a positive influence on public health and provides support for further development and standards for proper awareness of suicide in the public view.

A Multifactorial Interpretation of a Teenager's Suicide: Based on Krystal's Death in Casual Vacancy

Objectives

It is hard to accumulate research data on adolescents’ suicide, because friends and family of the suicide completers might be reluctant to share the experience. To overcome the lack of information on adolescent suicide victims, the authors examined the risk and protective factors for adolescents’ suicide from a character in a novel.

Methods

Krystal, an adolescent female in the novel The Casual Vacancy by Joanne Rowling, failed to overcome her unfortunate cir-cumstances and committed suicide. The authors analysed Krystal’s case based on the guideline for patients with suicidal behaviours to address the complicated situation of her death.

Results

Krystal grew up in a poor and dangerous environment. Despite the environmental hardships, she developed ego maturation with affectionate help from Mr Fairbrother, an assistant coach of the Girls’ Rowing Team and a parish councillor. The sudden passing away of Mr Fairbrother brought on a crisis of identity for Krystal. In addition, a villainous character raped her and her brother drowned to death, which brought her great sorrow. She felt helpless and committed suicide.

Conclusion

In spite of many risk factors for suicide, Krystal was able to keep her life with a few protective factors, a younger brother in the home, and a sense of responsibility for the family. After the loss of her brother, however, she collapsed in a moment. Krystal’s suicide might not only be a personal choice but a breakdown of the social protection system for the youth.

Emerging Adults' Attitudes and Beliefs About Suicide and Technology/Social Media

Suicide in emerging adults (18-29 years) is increasing in the United States, especially amidst coronavirus disease 2019. How the use of technology/social media affects suicidal behaviors is unclear. The purpose of this study was to examine attitudes and beliefs of emerging adults about suicide and identify whether relationships exist with technology/social media use. A total of 297 participants completed an online survey examining attitudes about suicide and technology use. Results indicate a normalization of suicide. Significant relationships were found with technology/social media, including a positive relationship between YouTube and glorification/normalization of suicide. Recommendations for primary and secondary suicide prevention are made for nurse practitioners in various settings.

Development of a Self-Harm Monitoring System for Victoria

The prevention of suicide and suicide-related behaviour are key policy priorities in Australia and internationally. The World Health Organization has recommended that member states develop self-harm surveillance systems as part of their suicide prevention efforts. This is also a priority under Australia’s Fifth National Mental Health and Suicide Prevention Plan. The aim of this paper is to describe the development of a state-based self-harm monitoring system in Victoria, Australia. In this system, data on all self-harm presentations are collected from eight hospital emergency departments in Victoria. A natural language processing classifier that uses machine learning to identify episodes of self-harm is currently being developed. This uses the free-text triage case notes, together with certain structured data fields, contained within the metadata of the incoming records. Post-processing is undertaken to identify primary mechanism of injury, substances consumed (including alcohol, illicit drugs and pharmaceutical preparations) and presence of psychiatric disorders. This system will ultimately leverage routinely collected data in combination with advanced artificial intelligence methods to support robust community-wide monitoring of self-harm. Once fully operational, this system will provide accurate and timely information on all presentations to participating emergency departments for self-harm, thereby providing a useful indicator for Australia’s suicide prevention efforts.

Sociodemographic Differences in Time Trends of Suicidal Thoughts and Suicide Attempts Among Adolescents Living in Amsterdam, The Netherlands

Abstract.Background: Suicidal thoughts and suicide attempts among adolescents are major public health problems. More insight into secular changes in suicidal thoughts and suicide attempts among adolescents from various sociodemographic groups is crucial for adequate and targeted policy-making and prevention. We therefore examined 5-year time trends in suicidal thoughts and suicide attempts among adolescents and potential differences in time trends between sociodemographic groups. Methods: Logistic regression analyses were based on annually repeated cross-sectional data including 26,273 multi-ethnic students (13–14 years old) in the second year of various levels of secondary education in Amsterdam, The Netherlands. Results: Overall, the prevalence of adolescents in Amsterdam with suicidal thoughts decreased from 17.6% during 2010–2011 to 13.2% during 2014–2015. The prevalence of adolescents reporting suicide attempts decreased from 2.9% to 1.9% over the observed 5-year period. We found differences in these time trends between subgroups based on ethnicity and educational level. Limitations: The use of confidential and self-reported data could have biased the results. Conclusion: In order for prevention policy to be effective it is important to pay attention to changes in risk groups for suicidal thoughts and suicide attempts over time.

13 Reasons Why: The Evidence Is in and Cannot Be Ignored

Decades of research overwhelmingly supports the public health necessity of safe, balanced, and responsible news media reporting on suicide.^1,2 When news media follow recommendations for safe reporting, the risk of copycat suicide decreases.³ The Recommendations for Media Reporting on Suicide were developed by leading experts in suicide prevention and in collaboration with several international suicide prevention and public health organizations, schools of journalism, media organizations, and key journalists, as well as Internet safety experts (www.reportingonsuicide.org). The recommendations are based on more than 100 international studies on suicide contagion. Furthermore, in recent years, Niederkrotenthaler and others have specifically examined suicide-related media portrayals focused on messages of hope, recovery, or mastery over a crisis. Research demonstrates that following such portrayals, those exposed experience a decrease in suicidal ideation, diminished distress, and an increased sense of hope.^4,5 Importantly, in some cases, fewer suicides are observed across the exposed population.¹ In other words, both suicide and resilience are contagious behaviors, and the content of suicide-related news media messaging can and does prevent tragic deaths.