International Journal of Environmental Research and Public Health Review Towards the Influence of Media on Suicidality: A Systematic Review of Netflix’s ‘Thirteen Reasons Why’ Martí Guinovart 1,2,3 , Jesús Cobo 1,2,3, * , Alexandre González-Rodríguez 2,4,5 , Isabel Parra-Uribe 1,2,3 and Diego Palao 1,2,3 1 Department of Mental Health, Hospital Universitari Parc Taulí, 1 Parc Taulí, 08208 Sabadell, Spain 2 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 3-5 Calle Monforte de Lemos, Pabellón 11, Planta 0, 28029 Madrid, Spain 3 Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Plaça Cívica, 08193 Bellaterra, Spain 4 Department of Mental Health, Hospital Universitari Mútua de Terrassa, 5 Plaça del Doctor Robert, 08221 Terrassa, Spain 5 Department of Psychiatry, University of Barcelona, 585 Gran Via de les Corts Catalanes, 08007 Barcelona, Spain * Correspondence: jcobo@tauli.cat; Tel.: +34-937231010 Highlights: • Fictionalized suicides have shown potential for suicide contagion. • ‘Thirteen reasons why’, released in 2017, has been reported to increase suicidality. • Positive and negative outcomes regarding suicide have been associated with the show. • Individual factors define vulnerable viewers that should be warned of the risk. Abstract: 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 Citation: Guinovart, M.; Cobo, J.; manual search of reference lists from inception until the 16 January 2023. Twenty-seven published González-Rodríguez, A.; Parra-Uribe, I.; Palao, D. Towards the Influence of articles were identified from an initial search of 496 studies. The positive effects of watching 13RW Media on Suicidality: A Systematic included a reduction in suicide stigma and a greater likelihood to discuss mental health concerns and Review of Netflix’s ‘Thirteen Reasons seek for help. However, several studies reported negative outcomes, including significant increases Why’. Int. J. Environ. Res. Public in the rate of deaths by suicide in adolescents, the number of admissions for suicidal reasons, and Health 2023, 20, 5270. https:// the prevalence and severity of suicidal ideation and self-harm behaviors in vulnerable viewers. doi.org/10.3390/ijerph20075270 Still, due to methodological limitations, no causal relationship could be established. Preventive Academic Editors: Paul measures are required to alert of the risk and should be particularly addressed to susceptible subjects. B. Tchounwou and Paul S. Links Psychoeducational programs should be focused on this kind of phenomena in vulnerable populations. Received: 29 January 2023 Keywords: ‘Thirteen reasons why’; Werther effect; suicide; media; self-harm Revised: 12 March 2023 Accepted: 14 March 2023 Published: 27 March 2023 1. Introduction It was 31 March 2017 when Netflix, an online streaming platform, released the first Copyright: © 2023 by the authors. season of ‘Thirteen Reasons Why’ (13RW). The thirteen-chapter series was based on the Licensee MDPI, Basel, Switzerland. multi-award winning novel of the same name, a text which had been written by Jane Asher This article is an open access article in 2007 and which sold more than 3 million copies [1,2]. distributed under the terms and The show depicts the suicide of Hannah Baker, a female adolescent who, prior to conditions of the Creative Commons death, decides to record thirteen audiotapes blaming several people for having pushed her Attribution (CC BY) license (https:// to the edge. The portrayal of the main character is presented in a tragic, often glamorized creativecommons.org/licenses/by/ way, and emphasizes the influence of environmental factors on suicide decision making. 4.0/). Int. J. Environ. Res. Public Health 2023, 20, 5270. https://doi.org/10.3390/ijerph20075270 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2023, 20, 5270 2 of 25 The last chapter contained a highly explicit scene showing how she finally manages to die by wrist cutting in the bathtub. The show assumes several conflictive premises (see Table 1) and this raises concerns as to how the series’ approach to suicide might induce viewers to imitate this behavior. Table 1. Myths and realities of suicide representation in 13RW. Suicide in 13RW Suicide in Clinical Practice Social phenomenon Health issue Sense of success (personal, social) Sense of failure (screening, case management) External responsibility Individual responsibility Suicide to achieve control (over oneself and others) Suicide as the result of a loss of control Rational act Irrational, illogical act Inevitable Evitable Voluntary, adaptive and justifiable choice Maladaptive, pathological reaction No accompanying symptoms Underlying mental disorder Health system reinforces the problem Health system as a potential solver of the problem Suicide is the only alternative Suicide is a symptom, not an alternative Suicide contagion through media, a phenomenon known as the ‘Werther effect’, can be approached if we hypothesize that media depictions of suicide might induce vulnerable viewers to mimic this behavior, especially sensationalist descriptions including vivid details [3]. Several previous experiences have shown confirmative results on the field, reporting an increase in suicide rates after the tragic deaths of Marilyn Monroe [3,4] and Robin Williams [5,6], among other celebrities. These copycat gestures tend to present themselves in the first weeks after the index episode and are usually exhibited by people with the same age, gender and sociodemographic profile who, these similarities aside, often use the same method [7–11]. Depression and negative life events are also risk factors for the imitation of celebrity suicides publicized in the media [9,10]. Not only real-life suicides have been suggested to have contagious potential. In the case of fictional suicides, some authors have pointed out that vulnerable subjects, when exposed to films that depict suicide, experience a rise in suicidality that correlates with the level of identification with the main character [12–15]. One week after TV series ‘Casualty’ depicted the deliberate self-poisoning of a teenager, overdose presentations increased by 17% in the UK, with 20% of patients declaring that the program had influenced their decision [16]. Similar reports regarding TV-dramatized adolescent suicides have been described in the USA [17] and Germany [18]. As the targeted audiences for 13RW mainly comprise adolescents and young adults, it would be sensible to consider that viewers of such ages are the population at risk of mimicking self-harm gestures after watching the series. In the era of social networking sites, parasocial relationships (and their influence on suicide models) need to be taken into consideration, especially in younger populations [19–21]. On the other hand, it is also true that other experiences where a Werther effect would have been expected did not show such outcomes. The suicide of Kurt Cobain, for example, as opposed to the celebrity deaths mentioned above, was not followed by a significant increase in suicide mortality [22,23]. As positive results are socially alarming and, con- sequently, more likely to be accepted in press, a publication bias cannot be discounted. Debate on the matter was already ongoing in the late 1980s, with some studies finding no reliable association between television coverage of suicides and self-inflicted deaths in adults [24] and teenagers [25]. A more recent meta-analytic review also concluded that current data do not support the theory of suicide contagion by fictional media [26]. Such contradictions suggest that the phenomenon—in the case it exists—is far more complex and nuanced than it appears at a simple view and depends of multiple, individualized, hardly controllable factors. Int. J. Environ. Res. Public Health 2023, 20, 5270 3 of 25 To avoid imitative behaviors, the World Health Organization (WHO) developed a booklet for media professionals that proposed how to treat suicide cases properly. This full-access resource was created in 2008 and last updated in 2017 [27]. These guidelines advise against using sensationalist language and recommend not to provide explicit graphic support or specific details about the site/method used. As responsible reporting about suicide can contribute to self-harm prevention (the so-called ‘Papageno effect’ [28], in contrast to the Werther effect), providing accurate information about where to seek help