Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

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.

Poisoning cases in the German crime series Tatort (crime scene) from 1974 to 2022

Poisoning occurs frequently in TV crime series but, to the best of our knowledge, has not yet been analyzed scientifically. This study examines the plausibility of poisoning cases in Germany’s most popular crime series, Tatort (crime scene), from 1974 to 2022. In the TV series, the increasing rate of poisoning in Germany as well as the increasing variety of substances leading to poisoning over the years are depicted. Largely in line with reality, similar substance categories and routes of administration are presented. However, poisoning outcomes in Tatort differ from reality: over 50% of the victims die in Tatort, whereas in reality, more than 80% survive. In > 95% of the episodes, the mechanism of action of a poison is not explained, omitting an important opportunity for raising public awareness. The TV series also deviates from reality in terms of the etiology of poisonings: External poison delivery is largely overrepresented, while the high rate of accidental poisonings in real life is underrepresented. Almost no accidental poisonings occur in Tatort, although this is the most frequent type of poisoning in real life. In Tatort, men are overrepresented as offenders and victims of poisoning compared to reality. Thus, the crime series does not convey the message that anyone can be a potential victim of poisoning and that particularly vulnerable groups need proper education and the best possible protection. This paper discusses the conflict between detailed, plausible episodes with cases of poisoning and the potential for imitation that they may cause.

Media Coverage of Senior and Celebrity Suicides and Its Effects on Copycat Suicides among Seniors

This study examined whether suicide rates in the elderly population are associated with media coverage of senior or celebrity suicides. Analyzing data from 2012 to 2015, we found that seniors were likely to be more influenced by media coverage of senior suicides than by celebrity suicides. Furthermore, the effects of media coverage of senior suicides were more significant when the reported reason was either health (mental or physical problems) or financial issues, such as poverty than other reasons.

Perceptions towards charcoal-burning suicide and the surge of this lethal method in Taiwan

Objective

Whether sociocultural perceptions of charcoal-burning suicide have influenced its rapid increase in prevalence is unclear. We aimed to explore perceptions of Taiwan’s general population regarding charcoal-burning suicide, their personal belief in life after death, and related feelings of thoughts associated with those who attempt charcoal-burning suicide.

Methods

An online web-based survey, focussing on sociocultural attitudes towards death, as well as perceptions towards charcoal-burning suicide, and those who attempt charcoal-burning suicide, was conducted from 14 January to 14 June 2016.

Results

In total, 1343 adults completed the online survey (mean age of 33.46; 66.6% women). Notably, 90.3% of participants considered charcoal burning to be an easily accessible suicide method. Multivariable analyses revealed that among the examined factors, the perceived ‘painlessness’ of charcoal-burning suicide was associated with an over seven-fold increased risk of choosing charcoal-burning suicide (OR = 7.394; p < 0.001; 95% CI: 2.614–20.912).

Conclusion

As reflected in this study, charcoal-burning suicide is perceived as easily accessible and painless. The perceived ‘painlessness’ may be the factor that distinguishes the choice of charcoal-burning suicide from that of other suicide methods. Future efforts to target these perceptions regarding charcoal-burning suicide may be warranted in both media reporting and suicide prevention programmes.

Characteristics of Presentations to the Emergency Department Following Attempted Suicide with Drugs

A relatively high proportion of attempted suicides employ self-poisoning with medication. Data from emergency department presentations can help to identify possible risk drug classes and provide a basis for preventive measures. This retrospective analysis included cases presenting at the emergency department of the University Hospital of Bern, Switzerland, from May 2012 to August 2016, after attempted suicide with drugs. We excluded attempted suicides with only alcohol or other non-medical substances. During the study period, there were 488 cases (466 patients) of attempted suicide with medical substances. The median patient age was 33 years (range 16–93) and 354 (73%) cases were female. The most commonly involved substances/drug classes were benzo-diazepines (n = 167, 34%), neuroleptics (n = 114, 23%) and paracetamol (n = 111, 23%). A total of 231 (47%) cases employed only a single substance. Common symptoms included somnolence (n = 245, 50%), tachycardia (n = 119, 24%) and nausea/vomiting (n = 76, 16%). In most cases, the poisoning was of minor severity (n = 231, 47%) and the patients were admitted to a psychiatric hospital (n = 264, 54%). Important preventive measures may include careful monitoring for suicidal behaviour when prescribing psychotropic drugs, in addition to restrictions in pack size. Efforts should also be made to enhance the awareness of health professionals qualified to prescribe or supply paracetamol.

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.

