Media influence on parasuicide. A study of the effects of a television drama portrayal of paracetamol self-poisoning

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.

13 Reasons Why Not: A Methodological and Meta-Analytic Review of Evidence Regarding Suicide Contagion by Fictional Media

BACKGROUND

For decades, policymakers and suicide prevention advocates have questioned whether exposure to media with suicide themes, whether television, movies, or music, could increase suicide risk among youth. To date, no clear picture has emerged, with data inconsistent AIMS: To access whether current evidence can support concerns that fictional media increases risk of viewer suicidal ideation.

MATERIALS & METHODS

Two broad forms of data consider the issue, namely society-level aggregate data, and data from smaller correlational and experimental studies. The current article examined the evidence for suicide contagion by fictional media with a methodological and meta-analytic review.

RESULTS

Results suggest that current data do not support the theory that suicide contagion by fictional media occurs.

DISCUSSION

In addition to lack of consistency in current research results, widespread methodological concerns limit confidence in conclusions from many studies. A commitment to better methods and open science is warranted.

CONCLUSION

It is recommended that individuals exercise caution in public statements linking suicide-themed fictional media to suicide contagion as data may not be able to support such claims.

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.

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.

A Social Semiotic Interpretation of Suicidal Behaviour in Young People

This article presents a study of nurses’ and doctors’ perceptions of young people who engage in suicidal behaviour. A contemporary view of grounded theory is used to guide the collection and analysis of qualitative data from nurses and doctors working with young people in an accident and emergency department, paediatric medicine and child and adolescent mental health services (adolescent inpatient unit). The analysis of 45 semi-structured interviews generated the category: Processes of communication and associated meanings: Another voice, Complex messages and Seeing and using the social environment. A social semiotic framework is used to explore the way in which nurses and doctors perceive young people who engage in suicidal behaviour. The article concludes by considering the implications for policy and practice.

The Clustering and Contagion of Suicide

Two general types of suicide cluster have been discussed in the literature; roughly, these can be classified as mass clusters and point clusters. Mass clusters are media related, and the evidence for them is equivocal; point clusters are local phenomena, and these do appear to occur. Contagion has not been conceptually well developed nor empirically well supported as an explanation for suicide clusters. An alternative explanation for why suicides sometimes cluster is articulated: People who are vulnerable to suicide may cluster well before the occurrence of any overt suicidal stimulus, and when they experience severe negative events, including but not limited to the suicidal behavior of one member of the cluster, all members of the cluster are at increased risk for suicidality (a risk that may be offset by good social support).

Crucial elements in suicide prevention strategies

Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour. On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented. Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined.

Suicide in films: the impact of suicide portrayals on nonsuicidal viewers' well-being and the effectiveness of censorship

The effects of suicide films on recipients' emotional and mental state, as well as the influence of censorship, was studied. Nonsuicidal subjects watched the original or a censored version of a suicide film or a drama without suicide. Data were collected by questionnaires. The viewing led to a deterioration of mood and an increase in inner tension and depression scores, but also to a rise in self-esteem and life satisfaction and to a drop in suicidality. There were no relevant differences between the film groups. The more a subject identified with the protagonist, the greater were the negative effects.

Suicide in the media: a quantitative review of studies based on non-fictional stories

Research on the effect of suicide stories in the media on suicide in the real world has been marked by much debate and inconsistent findings. Recent narrative reviews have suggested that research based on nonfictional models is more apt to uncover imitative effects than research based on fictional models. There is, however, substantial variation in media effects within the research restricted to nonfictional accounts of suicide. The present analysis provides some explanations of the variation in findings in the work on nonfictional media. Logistic regression techniques applied to 419 findings from 55 studies determined that: (1) studies measuring the presence of either an entertainment or political celebrity were 5.27 times more likely to find a copycat effect, (2) studies focusing on stories that stressed negative definitions of suicide were 99% less likely to report a copycat effect, (3) research based on television stories (which receive less coverage than print stories) were 79% less likely to find a copycat effect, and (4) studies focusing on female suicide were 4.89 times more likely to report a copycat effect than other studies. The full logistic regression model correctly classified 77.3% of the findings from the 55 studies. Methodological differences among studies are associated with discrepancies in their results.

Television and Adolescent Use of Over-the-Counter Analgesic Agents

BACKGROUND:

Portrayals of the use of over-the-counter (OTC) analgesics on television may stimulate their use.

OBJECTIVE:

To explore the association between taking OTC analgesics and television viewing by adolescents.

METHODS:

A standardized self-administered questionnaire among first-year (mean age 13.16 y) and fourth-year (mean age 16.37 y) secondary students in Flanders, Belgium (n = 2546) was administered in a school setting. The independent variable was television viewing; control variables were school year, gender, drinking alcohol, days off sick, computer gaming, and Internet use. The main outcome variable was monthly use of OTC analgesics.