and educating the public without spreading myths are strategies that should be promoted. The tone and esthetics of the series, however, diverge significantly from these postulates. The series obtained such positive reviews from critics and audiences that, shortly after, a second season premiered to expand the story. The continuation of 13RW aired on the 18 March 2018 but, unlike the first season, alerting videos and warning cards were added at the beginning of each episode informing of the treated topics. An informative documentary, entitled ‘Thirteen Reasons Why: Beyond the Reasons’, was also released: a special program where the cast, screenwriters, producers and mental health professionals discussed scenes dealing with difficult issues. As forthcoming evidence seemed to support the increase in suicide risk following exposure to 13RW, and in the light of the rising social alarm, the suicide scene in the last episode of season one was finally edited in July 2019. The story was extended into a third and a fourth season. However, these final chapters deviated significantly from the original story, had nothing to do with suicide and received generally negative reviews from both critics and audiences. In any case, 13RW represents the first reported case of a dramatized suicide being broad- casted from an online streaming platform. Streaming services have represented a change in the pattern of content consumption as they offer the opportunity to binge-watch the episodes and to replay certain scenes over and over [29]. In consequence, it would be sensible to analyze to what degree suicide contagion transmitted through Netflix may have differed from previous instances with more traditional media (literature, press, television, or cinema) [30]. Objectives of the Study In this study, we aimed to provide a systematic review of scientific publications that have linked 13RW with any outcome related to suicidality, considering data obtained from (1) objective sources (such as suicide mortality rates, suicide attempts rates, or registers of information seeking behaviors for suicide in any context) and (2) subjective perceptions from 13RW viewers (such as self-reported suicidal ideation or attempts, behavioral changes attributed to the show, or suicide knowledge and stigma). Additionally, we aimed to determine if current evidence on 13RW supports the pres- ence of a Werther (pro-suicidal) or a Papageno (anti-suicidal) effect. Finally, we aimed to assess whether individuals with the same features as 13RW’s protagonist (adolescent females) have been influenced differently by the possible effects of the show when compared to other subjects. 2. Methods This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [31]. 2.1. Inclusion and Exclusion Criteria ‘Suicide’ was defined as the act of taking one’s own life voluntarily with the intent to die. ‘Suicidality’ is a broader concept that comprises a spectrum of symptoms, from suicidal ideation to actual suicide attempts, fatal or not [32,33]. To be included, articles had to meet the following eligibility criteria: (1) be original research articles; (2) be written in English, Spanish or Catalan; (3) be performed in humans; (4) consider ‘having watched any episode of any season of 13RW’ as the exposure of interest; (5) report any effect related to suicidality; and (6) express outcomes in quantitative terms. Int. J. Environ. Res. Public Health 2023, 20, 5270 4 of 25 Exclusion criteria were, as follows: (1) be articles with non-empirical designs (e.g., case reports, reviews, book chapters, opinion letters, commentaries, conference papers or meeting abstracts); (2) be written in other languages apart from English, Spanish or Catalan; (3) be performed in vitro or in animals; (4) focus on other exposures (e.g., having read the book on which 13RW is based, or watched any other show related to the issue, but not specifically 13RW); (5) analyze other effects in the field of mental health, but not specifically suicidality (e.g., depression, anxiety or resiliency); and (6) express results in qualitative terms. The presence of a reference group was not required. No restrictions were considered in terms of age, gender, ethnicity, country or publication year. 2.2. Search Strategy Four bibliographic databases (Medline, Web of Science, Scopus, and PsycInfo) were as- sessed up to the 16 January 2023. The search strategy used the terms: (“thirteen reasons why” OR “13 reasons why”) AND (suicide OR suicidal OR suicidality). The reference lists of the included studies and other relevant papers were manually searched for additional articles. Two independent systematic searches were conducted. Working by title and abstract reading, two reviewers (blinded to each other’s decision) independently completed article selection. After all the studies had been screened, the researchers discussed the results arti- cle by article for inclusion and, in cases of opinion disparity, consensus between reviewers prevailed. Selected references were full-text read for a second screening before proceeding to data extraction. 2.3. Risk of Bias and Quality Assessment from Included Studies The Appraisal tool for Cross-Sectional Studies (AXIS tool) is a 20-item critical appraisal instrument which was created to address study design and reporting quality as well as the risk of bias in cross-sectional studies. It was developed in 2016 and with the aim of incorporating it in systematic reviews, guidelines and clinical decision making [34,35]. In the present study, this tool was used to assess the quality and risk of bias for included articles. As in article selection, two reviewers scored all the included studies separately and, afterwards, they compared their results. In cases of disparity, each item of the scale was discussed by both reviewers until an agreement was reached. 2.4. Data Extraction and Data Synthesis from Included Studies The following data from the selected studies were recorded in a pre-designed form: (1) study author and publication year; (2) dependent variable(s); (3) participants, recruit- ment/source and setting; (4) study design; and (5) main outcomes. Data extraction was conducted by two authors and, in cases of doubt, results were discussed with two other investigators and solved by consensus from all authors. Preliminary searches showed that, according to their design, studies could be divided into two categories: (1) studies reporting outcomes based on objective measures, such as population registers, hospital attendance rates, or prevalence of use of certain resources; and (2) studies reporting outcomes based on subjective measures, which basically means self- reported questionnaires from viewers of the show. Objective measures offer more consistent evidence and are less prone to interpretation. Subjective measures, on the other hand, are highly dependent on the sample that has been chosen and should be addressed more carefully, considering the risk of bias. Accordingly, results were synthetized in two different charts, one for objective data and another for results obtained with self-reported tools. The considerable between-study heterogeneity hampered the ability to perform a meta-analysis. Therefore, a narrative synthesis of the included articles is presented. 3. Results The comprehensive electronic search strategy yielded 490 potentially relevant studies. Six further papers were added from the reference list hand-search (see Figure 1). After Int. J. Environ. Res. Public Health 2023, 20, 5270 5 of 25 removing duplicates and screening for title, abstract, and full-text, 27 non-overlapping articles contributed to the final data synthesis. Figure 1. PRISMA flow chart with included and excluded studies, with reasons. 3.1. Outcomes in Association with 13RW Based on Objective Measures (See Table 2) Fourteen studies were identified and all of them had been performed in the USA or Canada. Int. J. Environ. Res. Public Health 2023, 20, 5270 6 of 25 Table 2. Summary of the articles reporting outcomes in association with 13RW based on objective measures. Article Dependent Variable(s) Sample Design Results Ecological study comparing Google - 1.5 million excess searches (+19%). Search trends with the term ‘suicide’ - Examples: “how to commit suicide” (+26%), “commit suicide” Ayers et al., 2017 Google searches including the searches for suicide in the 19 days after (data extracted from Google Trends), (+18%), “how to kill yourself” (+9%), “suicide hotline number” [36] term ‘suicide’ the release of 13RW’s first season with USA (+21%), “suicide hotline” (+12%), “suicide prevention” (+23%) expected values and “teen suicide” (+34%). 