The Werther Effect, the Papageno Effect or No Effect? A Literature Review

This paper examines the association between media reporting on suicides and the subsequent suicides. Scientific papers from two online bibliographic sources Medline (PubMed) and PsycINFO were searched. The sample included 108 research papers examining the impact of different types of media stories on suicides. The review revealed that although the media can be a double-edged sword and serve both as a risk and a protective factor, the vast majority of research suggests that the relationship between the media reporting and the actual suicide rates is causal and real. Moreover, both the quantity and the quality of media reporting may trigger additional suicides in society. Simultaneously, research suggests that especially non-fictional presentations of celebrities’ suicides in newspapers and on television news have the biggest influence on the subsequent suicides. Additionally, a strong modelling effect of media reporting on suicide is based on nationality, age, and gender. However, research shows that because a negative reporting style can be modifiable and improved, the media can also have an educative or preventive effect and can reduce the risk of contagion. Consequently, it is important to monitor the implementation of media recommendations for the reporting of suicide, and continuous education of reporters is needed.

The Werther Effect, the Papageno Effect or No Effect? A Literature Review

This paper examines the association between media reporting on suicides and the subsequent suicides. Scientific papers from two online bibliographic sources Medline (PubMed) and PsycINFO were searched. The sample included 108 research papers examining the impact of different types of media stories on suicides. The review revealed that although the media can be a double-edged sword and serve both as a risk and a protective factor, the vast majority of research suggests that the relationship between the media reporting and the actual suicide rates is causal and real. Moreover, both the quantity and the quality of media reporting may trigger additional suicides in society. Simultaneously, research suggests that especially non-fictional presentations of celebrities’ suicides in newspapers and on television news have the biggest influence on the subsequent suicides. Additionally, a strong modelling effect of media reporting on suicide is based on nationality, age, and gender. However, research shows that because a negative reporting style can be modifiable and improved, the media can also have an educative or preventive effect and can reduce the risk of contagion. Consequently, it is important to monitor the implementation of media recommendations for the reporting of suicide, and continuous education of reporters is needed.

A Content Analysis and Comparison of Two Peaks of Newspaper Reporting During a Suicide Cluster to Examine Implications for Imitation, Suggestion, and Prevention

Abstract. Background: During 2007–2008, media attention focused on a cluster of youth suicides in the UK. There were two peaks (P1, P2) in the volume of newspaper reporting of the deaths. The number of possible suicides was greater than expected at the time of the first peak but not at the time of the second. Aims: To explore any differences in the content of the reporting peaks and to consider implications for imitation and prevention. Method: A content analysis of two peaks of newspaper reporting was conducted. Results: There were 204 articles in P1 (December 27, 2007 to February 19, 2008) and 157 in P2 (February 20, 2008 to March 15, 2008). Four main themes were identified: individual stories; possible causes; features of reporting of the cluster; and educating and informing the public. P1 articles more frequently contained: explicit details of method; photographs of the deceased, and contained more characterization of individuals. Limitations: The focus was on print media, future studies should incorporate online and social media content. Conclusion: The findings provide some support for the hypothesis of a process of suggestion initiated by sensationalist reporting in P1. This contributes to the evidence base of the role of the press in suicide imitation and prevention, highlighting the importance of care when reporting suicides.

The opioid crisis: a contextual, social-ecological framework

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

Knowledge of Suicide Risk Factors, But Not Suicide Ideation Severity, Is Greater Among College Students Who Viewed 13 Reasons Why

Objective: To test associations between viewing 13 Reasons Why, Season 1 and past week suicide ideation severity, behavior risk, stigma, and knowledge in college students. To explore whether personal exposure to suicide and depressive symptom severity moderated these associations. Participants: Eight-hundred and eighteen college students, 64% (n = 522) of whom watched 13 Reasons Why. Methods: Students completed surveys online. Multivariate negative binomial regressions were used to test associations between watching 13 Reasons Why and suicide-related variables, and interaction terms. Results: Suicide ideation severity and suicide behavior risk were not significantly associated with viewing 13 Reasons Why; however, there was limited statistical power to detect associations. The association between watching 13 Reasons Why and greater suicide knowledge was stronger among those who did not have personal exposure to suicide. Conclusions: 13 Reasons Why may be a platform for psychoeducation on suicide, particularly among those who do not have personal exposure.

Pluralism and incommensurability in suicide research

This paper examines the complex research landscape of contemporary suicidology from a philosophy of science perspective. I begin by unpacking the methods, concepts, and assumptions of some of the prominent approaches to studying suicide causation, including psychological autopsy studies, epidemiological studies, biological studies, and qualitative studies. I then analyze the different ways these approaches partition the causes of suicide, with particular emphasis on the ways they conceptualize the domain of mental disorder. I argue that these different ways of partitioning the causal space and conceptualizing mental disorder result in incommensurabilities between the approaches. These incommensurabilities restrict the degrees to which the different approaches can be integrated, thus lending support to explanatory pluralism in the study of suicide causation. They also shed light on some of the philosophical underpinnings of the disagreement between mainstream suicidology and the emerging area of critical suicidology.

