Commentary: Thirteen Reasons Why: The Impact of Suicide Portrayal on Adolescents’ Mental Health
Morgan James Grant*, Hala El-Agha, Thuy-Tien Ho, Shobal D. Johnson
Texas Woman’s University, Texas, United States
Thirteen Reasons Why (13RY) is a Netflix series that tells the story of a high school girl named Hannah Baker, who died from suicide due to a series of painful events of betrayal, sexual assault, bullying from classmates, and lack of support from friends, family, and school staff. She prepared and left behind a box with a suicide note and 13 audiotapes to give insight into her suicide. In Thirteen Reasons Why: The impact of suicide portrayal on adolescents’ mental health, Rosa et al. investigated “the influence of media portrayals of suicide on adolescent’s mood" by providing a descriptive, qualitative perspective of mental health, suicidality, and the prevalence of suicidal behavior or ideation, along with emotional processes most affected by the sensationalism and normalization of suicide. This commentary discusses the impact of suicide portrayal on adolescents and highlights the backlash that occurred in response to how 13RY depicted suicide by expanding on the study’s limitations, highlighting controversial issues, and making recommendations for future research by revealing the omission of certain key facts.
Thirteen Reasons Why (13RY) is a Netflix series that tells the story of a high school girl named Hannah Baker, who died from suicide due to a series of painful events of betrayal, sexual assault, bullying from classmates, and lack of support from friends, family, and school staff. She prepared and left behind a box with a suicide note and 13 audiotapes to give insight into her suicide. In Thirteen Reasons Why: The impact of suicide portrayal on adolescents’ mental health, Rosa et al.1 investigated “the influence of media portrayals of suicide on adolescent’s mood.” Brazilian adolescents recruited through social media from 13RY-themed groups completed questionnaires assessing depressive mood and suicidality the month before watching 13RY and after watching 13RY1. Participants who were unmotivated and had greater feelings of sadness, as well as participants with a previous history of suicidal ideation, suicide attempt, or self-injury, were more likely to report declines in mood after watching 13RY1. The study provided a descriptive, qualitative perspective of mental health, suicidality, and the prevalence of suicidal behavior or ideation. The authors also examined the emotional processes most affected by sensationalism and normalization of suicide. By expanding on the study’s limitations, highlighting controversial issues, and making recommendations for future research by revealing the omission of certain key facts, this commentary discusses the impact of suicide portrayal on adolescents and examines the backlash against 13RY’s depiction of suicide.
In the United States, 129 individuals die by suicide each day, making suicide the tenth leading cause of death nationwide and the second leading cause of death among adolescents between ages 15 to 192,3. In the past two decades, suicide rates among adolescents have reached an all-time high, and suicide rates among female adolescents have steadily increased2. Suicide most often occurs when an individual feels hopeless and believes there are no other options available. According to the American Foundation for Suicide Prevention4, warning signs include talking about suicide; a change in behavior such as isolation from family or friends; aggression; increased use of alcohol or drugs; and mood changes such as depression, anxiety, irritability, agitation, or anger. Risk factors include a mental health diagnosis; environmental factors such as access to lethal methods, prolonged stress, or an increase in stressful events; historical factors such as previous suicide attempts, childhood abuse, neglect, or trauma; and family history of mental illness, suicide attempts, or suicide completions4.
The crux of the controversy surrounding 13RY is the incongruity between the intent of the popular show and delivery of the message. The show intended to provide awareness of mental health and spark discussions through the popular streaming service Netflix. Yet, the show provided viewers with examples on how to engage in self-harm and ways to attempt suicide. This glamorization of suicide has been implicated to have profound effects on viewers who suffer from mental illness, especially those who have contemplated suicide or engaged in self-harm to cope with trauma, neglect, and even abuse. The show frequently employed suicide-stigmatizing language. For example, when one of the main characters, Skye, is found to have a series of cuts on her arm by a classmate, she brazenly responds, “Suicide is for cowards. This is what you do to not commit suicide”5. This affirms the general belief that cutting, a form of non-suicidal self-injury, is better than cowardly attempts at suicide. Given the popularity of the series, the dissemination of such an affirmation to a wide swath of the public is potentially dangerous. To put into context the magnitude of the show’s reach, 13RY had 6.08 million viewers in the United States within the first three days of season two’s premiere episode6. It is estimated that 75% of these viewers are 34 years of age and younger. Notably, self-injury predominates in the young adult population, which comprises 75% of the show’s viewership7.
