Produção Nacional
Revisado por pares
Revisiting the Werther Effect in the 21st Century: Bullying and Suicidality Among Adolescents Who Watched 13 Reasons Why
2018; Elsevier BV; Volume: 57; Issue: 8 Linguagem: Inglês
10.1016/j.jaac.2018.02.019
ISSN1527-5418
AutoresAline Zimerman, Arthur Caye, André Zimerman, Giovanni Abrahão Salum, Ives Cavalcante Passos, Christian Kieling,
Tópico(s)Child and Adolescent Psychosocial and Emotional Development
ResumoUnlike most leading causes of death in the United States, suicide rates have not declined during the past 50 years.1Curtin S.C. Warner M. Hedegaard H. Increase in Suicide in the United States, 1999-2014. National Center for Health Statistics, Hyattsville, MD2016Google Scholar Among young people the situation is even more dramatic, because suicide rates are rising,2QuickStats: suicide rates for teens aged 15-19 years, by sex—United States, 1975-2015.MMWR Morb Mortal Wkly Rep. 2017; 66: 816Crossref PubMed Scopus (45) Google Scholar and suicide is now the second cause of death in 15- to 29-year-olds globally.3WHOMental health: suicide data.http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/Google Scholar It has been suggested that descriptions of suicide in the media might affect behavior and that the young might be more vulnerable to this effect.4Canadian Paediatric SocietyImpact of media use on children and youth.Paediatr Child Health. 2003; 8: 301-306Crossref PubMed Scopus (66) Google Scholar In the late 18th century, the novel The Sorrows of Young Werther by Johann Wolfgang von Goethe was blamed for unleashing a suicide epidemic among young men in Europe. There are now real social and scientific concerns on the possible contagion effect of descriptions of suicides in fictional and nonfictional works.5Phillips D.P. The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect.Am Sociol Rev. 1974; 39: 340-354Crossref Scopus (608) Google Scholar, 6Gould M.S. Lake A.M. The Contagion of Suicidal Behavior. National Academies Press, Washington, DC2013Google Scholar The premise that exposure to accounts of suicides can cause predisposed individuals to make attempts is supported by a number of ecologic studies7Gould M.S. Suicide and the media.Ann N Y Acad Sci. 2001; 932: 200-202Crossref PubMed Scopus (229) Google Scholar, 8Phillips D.P. Carstensen L.L. Clustering of teenage suicides after television news stories about suicide.N Engl J Med. 1986; 315: 685-689Crossref PubMed Scopus (272) Google Scholar; however, most research on the topic is outdated, because the relation between teenagers and the media is rapidly changing.9Common Sense Media ConsultingThe Common Sense census: media use by tweens and teens.https://www.commonsensemedia.org/sites/default/files/uploads/research/census_researchreport.pdfGoogle Scholar Moreover, ethical and methodologic aspects frequently hamper the empirical investigation of this issue. The commercial success of the Netflix show 13 Reasons Why10Nededog, J. RANKED: The 13 most popular Netflix original shows. Business Insider. http://www.businessinsider.com/most-popular-netflix-shows-2017-4/#13-grace-and-frankie-1. Published April 13, 2017. Accessed February 8, 2018.Google Scholar was followed by a heated debate on how it approaches the story of an adolescent who commits suicide after being bullied at school.11Louis CS. For families of teens at suicide risk, '13 Reasons' raises concerns. The New York Times. https://www.nytimes.com/2017/05/01/well/family/for-families-of-teens-at-suicide-risk-13-reasons-triggers-concerns.html. Published May 1, 2017. Accessed February 8, 2018.Google Scholar Several experts argued that the show could result in an increase in suicidal thoughts and behaviors,12Brooks M. Teen suicide experts blast Netflix series "13 Reasons Why". Medscape. https://www.medscape.com/viewarticle/879606. Published May 5, 2017. Accessed February 8, 2018.Google Scholar, 13Koplewicz HS. '13 Reasons Why' spreads suicide like a disease: column. USA Today. https://www.usatoday.com/story/opinion/2017/05/05/13-reasons-why-suicide-mental-health-dangerous-column/101262330/?utm_source=feedblitz&utm_medium=FeedBlitzRss&utm_campaign=news-opinion. Published May 5, 2017. Accessed February 8, 2018.Google Scholar which was reinforced by a recently published article that presented an association between the show release date and suicide-related Google searches.14Ayers J.W. Althouse B.M. Leas E.C. Dredze M. Allem J.-P. Internet searches for suicide following the release of 13 Reasons Why.JAMA Intern Med. 2017; 177: 1527-1529Crossref PubMed Scopus (93) Google Scholar However, to our knowledge, direct evidence on whether the show influences adolescent thinking and behavior is lacking. To address this issue, we assessed adolescents who watched 13 Reasons Why by asking how it affected them in regard to bullying and suicidal ideation. The study was approved by the research ethics committee of the Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil). We created online surveys in English and in Portuguese with questions related to bullying, depression, and suicide before and after watching the first season of 13 Reasons Why. We asked respondents whether they had ever been bullied or had bullied someone else before watching the show; for those who answered affirmatively to any of these 2 questions, we used a 5-point Likert scale to assess how much they believed watching the series had changed the way they felt or behaved regarding bullying. For those who had not engaged in bullying before the show, we asked