Reanalysis of the Bridge et al. study of suicide following release of 13 Reasons Why

Bridge et al. recently presented a time series analysis of suicide rates in the US following the release of the 2017 Netflix series "13 Reasons Why." Their analysis found a powerful effect of the show on boys ages 10-17 for nine months after the show was released in April 2017. I questioned this finding on two grounds. First, contagion would be expected to be stronger for girls than boys for this story, and second their analysis did not take into account strong secular trends in suicide, especially in boys from 2016 to 2017. I reanalyzed their data using a simple auto-regression model that tested for changes in rates after removing auto-correlation and national trends in suicide. I found that the increase for boys observed by Bridge et al. in April was no greater than the increase observed during the prior month before the show was released. There were also no effects in later months of that year. For girls, I found a small but nonsignificant increase in suicide in April that was unique to that month, potentially consistent with a combined protective and harmful effect of the show. In total, I conclude that it is difficult to attribute harmful effects of the show using aggregate rates of monthly suicide rates. More fine-grained analyses at the weekly level may be more valid but only after controlling for secular changes in suicide that have been particularly strong since 2008 in the US.

The Portrayal of Suicidal Behavior in Police Television Series

Fictional suicidal behavior can affect the public as a risk or a protective factor, and it may reflect how suicide is perceived in a society. However, surprisingly little is known of how suicidal behavior is portrayed in television series. The aim of this study was to investigate the characteristics of televised fatal and non-fatal suicidal behavior, preventative interventions, and the portrayal of people bereaved by suicide. All episodes (N = 475) of four Belgian police series were screened against inclusion and exclusion criteria, and 87 episodes with a total of 54 suicides, 13 attempted suicides, 13 suicide threats, and 20 characters bereaved by suicide were included in a quantitative and qualitative analysis. Televised suicidal behavior was primarily motivated by external motives, such as social/relational issues or the death of a significant other, and to a lesser extent, by internal motives, such as mental or physical health related issues. Interventions were likely to prevent suicide. People bereaved by suicide were mostly portrayed as individuals seeking justice. Shame, revenge, and escape were the major qualitative themes associated with suicidal behavior. Two prototypes emerged: a ruthless, "psychopath" type criminal, who kills him/herself before being arrested, and a suicidal individual struggling with devastating life events. The study provided unique insights in how suicidal behavior is televised in Belgian police series. Though some characteristics were portrayed adequately, mental health related issues were overlooked, spectacular suicide methods were overrepresented, and the bereaved characters were mostly unidimensional revengers. Strategies for improving the accuracy of televised suicidal behavior should be studied.

Presentations Related to Acute Paracetamol Intoxication in an Urban Emergency Department in Switzerland

Aim

To investigate the characteristics of Emergency Department (ED) presentations due to acute paracetamol intoxication.

Methods

Retrospective observational study of patients presenting to the ED of Bern University Hospital between May 1, 2012, and October 31, 2018, due to a paracetamol overdose (defined as intake of >4 g/24 h). Cases were identified using the full-text search of the electronic patient database and were grouped into intentional (suicidal/parasuicidal) and unintentional intoxications (e.g., patient unaware of maximal daily dose).

Results

During the study period, 181 cases were included and 143 (79%) of those were intentional. Compared to the patients in the unintentional group, patients in the intentional group were more often female (85% vs 45%, p < 0.001) and younger (median age 23.0 vs 43.5 years, p < 0.001), more frequently suffered from psychiatric comorbidities (93%, (including 49% with borderline personality disorder) vs 24%, p < 0.001), and paracetamol was more often taken as a single dose (80% vs 13%, p < 0.001). Although the median daily ingested dose was lower in the unintentional than in the intentional group (8.2 g vs 12.9 g, p < 0.001), patients in the unintentional group presented later (29% vs 84% within 24 h of ingestion, p < 0.001), included more cases of acute liver failure (nine (24%) vs six (4%), p < 0.001), and were more often hospitalised (24% vs 52% treated as outpatients, p=0.002). There were no significant differences between the groups regarding drug-induced liver injury (seven cases (5%) in the intentional and one (3%) in the unintentional group) or fatalities (one in each group).

Conclusions

The majority of presentations due to paracetamol poisoning were intentional, most commonly in female patients with borderline personality disorder. Patients with unintentional paracetamol intoxication had worse outcomes with respect to acute liver failure and hospitalisation. Future preventive measures should raise awareness of paracetamol toxicity in the general population and encourage particular attention and frequent follow-ups when prescribing paracetamol for vulnerable groups.

Media Guidelines for Reporting on Suicide: 2017 Update of the Canadian Psychiatric Association Policy Paper

This paper has been substantially revised by the Canadian Psychiatric Association's Research Committee and approved for republication by the CPA's Board of Directors on May 3, 2017. The original policy paper¹ was developed by the Scientific and Research Affairs Standing Committee and approved by the Board of Directors on November 10, 2008.

Qualitative exploration of the effect of a television soap opera storyline on women with experience of postpartum psychosis

BACKGROUND

Postpartum psychosis has recently been the focus of an in-depth storyline on a British television soap opera watched by millions of viewers.

AIMS

This research explored how the storyline and concomitant increase in public awareness of postpartum psychosis have been received by women who have recovered from the condition.

METHOD

Nine semistructured, one-to-one interviews were conducted with women who had experienced postpartum psychosis. Thematic analysis consistent with Braun and Clarke's six-step approach was used to generate themes from the data.