180,655 suicides occurred in individuals - 195 excess suicides among 10- to 17-year-olds in the 9 months aged 10 to 64 years in the period Ecological study comparing suicide rates after the release, with higher impact in males. Bridge et al., 2020 Number of suicides (global) 2013–2017 (data extracted from the in the 9 months after the release of - 28.9% increase in the first month after the release. [37] Centers for Disease Control and 13RW’s first season with expected values - No excess suicide mortality in other age groups. Prevention WONDER system), USA 775 admission records from patients Hospital aged 4 to 18, hospitalized for suicidal Ecological study comparing - 0.024 increase in the log of suicide admissions per month in the Cooper et al., 2018 admissions for suicidal ideation ideation or self-harm with the intent to hospitalizations for suicidal reasons in overall period. [38] or self-harm with intent to die die from January 2012 to October 2017 in the 7 months after the release of 13RW’s - The model that best explained the data indicated an increase in (youths) The Children’s Hospital at OU Medical first season with expected values the number of admissions following the show’s release. Center, Oklahoma, USA Emergency department - 95% sites reported significant increases compared to same Feuer and Havens, admissions for suicidal ideation Data obtained from surveys addressed Survey administration after the release month previous year. 2017 [39] or suicide attempts to 14 pediatric emergency services, USA of 13RW’s first season - 40% sites reported copycat gestures or attempts in the 30 days (youths) after the release. 289,350 hospitalizations and 815,582 emergency department visits for - Emergency department visits for suicidal reasons: increase in Ecological study comparing emergency the first and/or the second month after the release for all 10- to suicidal behavior from patients aged 6 to Emergency department and department and hospital admissions for 17-year-olds (males and females). 17 in the period 2016–18 (data extracted Le et al., 2022 [40] hospital admissions for suicidal suicidal behavior in the 21 months after - Hospital admissions for suicidal reasons: increase in the second from the Nationwide Inpatient Sample behavior (youths) the release of 13RW’s first season with month after the release for all females aged 10 to 17 (especially and the Nationwide Emergency expected values for Black females) and for those aged 6 to 9 who identified as Department Sample of the Healthcare Cost and Utilization Project), USA “Other” races/ethnicities. No increase in males. Suicide data from the period 1999–2017 - 66 excess suicides among 10- to 19-year-old males (+12.4%) and Ecological study comparing suicide rates 37 among females (+21.7%). Niederkrotenthaler (data extracted from the Centers for Number of suicides (global) in the 3 months after the release of - No excess suicide mortality in other age groups. et al., 2019 [41] Disease Control and Prevention 13RW’s first season with expected values - 26.9% increase in the hanging method, no increase in the WONDER system), USA firearm method. Int. J. Environ. Res. Public Health 2023, 20, 5270 7 of 25 Table 2. Cont. Article Dependent Variable(s) Sample Design Results 151,570 tweets containing the words - Highest publication frequency in the first month after the #13ReasonsWhy and/or Retrospective analysis of the content of release. The USA (43.7%) and the UK (13.5%) ranked first in the Pérez-Martínez Published comments on Twitter #PorTreceRazones (data obtained with Twitter posts in the 7.5 months after the subject of suicide. et al., 2020 [42] about 13RW related to suicide the platform Followthehashtag), release of 13RW’s second season - 32% report that 13RW does not adequately address suicide and worldwide 52.3% that it contributes to suicide debate. - Setting: 41% outpatient, 41% inpatient, 17% emergency department. 63 clinical notes from 31 patients, aged - Timing: 73% in the first 8 weeks after the release. Retrospective analysis of documented 11 to 17, attending Fairview Health - Diagnosis: 97% any mental health diagnosis, 84% major Clinical context where references to 13RW in pediatric patients Plager et al., 2019 Services, Minnesota (found by searching depressive disorder. references to 13RW are from October 2015 to September 2017 (23 [43] the University of Minnesota-affiliated - Presentation: 52% suicidal ideation, 19% suicide attempt. presented weeks after the release of 13RW’s first Fairview Health Services clinical data - In 21% and 32% of references (guardians and patients, season) repository), USA respectively), 13RW was reported to have made a contribution to worsening mental health symptoms. Reanalysis of the results from Bridge - Males: no increase in the first month (values were similar to the et al., 2020 [37], performed by using a month before the release). Romer, 2020 [44] Number of suicides (global) Same sample as in Bridge et al., 2020 [37] simple auto-regression model that - Females: small increase, though non-significant, in the first removed auto-correlation and national month after the release. trends in suicide - No significant increases in other months. Suicide data from individuals aged 10 to - No effect of 13RW in youth suicides once seasonality, Ecological study comparing suicide rates 29 in the period 2013–18 (data obtained auto-correlation, and longer-term trends were removed. Romer, 2022 [45] Number of suicides (youths) in the years of the release of 13RW’s first from the CDC’s National - The increase in male adolescent suicides detected in other and second season with expected values Vital Statistics System), USA studies [37,41,46] was attributed to seasonality. - 40 excess suicides (+18%). 264 suicides in people aged 29 and Ecological study comparing suicide rates - 24% and 23% increase among 10- to 19- and 20- to 29-year-olds, Sinyor et al., 2019 respectively, compared to the previous 3 years. Number of suicides (youths) under, identified through the Office of in the 9 months after the release of [46] - 24% and 23% increase in males and females, respectively, across the Chief Coroner of Ontario, Canada 13RW’s first season with expected values both age groups. - No increase in the cutting method. Int. J. Environ. Res. Public Health 2023, 20, 5270 8 of 25 Table 2. Cont. Article Dependent Variable(s) Sample Design Results - Significant increase in self-harm-related emergency department Emergency department visits for admissions in the 3 months after the release, continuing for self-harm from patients aged 10 to 45 in 5 months. Ecological study comparing emergency the period 2007–18 (data extracted from - Compared with expected values: 75 excess visits (+6.4%). Emergency department department visits for self-harm in the Sinyor et al., 2022 the National Ambulatory Care 60 excess visits in 10- to 19-year-olds. 85 excess visits in females. admissions for self-harm first year after the release of 13RW’s first [47] Reporting System, the No excess visits in other groups. (youths and young adults) season with expected values and with Ontario Health Insurance Plan Claims - Compared with values from the previous year: 10- to admissions from previous years Database, and the Registered Persons 19-year-olds: 290 excess visits (+25.4%); 20- to 29-year-olds: Database), Ontario, Canada 169 excess visits (+17%); 30- to 45-year-olds: 174 excess visits (+21.2%). - Excess of 4302 CTL conversations (first 18 days after the release) and 20,500 (first 36 days, 4 times higher). - Sub-analysis of suicidal thought-related conversations: excess Ecological study comparing the of 4782 (+31%) in the 36 days after. Use of Crisis Text Line (CTL), a Sugg et al., 2019 prevalence of daily CTL use in the - The suicides of Anthony Bourdain and Kate Spade (18th day technology-based platform for 584,157 total CTL conversations, USA [48] 36 days after the release of 13RW’s after the release) had a greater impact on CTL conversation crisis events second season with expected values volume than 13RW (2.7 times higher). - Differences between seasons 1–2 were attributed to the promotion of help-seeking behaviors before the release of season 2. Ecological study comparing the - Brief increase in CTL conversation volume (days 5–6 after the Use of Crisis Text Line (CTL), a release), followed by a much more substantial and significant Thompson et al., prevalence of daily CTL use after the technology-based platform for 70,330 total CTL conversations, USA decrease (12.7% in the 18 days after, 29.5% in the 49 days after). 