The viewership audience for 13RY was about 65% female8. Study participants were recruited through social media and online forums focused on 13RY1,9. Interestingly, adolescent females are more likely to suffer from mental health issues than are adolescent males, partly due to objectification and toxic masculinity10,11. Females are also more likely to be open about mental health issues1,9,12. Of the 7,004 questionnaires included in the study, about 83.8% of participants were female, while 16.2% of participants were male1. Other studies reported similar gender participation percentages1,12. After watching the first season of 13RY, 32.1% of participants reported improvements in mood and 23.7% reported a decline in mood1. A decline in mood after watching 13RY was significantly associated with sadness or being unmotivated1,13. A decline in mood was also associated with a higher risk for suicide1. Participants with more frequent or severe feelings of sadness, apathy, or thoughts of self-harm or suicidal ideation were more likely to report a decline in mood1,9,13,14. Media content may impact vulnerable individuals differently than non-vulnerable individuals1,13,15. Moreover, individuals with a history of self-harm, suicidal ideation, or suicide attempt are more likely to be negatively affected by media1,14,15. As a result, it is suggested that adolescent viewers watch 13RY with a trusted adult1,16. Taken together, these findings suggest a need for more rigorous research on the links between media content and suicide prevention, mental health, and trauma.
As with any research study, confounding factors and limitations should be considered and should be deliberately declared by the authors to justify the relevance of the research findings and implications for the literature. The primary purpose of the study by Rosa, et al.1 was to investigate how the mood and behavior of adolescents were affected after watching suicide portrayal in 13RY. The study was limited to only Brazilian adolescents1. Although Rosa and colleagues1 realized this limitation, attempting to imply further how adolescents in the United States and possibly other parts of the world may be affected by watching 13RY or similar shows could help shape future implementations of community-based health education and outreach programs between institutions and the public.
In the midst of social movements against sexual violence, harassment, and assault, the release of 13RY presented an opportune moment to nod to its younger female viewers heavily. Instead, viewers were presented with a case of activism gone wrong as the character Casey, who was depicted as a warrior for social justice, bolstered the stereotypical negative views of feminism. The ambiguous nature behind the story of Casey’s character portrayed her as angry—a trait often attributed to women who speak out but are often silenced—and her symbolism as a feminist undermines activism for rape victims and women in general17,18. By considering the detrimental effects of anti-feminism on its predominantly female study population, such contextualization of the female perspective by Rosa et al. could have helped affirm a woman’s power over her own body and psyche.
The authors identified variables within the study to measure the main outcome—"changes in mood after watching the series”1. However, no justification was provided for the literacy appropriateness of the questionnaires being tested on the adolescent research participants. More consideration should have been given to the well-recognized role of adolescent literacy established by prior research. For example, work published by Herrera et al. Herrera, et al.19 argues that multi-component social studies instruction positively impacts adolescent students’ reading comprehension, vocabulary, and general literacy. Exploring the available evidence-based standardized suicide risk assessment (i.e. Literacy of Suicide Scale and the Suicidal Ideation Attributes Scales) would have provided researchers with the benefit of quantifying the severity of an individual’s suicidal thoughts in addition to identifying specific attributes of such thoughts20,21. A discussion about the media health literacy of suicide among adolescents could have been provided. Due to omitting the adolescent level of literacy in the study and declaring “the questionnaire used was not a validated instrument for assessment of mood or suicidality”, Rosa et al. decreased the relevancy of the study and its applicability within the larger scientific framework1. Conducting a pilot experimental study to assess the appropriateness and feasibility of the words and phrases being used in the survey evaluation would have strengthened the clarity of the questions. The composition of the questionnaires in the context of appropriate literacy and assessment scales should also be validated to delineate the true feeling and interpretation of the research participants.
Suicide is one of the leading causes of death for American teens, and depression is a condition that afflicts millions of adolescents in this country. Importantly, individuals of these age groups are especially susceptible to harmful media content. Thus, understanding the links between mood, mental state, viewership, and media content is critical for reducing the rate of adolescent suicide. Despite the caveats therein, the study by Rosa et al.1 plays a vital role in the literature by highlighting how mood and behavior of adolescents are influenced by the depiction of suicide in fictional media, emphasizing the prevalence of suicide and the importance of adolescents’ mental health to the advocate audience.
- Rosa GSD, Andrades GS, Caye A, et al. Thirteen Reasons Why: The impact of suicide portrayal on adolescents' mental health. J Psychiatr Res. 2019;108: 2-6 doi: 10.1016/j.jpsychires.2018.10.018[published Online First: Epub Date].
- Frazee G, Morales PG. Suicide among teens and young adults reaches highest level since 2000. Secondary Suicide among teens and young adults reaches highest level since 2000 2019. PBS NewsHours at https://www.pbs.org/newshour/nation/suicide-among-teens-and-young-adults-reaches-highest-level-since-2000.