RESULTS

Public exposure provided by the postpartum psychosis portrayal was deemed highly valuable, and its mixed reception encompassed potentially therapeutic benefits in addition to harms.

CONCLUSIONS

Public awareness of postpartum psychosis strongly affects women who have experienced postpartum psychosis. This research highlights the complexity of using television drama for public education and may enable mental health organisations to better focus future practices of raising postpartum psychosis awareness.

DECLARATION OF INTEREST

GB is chair of action on Postpartum Psychosis. JH is director of action on Postpartum Psychosis. IJ is a trustee of action on Postpartum Psychosis and was a consultant to the BBC (television company) on the EastEnders storyline. CD is a trustee of action on Postpartum Psychosis, a trustee of BIPOLAR UK, vice chair of the Maternal Mental Health Alliance, and was a consultant to the BBC (television company) on the EastEnders storyline.

Mental illness and the media

Stigmatising opinions about mental illness are more common among young people than older people (Yarney, 1999). Whether the media should carry responsibility for this was the subject of the College's 13th Christmas Lecture for Young People. Over 300 school children gathered in central London to take part in a debate on the role of the media in the portrayal of mental illness. Alison Lowe introduced the debate by illustrating how common mental illness is. She invited everyone to look at the eight people sitting around them before adding, “In your lifetimes at least one of you will see a psychiatrist”.

Psychiatry and the media

Aspects of print, broadcast, film and ‘new media’ are related to their interactions with psychiatry. Frequent representations of mental health issues are paralleled by the adoption of psychological theories into media studies. Key areas are covered where psychiatric items diverge from other medical specialities, such as the depiction of suicide, the dominance of ‘human interest’ stories and negative representation of people with mental illness. Although the language of mental disorders is important, the power of the image needs to be examined. Media items also have implications for public mental health (children as vulnerable viewers) and the clinical practice of psychiatry that are not uniformly negative. Television has limitations and clinicians are encouraged to participate in radio and other media. Resources and practical advice for media contact are provided.

Newspaper Reporting on a Cluster of Suicides in the UK

Abstract. Background: Media reporting may influence suicide clusters through imitation or contagion. In 2008 there was extensive national and international newspaper coverage of a cluster of suicides in young people in the Bridgend area of South Wales, UK. Aims: To explore the quantity and quality of newspaper reporting during the identified cluster. Method: Searches were conducted for articles on suicide in Bridgend for 6 months before and after the defined cluster (June 26, 2007, to September 16, 2008). Frequency, quality (using the PRINTQUAL instrument), and sensationalism were examined. Results: In all, 577 newspaper articles were identified. One in seven articles included the suicide method in the headline, 47.3% referred to earlier suicides, and 44% used phrases that guidelines suggest should be avoided. Only 13% included sources of information or advice. Conclusion: A high level of poor-quality and sensationalist reporting was found during an ongoing suicide cluster at the very time when good-quality reporting could be considered important. A broad awareness of media guidelines and expansion and adherence to press codes of practice are required by journalists to ensure ethical reporting.

Suicide risk and suicide method in patients with personality disorders

OBJECTIVE

The influence of psychopathology on suicide method has revealed different distributions among different psychiatric disorders. However, evidence is still scarce. We hypothesized that having a diagnosis of personality disorder (PD) affect the suicide method, and that different PD clusters would influence the suicide method in different ways. In addition, we hypothesized that the presence of psychiatric and somatic co-morbidity also affects the suicide method.

METHOD

We examined 25,217 individuals aged 15-64 who had been hospitalized in Sweden with a main diagnosis of PD the years 1987-2013 (N = 25,217). The patients were followed from the date of first discharge until death or until the end of the follow-up period, i.e. December 31, 2013, for a total of 323,508.8 person-years, with a mean follow up time of 11.7 years. The SMR, i.e. the ratio between the observed number of suicides and the expected number of suicides, was used as a measure of risk.

RESULTS

Overall PD, different PD-clusters, and comorbidity influenced the suicide method. Hanging evidenced highest SMR in female PD patients (SMR 34.2 (95% CI: 29.3-39.8)), as compared to non-PD patients and jumping among male PD patients (SMR 24.8 (95% CI: 18.3-33.6)), as compared to non PD-patients. Furthermore, the elevated suicide risk was related to both psychiatric and somatic comorbidity.

CONCLUSION

The increased suicide risk was unevenly distributed with respect to suicide method and type of PD. However, these differences were only moderate and greatly overshadowed by the overall excess suicide risk in having PD. Any attempt from society to decrease the suicide rate in persons with PD must take these characteristics into account.