2019 [49] release of 13RW’s first season with crisis events - Sub-analysis of suicidal thought-related conversations: similar expected values decline during the same period. Int. J. Environ. Res. Public Health 2023, 20, 5270 9 of 25 In the pediatric population, all the available studies agreed that hospital and emer- gency department admissions for suicidal reasons increased in the first month/s after the show’s release [38–40,47], particularly among adolescents [40,47]. Whereas it was con- troversial if the raise in emergency department visits occurred in females [47] or in both gender groups [40], excess inpatient hospitalizations were described only upon females, particularly among those who had been identified as ‘Black’ in terms of ethnicity [40]. In clinical contexts, most references to 13RW were registered in individuals with current mental health diseases (97%), with major depressive disorder being the most prevalent issue (84%) [43]. Two studies analyzed the volume of Crisis Text Line (CTL) conversation, a technology- based platform for crisis events, after the release of the first [49] and second [48] seasons of 13RW, respectively. Whilst season 1 was followed by a significant decrease in CTL conversation volume, season 2 experienced a marked increase in the same outcome. These differences were attributed to the promotion of help-seeking behaviors before the release of the second season [48]. Google searches for suicide also increased significantly [36] and, in terms of the social network Twitter, the USA and the UK were the countries with more 13RW publications— ‘tweets’—discussing suicide [42]. Five studies regarding suicide mortality rates were detected. Three of them reported a significant increase of about 20% in adolescents (10- to 19- or 10- to 17-year-olds) in comparison with the expected values [37,41,46]. Specifically, Bridge et al. revealed a higher amount of deaths in the first month post-release (28.9%) [37]. Conversely, another author, Romer, disagreed with these results in two publications: in the first one, he re-analyzed the results of Bridge et al., concluding there was no statistically significant increase after removing trends and auto-correlation [44]; in the second, he went beyond and attributed the differences detected by the other authors to a seasonality effect [45]. No solid conclusion was reached in terms of gender: whereas Sinyor et al. and Niederkrotenthaler et al. reported a significantly higher impact in females [41,46], Bridge et al. described the same phenomenon in males [37]. Romer, however, detailed a positive but non-significant increase of incidence in girls during the month following the release in his first article [44] and no increase at all for either sex group in the second one [45]. As for method used, the hanging choice raised significantly, but the prevalence of cutting and firearm use was not altered [41,46]. Although one of the studies also outlined an excess of suicides in young adults (20- to 29-year-olds) [46], the rest did not report any extra suicide mortality in other age groups apart from among adolescents. 3.2. Outcomes in Association with 13RW Based on Subjective Measures (See Table 3) Thirteen publications registered effects in relation to suicide, all of them by using self- reported methods on 13RW viewers. Most studies comprised adolescent samples [50–58], whilst others included young adults [50,51,59–61] and even parents or guardians [50,51,53,54,62]. Only two studies were based on clinical populations [54,55] as the rest of them were performed with vulnerable subjects recruited through social networks [52,58], survey firms [50,51,59,62] or other procedures [53,56,57,60,61]. Several authors described positive outcomes after watching the series. Some of the items that were noted after 13RW exposure were better understanding of depres- sion/suicide, positive behavioral changes (in adolescents and young adults) [51], and increased suicide knowledge and suicide stigma reduction (in young adults) [60]. The series appeared to increase the likelihood to have conversations with parents about suicide and to seek information on the matter [51]; parents also reported better understanding of the topic, more comfort at discussing it, and a greater likelihood of prompting con- versation [62]. The number of viewed episodes was positively correlated with perceived norms about mental illness that, in the end, were related to changes in pro-social mental health behaviors [50]. In contrast, the only study that used a randomized design linked Int. J. Environ. Res. Public Health 2023, 20, 5270 10 of 25 the increase in the frequency of conversation and information seeking about suicide to presenting depressive symptoms after watching the show [57]. Audiences of 13RW were more likely to be female [55] and to have previously pre- sented more self-harm behaviors [52,55]. About 50% of viewers expressed negative reac- tions to 13RW [55] or believed it had increased their risk of suicide [54]. Mood worsening after 13RW was associated with premorbid sadness and lack of motivation and also implied a higher suicide risk [52]. Being a student was associated with higher suicide risk but, at the same time, higher suicide acceptance [59]. The increase in suicidal ideation that has been associated with the show was not homogeneous across studies and varied depending on individual factors. Higher identifica- tion with 13RW’s main character [54,55], real-life suicide exposure [53], having a previous history of suicidal thoughts [58], watching only some of the episodes of the series [59], and watching 13RW during a suicide cluster [56] were positively correlated with suicidal ideation. However, two studies found no differences in suicidal ideation before and af- ter watching the show [55,60], and another one even reported a protective effect [53]. In the case of self-reported suicide attempts committed after 13RW exposure, no significant association was reported. One study developed an artificial intelligence tool which could be administered to university students in a quasi-experiment, showing no statistically significant differences in the associations of the self-concept ‘SUICIDE’ and exposure to 13RW [61]. Int. J. Environ. Res. Public Health 2023, 20, 5270 11 of 25 Table 3. Summary of the articles reporting outcomes in association with 13RW based on subjective measures. Article Dependent Variable(s) Sample Design Results - Suicide risk: increased in current students and people who only watched some of the episodes. Suicide risk - Optimism: increased in those who watched the entire season; decreased in Optimism those who only watched some of it. 729 individuals aged 18 to 29, who - Suicide acceptance: increased in students; decreased in females. No relation Suicide acceptance Survey administration 10 days reported having access to Netflix. with watching 13RW. Arendt et al., 2019 [59] Self-harm before and 1 month after the release Recruited by the survey firm - Self-harm and suicidal ideation: increased in students who only watched Suicidal ideation of 13RW’s second season Qualtrics, USA some of the episodes and non-students who watched some or all the Intention to help a suicidal person episodes; decreased in students who watched all the episodes. - Intention to help a suicidal person: increased in non-students and those who watched all the episodes; decreased in those who only watched some of the episodes. Further analysis of the results from - The number of 13RW viewed episodes was positively correlated to Perceived norms about Same sample as in Lauricella et al., Lauricella et al., 2018 [51], by using perceived norms about mental illness. Carter et al., 2020 [50] mental illness 2018 [51] nested measurement - In viewers, these norms were related to change in pro-social mental health invariance models behaviors (manifested distinctively based on age and regional factors). Suicidal ideation Survey administration several - Suicidal ideation and suicidal behavior: no differences. Suicidal behavior 818 college students (522 of whom months after the release of 13RW’s - Suicide knowledge: increased in 13RW viewers, particularly among those Chesin et al., 2020 [60] Suicide knowledge had watched 13RW) aged 18 to 25 first season, comparing those who without personal exposure to suicide. Suicide stigma and recruited online, USA had watched the series to those who - Suicide stigma: decreased in 13RW viewers. Depressive symptoms had not - Self-reported depressive symptoms: increased in 13RW viewers. Parent-sensitive topic - Positive relation between topic understanding and comfort discussing these understanding, comfort topics. 