RESULTS:

On average, respondents watched 3 hours 18 minutes of television per day (boys more than girls, first-year students more than fourth-year students). Per additional hour of television per day, the odds that respondents were regular users of analgesics were 1.16 times higher (95% CI 1.08 to 1.24). For the 10% heaviest viewers, the odds were 2.30 times higher (95% CI 1.25 to 4.24) compared with the 10% lightest viewers. Odds of OTC analgesic use were higher for students reporting more sick days in the past year (OR 1.38, 95% CI 1.28 to 1.49), regular users of alcohol (OR 1.33, 95% CI 1.17 to 1.50), and girls (OR 1.92, 95% CI 1.35 to 2.73).

CONCLUSIONS:

A relationship was found between watching television and the use of OTC analgesics, even after controlling for gender and lifestyle measures. More research is needed to establish whether this relationship is causal.

Suicide and the Media

Summary: The association between the portrayal of suicide in fictional media and actual suicide has been debated since 1774, when it was asserted that Goethe's The Sorrows of Young Werther had led people to take their own lives. Since that time, a plethora of studies considering the association has been conducted. This review considered 34 studies examining the impact of fictional portrayal of suicide (in film and television, music, and plays) on actual suicidal behavior. It asked the question: “Is there any association, and if so, can it be considered causal?” Using strict criteria to establish causality, we found that the evidence was more equivocal than was the case for nonfictional reporting.

Suicide and the media

Evidence continues to amass on the significant impact of media coverage on suicide. The research literature on the impact of news reports of nonfictional suicides as well as fictional suicide stories is reviewed in order to determine the nature and scope of the influence of the mass media on suicide. The current review, building upon earlier reviews, is limited to English language publications or English translations of articles and/or abstracts. The interactive factors that may moderate the impact of media stories are also reviewed. Such interactive factors include characteristics of the stories (agent), individuals' attributes (host), and social context of the stories (environment). Recommendations are presented for the reporting of suicide stories, which may minimize the risk of imitative suicides. The media's positive role in educating the public about risks for suicide and shaping attitudes about suicide is emphasized. In summary, the existence of suicide contagion no longer needs to be questioned. We should refocus our research efforts on identifying which particular story components promote contagion under which circumstances and which components are useful for preventive programming.

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

OBJECTIVES

To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

DESIGN

Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.

SETTING

49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data.

SUBJECTS

4403 self poisoning patients; questionnaires completed for 1047.

MAIN OUTCOME MEASURES

Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers.

RESULTS

Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).

CONCLUSIONS

Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Suicidal behavior among young people in Singapore

The purpose of this study was to investigate suicidal behavior among young people in an Asian community. Tracing records of all patients below 21 years of age who attempted suicide and were managed in a teaching hospital, the authors found the incidence increased sixfold between 1991 and 1995. Young females of Indian origin were found to be a risk group. Differences in suicidal behavior among the three main ethnic communities appear to be influenced by various sociocultural factors. The most common diagnosis was adjustment disorder stemming from interpersonal losses and conflicts. Schizophrenia, alcohol, and other substance abuse were rarely reported.

Why has suicide increased in young males?

Several countries in the Western hemisphere have experienced a marked increase in suicide rates in young males in recent years. This article considers this phenomenon largely from the perspective of the United Kingdom, where rates of suicide in 15-24-year-old males nearly doubled in just over a decade. The possible reasons for this are considered, particularly in the context of relative stability of suicide rates in young females.

Parasuicide: a Singapore perspective

OBJECTIVES

This study was undertaken to determine whether there were ethnic and social variations in parasuicide in the population of Singapore.

METHODS

All hospital records of parasuicide from a teaching hospital between 1991 and 1995 were reviewed. Demographic data, reasons precipitating the suicide attempt and the psychiatric diagnoses were recorded. Altogether 814 patients were identified.

RESULTS

There was a general upward trend of cases admitted from 1991 to 1995. Young females appear to be the most vulnerable accounting for 60.5% of the study population. The Indian community has significantly higher risk of parasuicide compared to the Chinese and Malays. Overdose of medication was the most common method with paracetamol being implicated in 48.1% of all overdoses.

CONCLUSION

Differences in parasuicide rates amongst the three ethnic communities can be attributed to various socio-cultural factors. The phenomenon of parasuicide is of increasing importance as it particularly involves adolescents and young adults. Suicide prevention will continue to present a challenge for mental health professionals in the foreseeable future.

Contagion of deliberate self-harm among adolescent inpatients

OBJECTIVE

To explore the quantitative importance and clinical features of deliberate self-harm (DSH) contagion in a closed adolescent psychiatric unit.

METHOD

The authors investigated with statistical methods and a sociogram whether acts of DSH were clustered during a 12-month study period. Twelve subjects were involved in acts of DSH, and their mean length of hospitalization during the study period was about 90 days. Six adolescents with four or more contagion incidents were interviewed.

RESULTS

DSH incidents were clustered during the study period (p < .05). Most DSH incidents were skin cutting committed by depressed female subjects with borderline personality disorder. The majority of DSH contagion can be understood in terms of small-group rites for feelings of togetherness.

CONCLUSIONS

Even a majority of DSH events in closed adolescent units may be triggered by contagion, and DSH can spread to previously DSH-naive adolescents.