whether they had bullied anyone afterward. To measure depressive symptoms, the survey included the Patient Health Questionnaire–2 (PHQ-2),15Kroenke K. Spitzer R.L. Williams J.B. The Patient Health Questionnaire-2: validity of a two-item depression screener.Med Care. 2003; 41: 1284-1292Crossref PubMed Scopus (3546) Google Scholar which consists of 2 questions related to symptoms of depression during the past 2 weeks. Scores on the PHQ-2 range from 0 to 6, in which 0 indicates no cardinal depressive symptoms and 6 indicates feeling depressed and anhedonic practically every day. For this study, the questionnaire asked about the 2 weeks before watching the show. A score equal to or greater than 3 on the PHQ-2 is considered a positive screening result for depression. The last 2 questions in the survey referred to suicidal ideation. Participants were asked whether, before watching the show, they had ever thought about taking their own life (dichotomic) and how watching the show changed the way they felt about it (5-point Likert scale). Answers to this last question were operationalized as decreased (1 and 2), unchanged (3), and increased (4 and 5) suicidal ideation. For the group with no prior suicidal ideation, answers 1 to 3 were merged and considered as no increase in suicidal thoughts (see Supplement 1, available online, for details). For the primary analysis, we used Facebook advertising to reach adolescents living in the United States or Brazil who liked pages related to the television series. Participants included in this analysis were 12 to 19 years old, living in the aforementioned countries, who reported having watched all 13 episodes and completed the questionnaire. To address the potential of selection bias by including only participants who liked Facebook pages related to 13 Reasons Why and therefore might have a more favorable view of the show, we recruited a control group who had liked pages related to Netflix on Facebook but not 13 Reasons Why. We performed χ2 tests to compare results between the control and primary study groups. A p value less than .05 was considered statistically significant. A total of 280,973 people viewed the survey links and 26,103 responded. After excluding 2,382 people who did not complete the questionnaire, 2,214 who did not watch all episodes of the show, and 445 who were not 12 to 19 years old, 21,062 people were included in our sample. Most participants were girls, Brazilian residents, and 15 to 17 years old (Table 1). Most respondents screened positive for depression (PHQ-2 score ≥ 3) in the 2 weeks before watching 13 Reasons Why (65.6%) and 64.5% reported a lifetime history of suicidal ideation.Table 1Baseline Characteristics of Study Populationn (%)aAge (y), mean (SD)15.92 (1.7)GenderbOthers (self-reported): 111 (0.5%). Girls18,825 (89.4) Boys2,126 (10.1)Location United States4,192 (19.9) Brazil16,870 (80.1)DepressioncA positive screening result for major depression was considered a score of at least 3 on the Patient Health Questionnaire–2.13,817 (65.6)Suicidal ideation13,589 (64.5)Suffered bullying16,582 (78.7)Engaged in bullying8,692 (41.3)Note: aUnless otherwise indicated.b Others (self-reported): 111 (0.5%).c A positive screening result for major depression was considered a score of at least 3 on the Patient Health Questionnaire–2. Open table in a new tab Note: aUnless otherwise indicated. In this latter group, 16.5% expressed more and 59.2% reported less suicidal ideation after watching the show; 24.2% indicated no change. In the group of participants with no history of suicidal ideation, 6.4% reported an increase in suicidal thoughts after watching the show. Figure 1 displays the changes in suicidal thinking after watching the show among participants with low (0) and high (6) PHQ-2 scores. A total of 78.7% of participants said they had suffered bullying and, of these, 40.5% reported feeling better about it after the show. Of all participants, 41.3% stated they had engaged in bullying before watching the show; of those who had not, 97.3% reported unchanged behavior afterward. Of adolescents who had engaged in bullying, 95.5% reported they rethought such behavior after watching the show, and 90.1% of these who reconsidered their attitudes said they began bullying less afterward. There was no difference in changes in bullying behavior or feelings related to bullying according to PHQ-2 score or history of suicidal ideation in participants who reported bullying or suffering bullying before watching the show (see Figures S1 and S2, available online, for details). A total of 2,323 people met inclusion criteria for the control group (adolescents who liked Netflix-related pages but not 13 Reasons Why). No significant difference was found in the results between the primary sample and the control group regarding decrease in bullying (90.1% versus 92.1%, p = .07) and in suicidal ideation (59.2% versus 60.5%, p = .31). Our data demonstrate that watching 13 Reasons Why was associated with decreased rates of self-reported bullying-related attitudes and suicidal ideation among adolescents who took part in our survey. Results related to bullying were well distributed in the sample, whereas decreases in suicidal thinking were more pronounced in individuals with no depressive symptoms before watching the show. Regardless of the overall positive effect in this population, it is important to note that a more vulnerable subgroup—participants with depression and/or prior suicidal ideation—could be more negatively affected by