778 parent viewers of 13RW, and conversation Further analysis of the results from - Positive relation between comfort discussing these topics and prompting a Cingel et al., 2021 [62] obtained from the same sample as in prompting about Lauricella et al., 2018 [51] conversation. Lauricella et al., 2018 [51] suicide and other - Stronger association among parents residing in Australia, the USA, and the mental health issues UK, in comparison to parents in Brazil. 7004 individuals aged 12 to 18 who - Suicide risk (suicidal thoughts, self-harm or suicide attempts): only 25% reported having watched 13RW’s Survey administration 54–71 days reported never to have had any suicidal behavior or ideation. Suicide risk da Rosa et al., 2019 [52] first season, recruited through posts after the release of 13RW’s - Mood: 32.1% improved, 23.7% worsened; significantly associated with Mood changes on 13RW-themed social media first season feelings of sadness and lack of motivation before 13RW and suicide risk groups, Brazil after 13RW. Int. J. Environ. Res. Public Health 2023, 20, 5270 12 of 25 Table 3. Cont. Article Dependent Variable(s) Sample Design Results - Exposure to 13RW in youths: reduced depression, reduced suicidal ideation 174 individuals aged 11 to 18 and Survey administration with no time (both significant). Ferguson, 2021 Suicidal ideation their primary caregivers, recruited relation to the release of 13RW - Exposure to 13RW in parents: reduced depression (non-significant), no [53] Depressive symptoms online or by family members from (October 2017–May 2019), analyzed relation with suicidal ideation. Real-life suicide exposure was the only the university, USA with regression models significant predictor of suicidal ideation. - Models including 13RW were better than the ones without this variable. 87 individuals aged 10 to 17 who - 51% of viewers believed 13RW increased their suicide risk. presented to a psychiatric emergency - 39 viewers reported increased negative affect after 13RW and 40 referred department with a suicide-related Completion of a battery of increased positive affect. Hong et al., 2019 Perceived effects of - Identification with 13RW’s main character significantly correlated with concern from July 2017 to March self-reported measures during the [54] watching 13RW higher suicidal ideation and depressive symptoms. 2018 (49% of whom had watched emergency department visit 13RW), and their parents (n=87), - Likelihood to talk to others about mental health after 13RW: 28% increased, USA 28% decreased. Those who reported an increase were more likely to believe 13RW had not raised their suicide risk. - Better understanding of depression and suicide after 13RW: 59–88% teens 1722 teens (aged 13 to 17), 1798 and young adults, 44–83% parents. Survey administration several - Positive behavioral changes after 13RW: 67–76% teens and young adults. young adults (aged 18 to 22) and Perceived effects of months after the release of 13RW’s - Information seeking after 13RW: 38–68% (depression) and 36–65% (suicide) Lauricella et al., 1880 parents who completed an watching 13RW first season, comparing those who in teens and young adults. 2018 [51] online survey, recruited by IPSOS had watched the series to those who - 13RW helped having conversations with parents about suicide and Research; Australia/New Zealand, had not depression (56–71%). Brazil, UK, and USA - Individual characteristics (age, resilience, social anxiety) influence responses to the show. Perceived effects of - Females: more likely to have watched 13RW (63.3%). watching 13RW 242 individuals (122 of whom had - 55.9% expressed negative reactions to the show, while 33.8% expressed Suicidal ideation watched 13RW) aged 11 to 18, Completion of a battery of positive reactions. Nesi et al., 2020 Suicide attempts hospitalized in a psychiatric self-reported measures at hospital - Having watched 13RW was associated with greater likelihood of past-year [55] Non-suicidal self-injury inpatient facility between May 2018 admission NSSI (2.53 times higher), but not with suicidal ideation or suicide attempts. (NSSI) and January 2019, USA - Greater identification with and perceived likeability of the main character were associated with suicidal ideation and past-year NSSI. Suicidal ideation and suicide attempts 15,083 students (7th- to 12th-grade) Survey administration in April-May - Watching 13RW before the cluster: no significant association with suicidal during the suicide cluster from 34 public schools (recruited by 2018, 13–14 months after the release ideation or suicide attempts. Swedo et al., 2021 [56] - Watching 13RW during the cluster: increased suicidal ideation (AOR 1.4), that was reported in the local health department and of 13RW’s first season and 1–2 Ohio from August 2017 Ohio Department of Health), USA months after the second specifically higher for students without previous history of suicidal ideation to March 2018 (AOR 1.5). No association with suicide attempts. Int. J. Environ. Res. Public Health 2023, 20, 5270 13 of 25 Table 3. Cont. Article Dependent Variable(s) Sample Design Results Survey administration before (T1) 157 individuals aged 13 to 17, - Increased likelihood to discuss suicide among viewers at T2 and from T1 to T2. and one month after (T2) the release Social and mental recruited by a panel-based research - Higher levels of depressive symptoms at T2: more frequent conversations Uhls et al., 2021 of 13RW’s third season, randomizing health issues platform operated by the National about suicide from T1 to T2. [57] participants to intervention group Suicidal ideation Opinion Research Center at the - Reported little interest or pleasure in doing things at T2: increased (watching 13RW) and University of Chicago, USA likelihood to search information about suicide. non-intervention group Administration of a tool which had been created with artificial Distance between the intelligence (by using the Galileo - No differences between viewers and non-viewers. Wang et al., 2022 concept ‘SUICIDE’ and 81 college freshmen from a public method) six months after the release - Female viewers perceived themselves to be closer to the concept ‘SUICIDE’ [61] other topics in cognitive university, USA of 13RW’s first season to compare than male viewers. mapping those who had watched the series to those who had not 21,062 individuals, aged 12 to 19, who reported having watched all the - Suicidal ideation in subjects with a previous history of suicidal thoughts: Zimerman et al., 2018 Suicidal ideation Survey administration before and after 16.5% increased, 59.2% decreased, 24.2% unchanged. episodes of 13RW’s first season, [58] Depressive symptoms the release of 13RW’s first season - Suicidal ideation in subjects without a previous history of suicidal thoughts: recruited through Facebook advertising, USA and Brazil 6.4% increased, 93.6% unchanged. Int. J. Environ. Res. Public Health 2023, 20, 5270 14 of 25 3.3. Risk of Bias and Quality Assessment (See Tables 4 and 5) In general, the quality of the included studies is moderate; still, some methodological difficulties have been detected in most publications. Three studies reported conflicts of interest, as they were developed by the same research group that received indirect funding on behalf of Netflix; these studies highlight the potential positive effects of the series [50,51,62]. In many articles, there is also a surprising lack of references to an ethical approval by institutional committees and an absence of proper informed consent beyond the passive acceptance of participants. Int. J. Environ. Res. Public Health 2023, 20, 5270 15 of 25 Table 4. Risk of bias and quality assessment (AXIS tool results) of the articles reporting outcomes in association with 13RW based on objective measures. Niederkrotenthaler et al., 2019 [41] Pérez-Martínez et. al, 2020 [42] Feuer and Havens, 2017 [39] Thompson et al., 2019 [49] Cooper et al., 2018 [38] Bridge et al., 2019 [37] Sinyor et al., 2019 [46] Sinyor et al., 2022 [47] Plager et al., 2019 [43] Ayers et al., 2017 [36] Sugg et al., 2019 [48] Le et al., 2022 [40] Romer, 2020 [44] Romer, 2022 [45] Introduction 1 Were the aims/objectives of the study clear? Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Methods 2 Was the study design appropriate for the stated aim(s)? Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes 3 Was the sample size justified? No No No No No No No No No No No No No No Was the target/reference population clearly defined? (Is it 4 No Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes No clear who the research was about?) Was the sample frame taken from an appropriate population 5 base so that it closely represented the target/reference No Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes No population under investigation? Was the selection process likely to select 6 subjects/participants that were representative of the Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes No target/reference population under investigation? Were measures undertaken to address and categorize 7 No No No No No No No No No No No No No No non-responders? Were the risk factor and outcome variables measured 8 Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes appropriate to the aims of the study? Were the risk factor and outcome variables measured 9 correctly using instruments/measurements that had been No Yes No No Yes No No No Yes Yes Yes Yes Yes No trialed, piloted or published previously? Is it clear what was used to determined statistical 10 Yes Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes significance and/or precision estimates? (e.g., p values, CIs) Were the methods (including statistical methods) sufficiently 11 Yes Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes described to enable them to be repeated? Int. J. Environ. Res. Public Health 2023, 20, 5270 16 of 25 Table 4. Cont. Niederkrotenthaler et al., 2019 [41] Pérez-Martínez et. al, 2020 [42] Feuer and Havens, 2017 [39] Thompson et al., 2019 [49] Cooper et al., 2018 [38] Bridge et al., 2019 [37] Sinyor et al., 2019 [46] Sinyor et al., 2022 [47] Plager et al., 2019 [43] Ayers et al., 2017 [36] Sugg et al., 2019 [48] Le et al., 2022 [40] Romer, 2020 [44] Romer, 2022 [45] Results 12 Were the basic data adequately described? Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Does the response rate raise concerns about non-response 13 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes bias? If appropriate, was information about non-responders 14 No No No No No No No No No No No No No No described? 15 Were the results internally consistent? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Were the results for the analyses described in the methods, 16 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes presented? Discussion Were the authors’ discussions and conclusions justified by 17 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes the results? 18 Were the limitations of the study discussed? No Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Other Were there any funding sources or conflicts of interest that 19 No No No No No No No No No No No No No No may affect the authors’ interpretation of the results? 20 Was ethical approval or consent of participants attained? No/No No/No Yes/No No/No No/Yes No/No No/No Yes/Yes No/No No/No Yes/No No/No Yes/No No/No Int. J. Environ. Res. Public Health 2023, 20, 5270 17 of 25 Table 5. Risk of bias and quality assessment (AXIS tool results) of the articles reporting outcomes in association with 13RW based on subjective measures. Zimerman et al., 2018 [58] Lauricella et al., 2018 [51] da Rosa et al., 2019 [52] Arendt et al., 2019 [59] Chesin et al., 2020 [60] Swedo et al., 2021 [56] Cingel et al., 2021 [62] Carter et al., 2020 [50] Wang et al., 2022 [61] Hong et al., 2019 [54] Uhls et al., 2021 [57] Nesi et al., 2020 [55] Ferguson, 2021 [53] Introduction 1 Were the aims/objectives of the study clear? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Methods 2 Was the study design appropriate for the stated aim(s)? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 3 Was the sample size justified? No Yes No No No No No No No No No No No Was the target/reference population clearly defined? (Is it clear 4 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes who the research was about?) Was the sample frame taken from an appropriate population base 5 so that it closely represented the target/reference population Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes under investigation? Was the selection process likely to select subjects/participants 6 that were representative of the target/reference population under Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes investigation? Were measures undertaken to address and categorize 7 Yes No No No No No No No No No Yes No No non-responders? Were the risk factor and outcome variables measured appropriate 8 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes to the aims of the study? Were the risk factor and outcome variables measured correctly 9 using instruments/measurements that had been trialed, piloted Yes No Yes No No Yes Yes Yes Yes Yes Yes No Yes or published previously? Is it clear which methods were used to determined statistical 10 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes significance and/or precision estimates? (e.g., p values, CIs) Were the methods (including statistical methods) sufficiently 11 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes described to enable them to be repeated? Int. J. Environ. Res. Public Health 2023, 20, 5270 18 of 25 Table 5. Cont. Zimerman et al., 2018 [58] Lauricella et al., 2018 [51] da Rosa et al., 2019 [52] Arendt et al., 2019 [59] Chesin et al., 2020 [60] Swedo et al., 2021 [56] Cingel et al., 2021 [62] Carter et al., 2020 [50] Wang et al., 2022 [61] Hong et al., 2019 [54] Uhls et al., 2021 [57] Nesi et al., 2020 [55] Ferguson, 2021 [53] Results 12 Were the basic data adequately described? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 13 Does the response rate raise concerns about non-response bias? No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes 14 If appropriate, was information about non-responders described? Yes No No No No No No No No No Yes No No 15 Were the results internally consistent? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Were the results presented for the analyses described in the 16 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes methods? Discussion Were the authors’ discussions and conclusions justified by 17 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes the results? 18 Were the limitations of the study discussed? Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Other Were there any funding sources or conflicts of interest that may 19 No Yes No Yes No No No Yes No No No No No have affected the authors’ interpretation of the results? 