May 24, 2018

Far more young people are entering the hospital for suicide-related reasons. Could shows like '13 Reasons Why' worsen the trend?

Daily Briefing

    A recent study finds the rate of suicide-related hospital and ED visits for pediatric patients more than doubled from 2008 and 2015—and experts say popular shows like Netflix's "13 Reasons Why," which premiered in 2017, could worsen that trend in the years to come.

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    Study findings

    For the study, published in Pediatrics, researchers used a database of 49 U.S. children's hospitals to assess billing data from 2008 to 2015 to identify ED visits and hospitalizations for suicide attempts and suicidal ideation among patients ages 5 to 17. The researchers did not analyze data on community hospitals. 

    The researchers found a total of 115,856 visits for suicide attempts or suicidal ideation among children ages 5 to 17 over the study's time period. According to the study, at 31 U.S. children's hospitals, the annual share of all visits for suicide ideation and suicide attempts nearly tripled from 0.66% in 2008 to 1.82% in 2015. The researchers found that more than 50% of the visits required a one-night hospitalization and about 14% required intensive care.

    The researchers found that older teens were more likely to visit the hospital for suicide attempts or suicidal ideation, accounting for the highest increase in hospital visits over the seven-year period when compared with the other age groups. In particular, the researchers found that among the hospital and ED visits for suicide attempts or suicidal ideation:

    • About 50% were for teens ages 15 to 17;
    • 37% were for adolescents ages 12 to 14; and
    • 13% were for children ages 5 to 11.

    The researchers also found girls made up two-thirds of visits, with the rate of increase highest among adolescent girls. According to the researchers, early puberty is a risk factor for suicide among girls.

    In addition, the researchers identified a seasonal trend in hospital visits. According to the study, visits reached a peak in mid-fall and fell to the lowest levels in the summer—indicating a strong relationship between the school year and the frequency of visits for suicidal ideation or suicide attempts.

    Discussion

    Gregory Plemmons, the study's lead author and a pediatrician and researcher at Vanderbilt University, said, "What our study made clear was school was a huge influence." He said, "We knew there was an association with school seasons, but actually seeing that mapped out was surprising." Still, he said, "The No. 1 thing to take home is that it's important to talk about this and important to ask about it." Plemmons said, "There's still a huge stigma and anything you can do to destigmatize it helps."

    But Plemmons and other experts also said the suicide themes in television shows such as the Netflix series "13 Reasons Why" could contribute to the increase in suicide attempts and suicidal ideation. For instance, Plemmons said that in light of his study's findings, the Netflix show raises concerns. "I think we're at a crossroads where we don't want to glamorize depression and suicide, which I think to some extent unfortunately that series does, but at the same time we want to continue to destigmatize mental illness and suicide," he said.

    Separately, Ruth Gerson—assistant professor of child and adolescent psychiatry at NYU Langone Health, director of Bellevue Hospital Center Children's Comprehensive Psychiatric Emergency Program, and co-editor of "Helping Kids in Crisis"—recommended that parents "ideally don't have your kid watch '13 Reasons Why,' or other shows with graphic depictions of suicide or self-harm." However, she added, "If your kid wants to watch it, watch it together—the whole series, not just one episode—and talk about what you see, so you can help your kid understand and process anything that is upsetting or triggering."

    And writing in USA Today, Anupam Jena, a professor at Harvard Medical School; Josh Gray, a director research at AthenaHealth; and Cass Sunstein, a professor at Harvard Law School, expressed similar concerns of the Netflix show, citing their own research comparing doctor's visits for suicide ideation among people ages 14 to 20 before and after the release of the show's first season.

    The authors found that the proportion of visits involving suicide ideation increased after the show's debut on March 31, 2017, jumping from about 0.19% (between January and March 2017) of all visits "to 0.27% of visits in April and 0.29% of visits in May"—representing "a more than 40% relative increase." The authors said their findings—especially when assessed in conjunction with a separate study showing a 19% increase in Google searches for how to commit suicide following the show's premiere—"are worrisome" and indicate the show's second season should serve as a "renewed cause for concern."

    Jena, Gray, and Sunstein commended Netflix for taking proactive steps to address these concerns, such as by having the actors in the show break character to speak about depression and treatment, but they said that alone wasn't enough. "Health care providers, particularly those caring for vulnerable teens, should be aware of the Season 2 release and the impact it might have on suicidal thinking and behavior," the authors wrote. "Some have recommended that at-risk youth not view the show—which could well be good advice."

    Access concerns

    Plemmons also cited ongoing concerns about access to mental health care for pediatric patients, noting that experts widely agree there are not enough mental health care providers or inpatient beds available for individuals in need of treatment. "We're lobbying every day for more facilities, more beds, more mental health providers," Plemmons said.

    Gerson echoed Plemmons' concerns, pointing out that many teens who visit EDs for suicide attempts do not receive mental health assessments and that medical physicians often do not have the training or support to conduct such evaluations or stabilize such patients. According to the Times, people who have attempted suicide and do not receive a mental health assessment in the ED are at a higher risk of making another suicide attempt.

    Gerson also said there are very few pediatric psychiatry EDs in the United States. She said at the  Bellevue Hospital Center's Children's Comprehensive Psychiatric Emergency Program, where she works, every child who enters the facility undergoes a complete mental health assessment, which can include conversations with the child, the parents, the outpatient therapist, pediatrician, and school. The center sees about 2,400 children and adolescents who undergo mental health evaluations annually. "We bring all this information back to the child and parent and make a safety plan," she said, noting that while She a "portion" of patients are admitted for inpatient care, the facility "also ha[s] access to immediate outpatient care which lets us do intensive therapy even without admitting the child to the hospital" (Haelle, "Shots," NPR, 5/16; Klass, "The Checkup," New York Times, 5/16; Whalen, Wall Street Journal, 5/15; Newman, U.S. News & World Report, 5/16; Jena et al., USA Today, 5/17).

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