The Response in Twitter to an Assisted Suicide in a Television Soap Opera

Abstract. Background: Concern has been expressed about the potentially contagious effect of television soap opera suicides and suicidal language in social media. Aims: Twitter content was analyzed during the week in which a fictional assisted suicide was broadcast on a British television soap opera, "Coronation Street." Method: Tweets were collected if they contained language indicating possible suicidal intent or used the word suicide. The modified Thompson tau method was used to test for any differences in the volume of tweets in both categories on the day of screening. Content analysis broke down the use of the word suicide into six thematic categories. Results: There was no evidence on the day of screening of an increase in tweets expressing possible suicidal intent but there was an increase in tweets containing the word suicide. Content analysis found the most common thematic category to be information or support, followed by the raising of moral issues in relation to suicide. Conclusion: It is possible that for certain high-profile media events Twitter may be used more as a civic reactive forum than as a medium for introspection or disclosure of distress.

To what extent does the reporting behavior of the media regarding a celebrity suicide influence subsequent suicides in South Korea?

This study investigated the nature of media coverage of a national entertainer's suicide and its impact on subsequent suicides. After the celebrity suicide, the number of suicide-related articles reported surged around 80 times in the week after the suicide compared with the week prior. Many articles (37.1%) violated several critical items on the World Health Organization suicide reporting guidelines, like containing a detailed suicide method. Most gender and age subgroups were at significantly higher risk of suicide during the 4 weeks after the celebrity suicide. Results imply that massive and noncompliant media coverage of a celebrity suicide can cause a large-scale copycat effect.

The timing of deliberate self harm behaviour

Objectives: To critically review the scientific literature relating to the timing of deliberate self harm behaviour and completed suicide.

Method: A literature search of the Medline and CINAHL databases from 1970-2002 was performed, using deliberate self harm, overdose, self poisoning, suicide, parasuicide, and time, timing, day, week, month and season as key words. Relevant secondary references were retrieved and hand searching of important journals was done.

Results: The time of day of non-fatal self harm shows a marked diurnal variation, with an evening peak that is related to non-violent episodes, concomitant alcohol use, and a younger age. It is not conclusively linked to the degree of suicidal intent or particular psychiatric diagnoses. Completed suicides more commonly occur earlier in the day, at the beginning of the week and during springtime, but show no overall increase during many national events and holidays.

Conclusions: Circadian biological mechanisms involving the serotonin-melatonin axis, Cortisol secretion and sleep abnormalities appear to be implicated. Psychosocial explanations for these epidemiological findings include alcohol use, a sense of personal isolation and the ‘broken promise’ effect.

Television's "crazy lady" trope: female psychopathic traits, teaching, and influence of popular culture

OBJECTIVE

This article describes notable illustrations of female psychopathy on modern television to review various characters that will have utility in teaching students about female psychopathy in distinction to male psychopathy and to encourage consideration of the potential effects that viewing these countless examples may have on a generation of young women.

METHODS

The authors use examples from soap operas, crime procedurals, reality television, fantasy, comedies, and young adult programs to illustrate gender differences in psychopathy and make specific teaching points. They also review the research literature related to popular culture's impact on behavior and gender roles.

RESULTS

Gender differences in real-world psychopathy are mirrored in television portrayals. For example, female psychopaths, on TV and in reality, use sexual manipulation, demonstrate unstable emotions, and employ social aggression to achieve their ambitions. The examples of female psychopathic traits are prevalent on TV and easily accessible for teaching purposes. Research does give some support for a popular culture impact on behavior and gender roles.

CONCLUSIONS

As compared to male psychopathy, female psychopathy is less recognized, and there are some notable differences in how the psychopathic traits manifest. Television provides myriad teaching examples that can highlight the gender distinctions such as use of sexual manipulation, emotional instability, and social aggression. Research suggests that the prevalence of "crazy ladies" on television may be negatively impacting gender stereotypes and normalizing bad behavior in young women.

How to adjust media recommendations on reporting suicidal behavior to new media developments

This study examines the inclusion of preventive factors and new media developments in media recommendations on suicide reporting. Of the 193 member states of the United Nations screened for media recommendations, information was available for 74 countries. Similarities and differences in their contents were analyzed by cluster analysis. Results indicate that of these 74 countries, 38% have national suicide prevention programs, 38% have media recommendations, and 25% have press codes including suicide reporting. Less than 25% of the media recommendations advise against mentioning online forums, suicide notes, pacts, clusters, hotspots, details of the person, and positive consequences. No more than 15% refer to self-help groups, fictional and online reporting. We conclude that media recommendations need to be revised by adding these preventive factors and by including sections on new media reporting.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Information sources used by the suicidal to inform choice of method

BACKGROUND

Choice of suicide method strongly influences the outcome of an attempt. Public knowledge of possible methods is an important but less frequently considered aspect of the accessibility of suicide. This qualitative study explored the sources of information shaping the near-fatal suicide attempts of 22 individuals.

METHODS

Respondents were recruited from nine hospitals in England. Semi-structured interviews were conducted to gain detailed narratives of the planning of the suicide attempt. Interviews were recorded, transcribed, then subjected to thematic analysis utilising constant comparison techniques.