20 Were ethical approval or consent of participants attained? Yes/No Yes/Yes Yes/No Yes/Yes Yes/Yes Yes/Yes Yes/Yes No/No Yes/No No/Yes Yes/Yes Yes/No Yes/No Int. J. Environ. Res. Public Health 2023, 20, 5270 19 of 25 4. Discussion The aim of the current study was to provide a review of the evidence on the role of 13RW as an influencing factor for suicide. Whereas previous analyses of other media productions have mainly focused on the suicide mortality rate, other variables—such as suicidal ideation or actual suicide attempts—have traditionally been neglected or, at least, not analyzed deeply enough. In the case of 13RW, the amount of studies focusing on several outcomes (not only deaths by suicide) has made it possible to analyze the problem from several angles, which can be considered a strength. Few dramatized depictions of suicide have been object of such interest and controversy, and in our era of information, the quantity of available publications has been considerable compared to past experiences. Still, several limitations need to be taken into account. As mentioned above, a publica- tion bias cannot be excluded when considering the media dimension of the series. This fact can be inferred from the proportionally low number of original research articles that have been published, in comparison with the amount of publications that have reviewed the issue and cited the few available studies over and over again. Nearly all the articles were performed in the USA and only a small proportion considered samples from other countries (Canada [46,47], Brazil [50–52,58,62], Australia, New Zealand, or the UK [50,51,62]), which can affect the generalization of the results. The number of individuals included for each study was generally low and mainly comprised adolescents and young adults, with small regard given to other age groups. Most authors used retrospective observational designs, implying methodological limitations that make it difficult to detect a causal relationship between the series and suicidality; additionally, some studies suggest that the observed effect of 13RW may not be specific to the series but attributable to exposure to suicidal images or news in general. Most studies are hardly replicable, being based on information that was obtained in a certain historic moment and which cannot be understood out of this context; in other words, it is impossible to isolate the crude effect of the series from the rest of social confounding factors that are known to have an influence on suicide rates: financial crisis, poverty, social changes in adolescence, migration, drug abuse, political challenges... and, consequently, the interpretation of the results requires extreme caution. Regarding the methodology of our study, the cross-sectional quality assessment tool that was used was not entirely suited to evaluate all of the studies included, as not all of them had a cross-sectional design [57,61]. In general terms, objective sources support the presence of a Werther effect following the release of 13RW. Regarding suicide mortality, most authors report an increase in the number of suicides completed by adolescents after the series’ release [37,41,46], and one of them also describes an increase in deaths by suicide in the group of young adults [46]. This higher repercussion among teenagers is in line with the Werther effect hypothesis, especially considering Hannah Baker’s age and the audiences for whom the show was intended, and it might have been aggravated if we consider that adolescence is a period of increased vulnerability, as individuals of such ages lack the emotional and cognitive strategies to cope with certain experiences or stressing factors. In addition, adolescents tend to search for behavioral reference models to identify with, which are generally outside the family environment and are often found in the media. On the contrary, two other studies written by the same author report no significant increase in suicide mortality after the series premiered [44,45]. Nevertheless, when Romer’s first article [44] is examined in detail, it is found that it is not an original research work, as it re-analyses Bridge et al.’s results [37] by using a different statistical approach. A letter exchange between both authors is available, with each trying to justify why their methodology is more precise and criticizing the other’s conclusions [63,64]. One of Romer’s criticisms of Bridge at al.’s work is based on the fact that the increase in excess suicides seems to have started one month before 13RW was released. Bridge attributed such a trend to different factors, such as (1) the situation of show promotion, suggesting that promotional material may contribute to suicide dissemination as well as the fiction itself; and (2) the fact that, although the series premiered the 31 March 2017, suicide debate had Int. J. Environ. Res. Public Health 2023, 20, 5270 20 of 25 already started by then, creating social concern about the problem and turning it into a ‘hot topic’ with contagious potential. In a second study published more recently with a new source of data [45], Romer used a statistical method that controlled for seasonal changes and auto-correlation to conclude that 13RW had not increased suicide rates, again opposing the results of other authors [37,41,46]; nevertheless, no formal response has been published yet. Contrary to expectations, no clear pattern has been identified in terms of gender, with some authors describing a greater impact of suicide mortality in females [41,44], males [37], both [46], or no groups [45]. As previous studies of the impact of fictionalized suicides reported an increased vulnerability in subjects with the same age and gender as the victim [7–11], it needs to be discussed why, in the case of 13RW, most studies give credit to the first statement but not to the second. The first possible explanation is a circumstance that has been repeatedly reported in literature: whereas females tend to attempt suicide more often, males are more successful at achieving it [65]. A second supposition is the fact that, surprisingly, Hannah’s suicide is not the only self-harm gesture that is pictured in the series: during the last seconds of the final episode of 13RW’s first season, Alex, a male classmate of Hannah’s, attempts suicide by gunshot—even though his action is dramatized in a more discrete (and undoubtedly less relevant) way than hers. A psychobiological hypothesis should also be taken into account if we consider that 13RW mainly affected adolescents, a critical age range where gender identity is still under development [66]. As contemporary youth populations are more diverse and globalized, their identification patterns go beyond the classic conventions of previous social models [67,68]. This brings into question whether the concept of identification with the main character transcends age and gender, or is better defined by other characteristics with which vulnerable individuals can empathize, such as the experiences of bullying, aggression and relationship problems that Hannah Baker suffered. Further research is required to identify which characteristics of fictional suicide portrayals may lead to contagion and to what extent they play a role in this phenomenon. On the other hand, it is also remarkable that wrist-cutting, the method chosen in the series, did not experience a raise among subjects who attempted suicide following exposure to the show, which would also have been in line with a Werther effect. According to published evidence, 13RW not only might have increased suicide mor- tality in adolescents, but also the need of medical assistance for psychiatric reasons in this population [38–40,43,47], suggesting a global repercussion of the series in the suicidality spectrum, from suicidal ideation to actual attempts. This effect has also been described in younger population (6- to 9-year-olds with “Other” races/ethnicities), but not in age groups over 19. As it occurred with suicide mortality, gender predominance obtained mixed results, with most reports describing increased rates of medical assistance in females. Self-reported responses to the show, mostly assessed by the articles that used subjective measures, obtained much more heterogeneous results: whilst some authors describe an increase in suicidal symptoms and behaviors, others report no association at all or even an anti-suicidal effect. Nevertheless, most of them agree that individual features affect viewers differently, modulating their reactions. Many of these risk factors had been described before (previous mental health history, higher identification with the suicidal character, etc.), but others were less known (exposure during a suicide cluster or watching only some episodes of the show). Suggesting a Papageno effect, some publications report pro-mental health outcomes (such as stigma reduction or better understanding of depression and suicide), but some of these effects seem quite unspecific and hardly attributable to the series. On the other hand, the methodological limitations of the studies based on subjective measures are considerable and their conclusions, though interesting and suggestive, must be dealt with carefully. Collecting information by indirect methods (surveys and other self-report measures) implies a memory bias, as the answers are inherently influenced by the person’s recall of the show and not only by the show itself. The fact that 13RW received generally favorable reviews from audiences and critics, consequently, may have caused the underestimation of its negative effects and the overestimation of