- American Foundation for Suicide Prevention. Suicide statistics. Secondary Suicide statistics 2019. https://afsp.org/about-suicide/suicide-statistics/.
- American Foundation for Suicide Prevention. Risk factors and warning signs. Secondary Risk factors and warning signs 2019. https://afsp.org/about-suicide/risk-factors-and-warning-signs/.
- Koehler S. 13 reason why '13 Reasons Why' is dangerously problematic. Secondary 13 reason why '13 Reasons Why' is dangerously problematic 2017. https://www.huffpost.com/entry/13-reasons-why-13-reasons-why-is-dangerously-problematic_b_590b6df9e4b046ea176ae8e2.
- Gaus A. Netflix has many reasons to be worried about pay for '13 Reason Why' cast. Secondary Netflix has many reasons to be worried about pay for '13 Reason Why' cast 2018. https://www.thestreet.com/technology/netflix-stars-want-more-money-14680569.
- Swannell SV, Martin GE, Page A, et al. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav. 2014; 44(3): 273-303 doi: 10.1111/sltb.12070[published Online First: Epub Date].
- Budowski J. ‘13 Reasons Why’ season 2 ratings reveal key info about viewers Secondary ‘13 Reasons Why’ season 2 ratings reveal key info about viewers 2018. https://decider.com/2018/05/30/13-reasons-why-season-2-ratings/.
- Zimerman A, Caye A, Salum G, et al. Revisiting the Werther effect in the 21st century: bullying and suicidality among adolescents who watched 13 Reasons Why. Journal of the American Academy of Child and Adolescent Psychiatry. 2018; 57(8): 610-13. e2
- Jenney A, Exner-Cortens D. Toxic masculinity and mental health in young women: An analysis of 13 reasons why. Affilia. 2018; 33(3): 410-17.
- 13 Reasons Why. Gender Forum; 2018. Prof. Dr. Beate Neumeier.
- Bridge JA, Greenhouse JB, Ruch D, et al. Association between the release of Netflix's 13 Reasons Why and suicide rates in the United States: An interrupted time series analysis. J Am Acad Child Adolesc Psychiatry. 2019 doi: 10.1016/j.jaac.2019.04.020[published Online First: Epub Date].
- Thompson LK, Michael KD, Runkle J, et al. Crisis Text Line use following the release of Netflix series 13 Reasons Why Season 1: Time-series analysis of help-seeking behavior in youth. Prev Med Rep. 2019; 14: 100825 doi: 10.1016/j.pmedr.2019.100825[published Online First: Epub Date].
- Campo JV, Bridge JA. Exploring the Impact of 13 Reasons Why: Looking for Light Amidst the Heat. J Am Acad Child Adolesc Psychiatry. 2018; 57(8): 547-49 doi: 10.1016/j.jaac.2018.05.012[published Online First: Epub Date].
- Zarin-Pass M, Plager P, Pitt MB. 13 things pediatricians should know (and do) about 13 Reasons Why. Pediatrics. 2018; 141(6): e20180575.
- Jacobs T. More evidence linking '13 reasons why' with teen suicide attempts. Secondary More evidence linking '13 reasons why' with teen suicide attempts 2018. https://psmag.com/education/more-evidence-links-13-reasons-why-with-teen-suicide-attempts.
- McClean EJ, Martin SR, Emich KJ, et al. The social consequences of voice: An examination of voice type and gender on status and subsequent leader emergence. Academy of Management Journal. 2018; 61(5): 1869-91.
- Salerno JM, Peter-Hagene LC, Jay AC. Women and African Americans are less influential when they express anger during group decision making. Group Processes & Intergroup Relations. 2019; 22(1): 57-79.
- Herrera S, Truckenmiller AJ, Foorman BR. Summary of 20 Years of Research on the Effectiveness of Adolescent Literacy Programs and Practices. REL 2016-178. Regional Educational Laboratory Southeast 2016.
- van Spijker BA, Batterham PJ, Calear AL, et al. The suicidal ideation attributes scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation. Suicide Life Threat Behav. 2014; 44(4): 408-19 doi: 10.1111/sltb.12084[published Online First: Epub Date].
- Voracek M, Egle J, Schleicher S, et al. The beliefs in the inheritance of risk factors for suicide scale (BIRFSS): further results on demographic correlates, dimensionality, reliability, and validity. Omega Westport. 2007; 55(4): 279-96 doi: 10.2190/OM.55.4.c[published Online First: Epub Date].