RESULTS

Information sources discussed most frequently were television, news stories, the Internet, and previous self-harm. Others were professional resources, personal knowledge of others' attempts and information gleaned from healthcare professionals. Many respondents reported seeing media portrayals or reports of suicide, which had contributed to their awareness of suicide methods. Several provided examples of direct imitation. Some had deliberately sought information about methods when planning their attempt--mostly from the Internet. Past experience was used to identify 'best' methods and perfect implementation.

LIMITATIONS

The frequency with which sources of information are 'used' by particular groups and their relative import cannot be inferred from a qualitative sample. Near-fatal cases may differ from completed suicides.

CONCLUSIONS

The media is an important contributor to the cognitive availability of suicide in society and could be used for prevention through carefully crafted portrayals of suicide designed to generate negative social perceptions of popular methods. Understanding of how sources of information can influence perceptions of suicide could inform the content of clinical conversations with patients.

What can be done to reduce mortality from paracetamol overdoses? A patient interview study

BACKGROUND

Paracetamol (acetaminophen) is the most common self-poisoning agent in the UK and a leading cause of fatal hepatotoxicity. Following legislation in 1998 to limit pack sizes, beneficial effects on paracetamol-related mortality and morbidity were reported in England. However, there are still over 100 deaths a year and evidence of breaches of sales guidelines.

AIM

To investigate characteristics of people taking larger paracetamol overdoses and compliance with sales guidelines, to inform possible further initiatives to reduce paracetamol fatalities.

DESIGN AND METHODS

Interview study of 60 general hospital patients who took overdoses of over 16 paracetamol tablets (8 g).

RESULTS

Half of all paracetamol overdoses involved over 16 tablets. Patients were predominantly young (three-quarters aged 16-40 years) and female (58.3%); over half (53.3%) had taken a previous paracetamol overdose. Three-quarters said they wanted to die. Half took the overdose within an hour of first thinking of it, half (53.3%) took tablets already in the home and 58.3% bought tablets specifically for the overdose. Ten people tried to buy more than 32 tablets in one transaction; four succeeded. Most knew that a paracetamol overdose could cause death or permanent damage (88.3%) and harm the liver (80.0%) but 70.0% thought they would lose consciousness. Warnings on packs had little deterrent effect. Media and internet influences were identified. Patients chose paracetamol because it was cheap and easily available.

CONCLUSIONS

Further measures to reduce breaches of sales guidelines and the dangers of paracetamol overdose are required. Media and internet site producers should follow guidelines on reporting suicide.

Belief in a Werther Effect: third-person effects in the perceptions of suicide risk for others and the moderating role of depression

Werther Effect research has almost solely focused on the behavioral level of media effects. Clinically relevant predispositions like depression as well as the moderating role of media effects on a perceptional level have been omitted so far. To bridge this gap, we reanalyzed the data of an experiment conducted by Rustad, Small, Jobes, Safer, and Peterson: volunteer students' ratings for their self-risk of depression and suicide as well as their perceptions of others' suicide risk were investigated. While a Werther Effect could not be observed, there is a general overestimation of media influences on others--presumed Werther Effects--that are moderated by the personal degree of depression.

The development of a guideline and its impact on the media reporting of suicide

CONTEXT

A causal association between media reporting of suicides and the subsequent actual suicides has been observed. There are no studies from India regarding media reporting of suicide. This study examines whether educating media professionals about responsible reporting of suicides can change the quality of reporting.

AIMS

To study the impact of a guideline on the reporting style of suicides by journalists.

SETTINGS AND DESIGN

Newspaper reports in the local language examined by psychiatrists.

MATERIALS AND METHODS

The Department of Psychiatry of a Teaching Hospital conducted a workshop for journalists, with the collaboration of media and mental health professionals and came out with a guideline about responsible reporting of suicide. Using this, a proforma was designed for assessing newspaper reports of suicides. All the suicide reports in the leading newspapers in Kerala were analyzed for one year prior to the workshop, the immediate next year, the second year, and six years later, using the 15 item proforma and whether each report was concordant or discordant to each item in the proforma was noted.

RESULTS

The total concordant responses were 43.7% in the year prior to the workshop, 45.2% during the first year following the workshop, 46.2% in the next year, and 45.7% after six years. When the trend of each item was examined, the concordance rates were increasing in each item, except two. There was no statistical significance.

CONCLUSIONS

A workshop for journalists could bring about positive changes in the media reporting of suicides. The changes persisted over the years, although they did not reach statistical significance.

Impact of screening for risk of suicide: randomised controlled trial

BACKGROUND

Concerns have been expressed about the impact that screening for risk of suicide may have on a person's mental health.

AIMS

To examine whether screening for suicidal ideation among people who attend primary care services and have signs of depression increases the short-term incidence of feeling that life is not worth living.

METHOD

In a multicentre, single-blind, randomised controlled trial, 443 patients in four general practices were randomised to screening for suicidal ideation or control questions on health and lifestyle (trial registration: ISRCTN84692657). The primary outcome was thinking that life is not worth living measured 10-14 days after randomisation. Secondary outcome measures comprised other aspects of suicidal ideation and behaviour.