the detection of positive reactions. For the future, Int. J. Environ. Res. Public Health 2023, 20, 5270 21 of 25 focusing on prospective designs would be a better means of assessing the impact of positive and negative consequences instead of searching a global effect. Other outcomes that have emerged from the articles included in this review are the increase in Google searches for suicide [49] and the increase in Twitter posts discussing this topic [42] that followed the show’s release. Such evidence, combined with the results of the rest of studies, suggests that 13RW probably had enough potential to trigger a social interest in the subject, one that was amplified and disseminated through media like a wave. This might have induced an anti-suicidal effect in general population, but also a pro-suicidal effect in vulnerable subjects. Consequently, these pro-suicidal and anti-suicidal effects of 13RW may not be attributed to the fiction alone, but also to the social context that was created because of the series, where media had a clear influence. An example of this phenomenon is the variation of CTL volume conversation across 13RW season 1 and season 2 [48,49], which could be used as a clue to evaluate the impact of the series with and without a suicide prevention campaign—a strategy that was used only for the second season. Although the series and the social context were similar in both cases, the approach from the media differed and such variations might have altered the audiences’ responses. At this point, it may be sensible to wonder if the approach to the topic in the second case might have contributed to spreading help-seeking behaviors and to what extent they reduced the impact on suicidality. When products which are aimed at sensitive audiences are being prepared, it is highly advisable to seek specialized counseling and to prevent vulnerable subjects from suffering possible adverse effects on their emotional stability and related behaviors. Netflix itself decided to apply these changes after detecting the first indices of negative outcomes presumably attributed to the show. From our point of view, it would not be difficult to integrate educational consultants into creative teams to confirm that media material fulfills prevention standards before it is released. Interactive warnings before each episode could be used to ask viewers if they are—or have been—under specialized follow-up for suicidal reasons, and to remit them to their therapeutic referents for advice in case they feel the show might worsen their mental stability. It has also been proposed that 13RW could be used as supporting material for sui- cide prevention campaigns and even as an educational tool in high schools and medical centers [69–72]. However, evidence suggests that its potential employment is clearly under- mined by the risk of affecting vulnerable subjects and, certainly, we would not recommend its use outside of an educative setting that contextualizes the show and provides proper information about suicide and its portrayal in the series (see Table 1). The discussion of the current study would be incomplete without mentioning a previ- ous systematic review, published in April 2022, that focused on the association between 13RW’s first season and suicidal ideation/behaviors, mental health symptoms, and help- seeking behaviors in youths [73]. The study was instructive and well-written, used a robust methodology and reached conclusions that were in line with ours in general terms. The authors included references up to January 2022 and, from an initial search of 645 studies, they found 17 publications that fulfilled inclusion criteria. In contrast, the present review in- cluded articles up to January 2023, considered all age groups and exposure to any season of the series, excluded qualitative designs, and used a different search strategy. That led to 496 studies, 27 of which could be accepted for data extraction: as a result, 12 non-overlapping references could be added to the synthesis [39,40,42,44,45,48,51,53,57,59,61,62]. Although it could be argued that a previous systematic review undermines the potential originality of the current study, the subject is so complex and heterogeneous that an updated review, in the authors’ judgement, enrichens and completes the previous results and discussion, contributes to expand the debate on the topic, and opens the door to further research. One final consideration should be made. Although most research about 13RW has focused on how it may play a role in suicide dissemination, several authors have discussed the same phenomenon in the case of sexism [74,75], racism [75], cyberbullying [76], and sexual assault [77,78]. Such experiences have pointed out that, as for self-harm, aggressive Int. J. Environ. Res. Public Health 2023, 20, 5270 22 of 25 behaviors also have a potential for imitation that might be influenced by media. This hy- pothesis raises questions on how collective responsibility, when combined with individual vulnerability, might contribute to the perpetuation—and even potentiation—of certain stereotypes that, in the end, result in discrimination and violence. Such issues deserve further investigation and should be addressed with properly designed studies. 5. Conclusions The outcomes associated with 13RW have been mainly reported in individuals with the same age as the show’s protagonist (adolescents), showing scarce impact in other age groups. Most studies that analyzed data from objective sources suggest a Werther effect of the series (higher suicide mortality, higher medical admissions for suicidal reasons) and a higher interest for suicide in the network after the release. In contrast, studies based on subjective reports describe higher suicidal ideation in vulnerable individuals but also a possible Papageno effect in general population. However, this theoretical anti-suicidal effect would be offset by the tangible pro-suicidal consequences that have been attributed to the show. Methodological limitations are not to be disdained and, therefore, no causal association can be established between the series and suicidality. From a public health perspective, 13RW represents a fine example of suicide represen- tation through media and its social and clinical repercussions. Primary prevention is the best strategy to address this problem and it should be particularly aimed at individuals with risk factors. Concrete measures to address the problem would be the revision of sensi- ble material by qualified psychopedagogical personnel with a preventive, gender-based perspective; the promotion of psychoeducational programs among vulnerable viewers and their familiar, social and educational communities; and the use of warnings that alert of the risk before the show is displayed. Future fictional dramas planning to depict suicide should review this case to learn from its strengths and weaknesses, which will assist in contributing to the suicide prevention task. Author Contributions: Conceptualization, M.G. and J.C.; Methodology, M.G. and A.G.-R.; Validation, J.C. and A.G.-R.; Formal Analysis, M.G. and J.C.; Investigation, M.G. and J.C.; Resources, D.P.; Writing—Original Draft Preparation, M.G.; Writing—Review and Editing, J.C., A.G.-R. and I.P.-U.; Visualization, M.G.; Supervision, I.P.-U. and D.P.; Project Administration, D.P.; Funding Acquisition, D.P. All authors have read and agreed to the published version of the manuscript. Funding: The project received funding from the Spanish Ministry of Science and Innovation/ISCIII/FEDER (PI21/01148); the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement of the Generalitat de Catalunya (2017 SGR 1412); the CERCA program of the Institut d’Investigació i Innovació Parc Taulí (I3PT); the Instituto de Salud Carlos III; and the CIBER of Mental Health (CIBERSAM). Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The data presented in this review are available upon request from the corresponding author. Acknowledgments: The authors would like to highlight the contribution of those members of Hospital Universitari Parc Taulí who, despite having collaborated in the paper, could not be stated as authors: Mireia Agut, Alicia Capilla, Annabel Cebrià-Meca, Laura Comendador, Marina Esteve, Rebeca Gracia, Carmen Massons, Maria Teresa Muñoz, Joan Carles Oliva, and Irene Santacreu. 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