watching the show. These results suggest that although the series has the potential to have positive effects for most of its viewers, it could have negative effects on high-risk individuals. For this reason, the decision of whether to watch the show should be individualized and decided jointly by adolescents, parents, and medical authorities,16American Foundation for Suicide PreventionTips for parents to talk with their children about 13 Reasons Why and suicide.https://afsp.org/wp-content/uploads/2017/05/TipsForParents_2017.pdfGoogle Scholar taking into consideration each adolescent's characteristics and the effects of the show observed in this study. Also, although higher rates of suicidal ideation after watching the series were more pronounced in the group with pre-existing psychopathology, the rates among those with no depressive symptomatology or suicidal ideation were non-negligible. It is concerning that 4.7% of adolescents with no prior suicidal thoughts or symptoms of depression (PHQ-2 score = 0) reported they thought more about taking their own life after watching the series. Despite the advantages of targeting adolescents using social media, there are intrinsic limitations to the method for selection bias, so the present results might not be generalizable to all teenagers. First, only people who use Facebook were invited to the survey, and only 7.5% of those approached to participate provided valid responses, which might not represent the show's general audience. The respondent sample had a very high prevalence of bullying, depression, and suicidal thoughts. Second, although a control group showed no differences in the responses compared with the original sample, the survey was primarily targeted at adolescents who had liked pages related to 13 Reasons Why and, therefore, had a potentially favorable bias toward the show. Third, although it is a common and accepted method of measuring this behavior, self-reporting of bullying might be associated with potential reliability issues. Another important limitation refers to the fact that suicidal thoughts before and after watching the show were assessed retrospectively. Because our survey did not include a question addressing how adolescents perceived the suicide scene specifically, we could not assess this controversial issue. It also is noteworthy that, although analyses in this study were focused on bullying, depression, and suicide, there could be other potentially relevant unmeasured effects related to watching the show (eg, related to the portrayal of seeking help in the series). Fourth, because of the retrospective design and lack of a contemporaneous control group that watched a different show that did not address bullying or suicide, it was not possible to identify spontaneous fluctuations or to establish a causal link between watching 13 Reasons Why and the changes in thinking and behavior we observed. Public affairs involving emotional issues—such as suicidal behavior induced by a television show—frequently provoke the spread of emotional opinions and reactions. The present report provides empirical evidence on the potential benefits and risks of the first season of the Netflix series 13 Reasons Why on adolescents' behavior, suggesting a predominant decrease in bullying and suicidality and indicating an increased probability of harmful effects to a subgroup of vulnerable youths. Suicide among adolescents is a major public health issue, but one for which preventive strategies are currently available.17American Foundation for Suicide PreventionA teachable moment: using 13 Reasons Why to initiate a helpful conversation about suicide prevention and mental health.https://afsp.org/campaigns/look-ways-mental-health-awareness-month-2017Google Scholar We hope that a better understanding of such a complex phenomenon can ultimately help us identify and assist those in need. Figure S2Bullying Behavior After Watching 13 Reasons WhyShow full captionNote: The Patient Health Questionnaire-2 (PHQ-2) depression scale ranges from 0 to 6, in which 0 indicates no depressive symptoms in the 2 weeks before watching the show and 6 indicates feeling down and anhedonic practically every day during the same period.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Note: The Patient Health Questionnaire-2 (PHQ-2) depression scale ranges from 0 to 6, in which 0 indicates no depressive symptoms in the 2 weeks before watching the show and 6 indicates feeling down and anhedonic practically every day during the same period. Exploring the Impact of 13 Reasons Why: Looking for Light Amidst the Heat . . .Journal of the American Academy of Child & Adolescent PsychiatryVol. 57Issue 8PreviewA Letter to the Editor by Kieling and collegues1 in this month's Journal attempts to explore the impact of the Netflix series 13 Reasons Why (13RW) on the thinking and behavior of adolescent viewers. The series is an adaptation of a 2007 novel by Jay Asher, and tells the story of an adolescent girl who dies by suicide following a series of traumas and disappointments that she catalogues before her death on 13 audiotapes. The tapes are left behind with the expectation that each of the individuals presumably responsible for her suicide will listen and better understand their individual and collective failures. Since its release and airing in 2017, the show has generated considerable heated debate and controversy, largely due to concerns about its potential for suicide contagion. Full-Text PDF
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