RESULTS

A total of 443 participants were randomised to early (n = 230) or delayed screening (n = 213). Their mean age was 48.5 years (s.d. = 18.4, range 16-92) and 137 (30.9%) were male. The adjusted odds of experiencing thoughts that life was not worth living at follow-up among those randomised to early compared with delayed screening was 0.88 (95% CI 0.66-1.18). Differences in secondary outcomes between the two groups were not seen. Among those randomised to early screening, 37 people (22.3%) reported thinking about taking their life at baseline and 24 (14.6%) that they had this thought 2 weeks later.

CONCLUSIONS

Screening for suicidal ideation in primary care among people who have signs of depression does not appear to induce feelings that life is not worth living.

Trends in explicit portrayal of suicidal behavior in popular U.S. movies, 1950-2006

Trends in suicidal behavior portrayal in movies may reflect greater societal acceptance of suicide with potential adverse effects on adolescents. To assess the potential for such adverse effects, explicit portrayals of suicidal behavior and the ratings of films were coded in top-grossing U.S. movies from 1950-2006 (N = 855). Suicidal behavior portrayal in films increased linearly from 1950 to 2006. From 1968-1984, movies rated R by the Motion Picture Association of America had 5 times more highly explicit suicide behavior portrayals than did G/PG films. After the adoption of the PG-13 category in 1985, PG-13 and R films were indistinguishable on this measure. The results indicate the need for further study of the effects of suicidal behavior portrayals on adolescent movie audiences.

Suicide coverage in U.S. newspapers following the publication of the media guidelines

A nationally representative sample of 968 local and national newspapers was examined to determine whether the 2001 U.S. media guidelines were followed in articles published in 2002-2003, and featuring individual cases of suicidal behavior (N = 157). We found that, during this period of time, U.S. newspaper suicide coverage did not consistently reflect the influence of the media guidelines. On the positive side, only 19% of stories included inappropriate imagery. On the negative side, suicide stories often detailed suicide method (56% of stories) and location (58%), and rarely provided information about warning signs and risk factors (1%), the roles of depression (4%) and alcohol (2%), and prevention resources (6%). Our findings, together with previous evidence, suggest the need for sustained dialogue with the media about suicide reporting.

Media coverage and public reaction to a celebrity cancer diagnosis

BACKGROUND

Celebrity diagnoses can have important effects on public behaviour. UK television celebrity Jade Goody died from cervical cancer in 2009. We investigated the impact of her illness on media coverage of cervical cancer prevention, health information seeking behaviour and cervical screening coverage.

METHODS

National UK newspaper articles containing the words 'Jade Goody' and 'cancer' were examined for public health messages. Google Insights for Search was used to quantify Internet searches as a measure of public health information seeking. Cervical screening coverage data were examined for temporal associations with this story.

RESULTS

Of 1203 articles, 116 (9.6%) included a clear public health message. The majority highlighted screening (8.2%). Fewer articles provided advice about vaccination (3.0%), number of sexual partners (1.4%), smoking (0.6%) and condom use (0.4%). Key events were associated with increased Internet searches for 'cervical cancer' and 'smear test', although only weakly with searches for 'HPV'. Cervical screening coverage increased during this period.

CONCLUSION

Increased public interest in disease prevention can follow a celebrity diagnosis. Although media coverage sometimes included public health information, articles typically focused on secondary instead of primary prevention. There is further potential to maximize the public health benefit of future celebrity diagnoses.

Perceptions of diagnostic labels in forensic psychiatric practice: a survey of differences between nurses and other disciplines

This paper reports on a study of nurses' and non-nurses' perceptions of labels of mental illness and personality disorder in forensic services in the UK. The objectives of the study were to establish if differences in perceptions existed within, and between, the two groups of professionals. The research method was a survey design with 1,200 questionnaires distributed to nurses and 300 to other professionals in disciplines on forensic units in the UK, with response rates of 34.6% and 43%, respectively. The target population included clinical health care staff who had patient contact, including nurses, psychiatrists, psychologists, social workers, and occupational therapists. The results indicate that there are statistically significant differences within both nursing and non-nursing groups and also between the groups in relation to a "management" perspective for individuals labelled with a personality disorder and a "clinical" focus for individuals who are labelled as mentally ill. This paper adds research into the arena of forensic mental health in relation to the diagnostic labels of mental illness and personality disorders. It also adds evidence of a clinical response or a management response to such diagnostic labels which may impact on the practice of forensic psychiatry.

Effect of media reporting of the suicide of a singer in Taiwan: the case of Ivy Li

BACKGROUND

Suicide attempters are known to be vulnerable to the influence of media reporting of suicide events. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicide attempts and associated risk factors among suicide attempters.

METHODS

Sixty-three suicide attempters registered in a surveillance system of Taipei City Suicide Prevention Center were assessed using a structured interview soon after media reporting of the suicide of a young female singing star.

RESULTS

Forty-three (68%) respondents had encountered with the suicide news. Among them, 37% reported being influenced by the media reporting on their subsequent suicide attempts. Men (adjusted OR 6.36, 95% CI 1.29-31.44) and younger age groups (adjusted OR 4.93, 95% CI 1.04-23.45) were more susceptible to the media reporting. There was a positive modeling effect in method of suicide (charcoal burning) (adjusted OR 7.27, 95% CI 6.31-168.66).

CONCLUSIONS

This study has provided further evidence for suicide imitation among vulnerable people encountered with media reporting of celebrity suicide, and for the need to actively restrain reporting of suicides to decrease the imitation effect.

[Adolescence, substance abuse and suicide attempt by jumping from a window]

Suicide represents, in France, the second cause of death in youth aged 15 to 24. Sixteen per cent of juvenile mortality is attributable to suicide. The annual incidence of suicide attempts in this age group is estimated at about 40 000 cases. Jumping from high represents 6% of deaths from suicide: girls resort to this method twice as often as boys. The severity of somatic consequences and the frequency of sequels following a jumping from a window can hold center stage for a long time, at the risk of trivializing the psychopathology underlying such a violent acting-out. These clinical situations particularly involve a multidisciplinary follow up including an early and active participation of psychiatric consultation-liaison teams. Jumping from a window can occur even apart from established mental disorders, such as psychotic or mood disorders. Our four case-reports draw attention to risk factors represented by: substance abuse (alcohol, cannabis, but also cocaine, ecstasy...), the notion of previous suicide attempts and various drive disorders having a self-harm value or displaying an underlying impulsiveness (eating disorders, scarifications, shoplifting, running away...), the precipitating role of a recent loss of a parent or an important removal from family environment, the potential influence, especially in this age group, of spectacular cases of suicide amplified by the Medias ("Werther effect"). Paradoxically, to belong to a well-off milieu can also contribute to the risk of such acting-out, when parents replace affection and availability by an easy access to various consumer goods and a permissive education, thus opening the way to the encounter with different substances.

Representations of non-suicidal self-injury in motion pictures

The aim of this study was to investigate representations of non-suicidal self-injury (NSSI) in popular media. Forty-one motion pictures were viewed, coded, and analyzed. NSSI was correlated with mental illness, child maltreatment, and substance abuse. NSSI was generally portrayed as severe, habitual and covert. Further, depictions of NSSI were often sensationalized and featured prominently. NSSI was less likely to be associated with completed suicide than other psychological factors, but more closely associated with suicide than NSSI is in the community. Although NSSI was associated with psychiatric illness, few characters were receiving psychiatric care at the time of NSSI. However a significant proportion received support after engaging in NSSI. The portrayal of NSSI is generally accurate regarding correlates and function, but is inaccurately associated with suicide. Implications of the relatively accurate portrayal of NSSI are discussed in light of the potential for imitation, and the possibility of using cinematherapy to promote effective problem resolution.

Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality

BACKGROUND

Historical studies of news media have suggested an association between reporting and increased drug abuse. Period effects for substance use have been documented for different classes of legal and illicit substances, with the suspicion that media publicity may have played major roles in their emergence. Previous analyses have drawn primarily from qualitative evidence; the temporal relationship between media reporting volume and adverse health consequences has not been quantified nationally. We set out to explore whether we could find a quantitative relationship between media reports about prescription opioid abuse and overdose mortality associated with these drugs. We assessed whether increases in news media reports occurred before or after increases in overdose deaths.

METHODOLOGY/PRINCIPAL FINDINGS

Our ecological study compared a monthly time series of unintentional poisoning deaths involving short-acting prescription opioid substances, from 1999 to 2005 using multiple cause-of-death data published by the National Center for Health Statistics, to monthly counts of English-language news articles mentioning generic and branded names of prescription opioids obtained from Google News Archives from 1999 to 2005. We estimated the association between media volume and mortality rates by time-lagged regression analyses. There were 24,272 articles and 30,916 deaths involving prescription opioids during the seven-year study period. Nationally, the number of articles mentioning prescription opioids increased dramatically starting in early 2001, following prominent coverage about the nonmedical use of OxyContin. We found a significant association between news reports and deaths, with media reporting preceding fatal opioid poisonings by two to six months and explaining 88% (p<0.0001, df 78) of the variation in mortality.

CONCLUSIONS/SIGNIFICANCE

While availability, structural, and individual predispositions are key factors influencing substance use, news reporting may enhance the popularity of psychoactive substances. Albeit ecological in nature, our finding suggests the need for further evaluation of the influence of news media on health. Reporting on prescription opioids conforms to historical patterns of news reporting on other psychoactive substances.

Suicide in adolescents: a worldwide preventable tragedy

The tragedy of suicide in adolescents is experienced by all countries of the world with as many as 200,000 youth and young adults ending their life in the prime of their life because of self-murder each year. Such a tragedy should be unacceptable to clinicians of the world and this article examines factors leading to such death in our youth with recommendations on how to prevent such a worldwide carnage. A major issue in suicide prevention is to screen all children and adolescents for depression and other factors that may trigger suicide in adolescence.

Suicide

Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries.