Health Soc Care Community. 2020;00:1–14. wileyonlinelibrary.com/journal/hsc  |  1© 2020 John Wiley & Sons Ltd

1  | INTRODUC TION

Suicide is a significant public health concern and it is estimated that approximately 800,000 people die by suicide globally each year (World Health Organization, 2018). The role that media plays in contributing to suicide rates has been the focus of much debate and research. The idea that portrayal or reporting of suicide in the media can lead to imitation or contagion effects has been referred to historically as the Werther Effect. This term was named after a book published in 1774 called The Sorrows of Young Werther, in which the protagonist dies by suicide. It is believed that through the re-lease of the book, large numbers of imitation suicides across Europe occurred. The Werther Effect has been tested by a large body of research. Much of this research has focused on the reporting of ce-lebrity suicides in the media- in television, print media, radio and internet-based news, and meta-analyses have concluded that media reporting of celebrity or high-profile suicides are associated with in-creased suicide rates and suicide method chosen (Niederkrotenthaler

et al., 2012). Many reviews have concluded that media reporting of suicide and the portrayal of suicide in both fictional and nonfic-tional media, can increase suicidal behaviour, and there is sufficient evidence to suggest that this link is causal (Pirkis & Blood, 2001a, 2001b; Stack, 2005).

Within the last two decades, research has progressed from look-ing broadly at association between suicide portrayed in the media and impact on suicide rates, to increasingly examining the more nu-anced effects of portrayals of suicide in the media and how factors or conditions can alter or mediate impact. In contrast to the Werther Effect, The Papageno Effect has also increasingly been researched and refers to possible protective or positive effects that media re-porting of suicide can have, such as bringing about necessary aware-ness and stigma reduction, and education about help and support options.

Media reporting recommendations have been established by various organisations including the World Health Organization (World Health Organisation, 2017). These recommendations

Received: 11 February 2020  |  Revised: 20 May 2020  |  Accepted: 2 July 2020

DOI: 10.1111/hsc.13112

R E V I E W A R T I C L E

The impact of screen media portrayals of suicide on viewers: A rapid review of the evidence

Miriam Posselt MPsychClin, PhD  | Heather McIntyre BA(Hons), GradDipAppSci  | Nicholas Procter MBA, PhD

Mental Health and Suicide Prevention Research Group, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia

CorrespondenceMiriam Posselt, Mental Health and Suicide Prevention Research Group, UniSA Clinical and Health Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia, Australia.Email: Miriam.posselt@unisa.edu.au

AbstractThis rapid review aimed to review recent published literature and describe the cur-rent evidence regarding the impact, on viewers, of portrayals of suicide in screen/ moving-image fiction and non-fiction media, such as television/web series, films and documentaries. We searched various databases for research conducted within the past decade (2009–2019). A total of 16 articles were eligible for inclusion. The litera-ture reported varying impacts of portrayals of suicide through moving-image media such as increased suicidal ideation and behaviour, as well as positive impacts such as increased help-seeking behaviour. While there is limited evidence which focuses specifically on the impact of moving-image media, the studies included in this re-view highlight concerning trends regarding the impact of media portraying deaths by suicide on subsequent suicidality. However, positive impacts on suicide awareness, literacy and help-seeking behaviour were also identified.

K E Y W O R D S

documentaries, film, media, self-harm, suicidal ideation, suicide, television

2  |     POSSELT ET aL.

outline the importance of not using sensationalist language, avoiding mention or imagery of the location, avoiding reference to the method and or means and providing the media consumer with support options (Mindframe, 2019; World Health Organisation, 2017).

While there are several reviews that examine portrayal of sui-cide in media broadly, such as the impact of various and mixed forms of media, none appear to focus on the specific impact of portraying suicidal behaviour in fiction and non-fiction moving-image media, such as television, videos, films and documentaries. We believed it was important to differentiate between the effect of print media/media about celebrity suicides from screen/moving-image media. This is because there has been a large focus on media reporting of suicides, mostly celebrity suicides and this has dominated conver-sations and understandings about the contagion effects of media on suicide. There has been much less focus on the impact of screen media, such as television, movies, documentaries and music vid-eos. The present review has been conducted at a time where there has been considerable public, media and research attention paid to possible Werther and Papageno Effects of a popular web series, 13 Reasons Why. The series depicts a fictional character ending her life in the final episode of the first season, after documenting the 13 reasons that led to her decision to suicide. The first season was released in 2017 and was followed by much discussion concerned with the potential glamorising of suicide and depicting it as a solu-tion to the problems and events documented. Despite criticism, the second season was released in 2018 and there have been two more seasons released since then. Coinciding with this, in 2018 a documentary film was released called The Ripple Effect in which the non-fiction personal story of Kevin Hines, who attempted suicide at age 19 years is shared. The film is intended to be educational and inspirational, sharing a message of hope and gratitude to have sur-vived his attempt. However, coupled with images of the location of his attempt and at times graphic descriptions of suicide methods, it is possible that the film has the potential for triggering of nega-tive effects in addition to possible Papageno effects. Although, to our knowledge these possibilities have not been explored by any research.

It is important to examine the evidence specifically in relation to moving-image media because there is evidence that a portrayal of suicide in the media is more likely to be associated with in-creased suicidality if it is broadcasted on television versus other media platforms, such as radio and print media (Pirkis, Burgess, Francis, Blood, & Jolley, 2006). Furthermre, research has found that films are increasingly portraying suicidal behaviour and that ratings for films with explicit suicidal content are increasingly being classified at lower classification levels such as PG rather than R (Jamieson & Romer, 2011). This research highlights the im-portance of understanding the unique impact of screen media and isolating and synthesising research specifically conducted on this topic.

Our research aimed to undertake an independent rapid review of the evidence regarding possible impacts of portraying suicide in

moving-image media involving both fictional and non-fictional char-acters, on the consumers of that media.

2  | METHODS

2.1 | Rapid review

We performed a time-limited rapid review to efficiently capture the current and recent evidence regarding the impact of portraying sui-cidal behaviour in moving-image media involving both fictional and non-fictional characters, on the consumers or viewers of that media. Rapid reviews have been found to yield similarly rigorous results when compared to systematic reviews (Watt et al., 2008). In this rapid review, we followed guidelines published by the World Health Organization (WHO) on conducting rapid reviews to strengthen health policy and system (Tricco, Langlois, & Straus, 2017), as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009). See Figure 1 for PRISMA flow diagram.

2.2 | Search strategy

The research team developed the search strategy. The search was conducted in March 2019 in the following databases: Academic Search Premier, Communication Mass Media, Embase, Health and Society, Humanities and Social Sciences, Medline, ProQuest Social Sciences, Psychology and Behavioural Sciences and PsycInfo. Various terms were used including suicide, self-harm, mass media,

What is known about this topic?

• Past reviews have focused on the impact of mixed-me-dium media portrayals of suicide.

• Some evidence suggests that media reporting of suicides is more likely to lead to increased suicidality if broad-casted on television versus other platforms. Therefore, there is justification to review the evidence on specifi-cally screen/ moving-image media portrayals.

What this paper adds?

• This review highlights imitation and contagion effects arising from moving-image media portraying suicide.

• Viewer characteristics such as higher levels (or histories) of depression, suicidality, dissociation, thought suppres-sion and identification with the protagonist appear re-lated to increased risk of suicidality.

• For some viewers, narratives of hope, help-seeking and portrayals of overcoming/ coping with a suicidal crisis can lead to positive outcomes.

     |  3POSSELT ET aL.

media. Search terms were limited to titles, abstracts and keywords, where this was a feature of the database. Limits were applied includ-ing: English language and time range of 2009–2019. See Appendix A for search strategy. Reference lists of included articles were also hand searched to obtain important additional results.

The research team engaged in a three-stage screening and study selection process as follows: (a) preliminary screening conducted by two reviewers (HE, MP) for any clearly inappropriate results (e.g. non peer-reviewed journal articles or not on topic); (b) all remaining ar-ticles were uploaded to review management software (Covidence) and a title and abstract screen was conducted by two reviewers (HE, MP); (c) full-text screening was then conducted with all remain-ing results by two reviewers (HE, MP). The research team (HE, MP, NP) discussed the results and any conflicts were resolved through discussions to achieve 100% agreement. Key information was ex-tracted from all studies into a structured data table. Two authors (HE, MP) conducted and cross-checked data extraction.

Studies were eligible for inclusion if the article was peer-re-viewed, primary research (any study design including mixed meth-ods, quantitative or qualitative), included an exposure/portrayal of suicide in moving-image media, included a measure of suicidal ide-ation, behaviour or literacy (knowledge, awareness, attitudes and help seeking) and published between 2009 and 2019. Studies must include moving-image media (e.g. films, videos, television series/web series and documentaries), either fiction or non-fiction. An age range was not applied to participants. Studies were excluded if the re-search focused on moving-image media combined with other forms such as television reporting of suicides combined with print media, and if it did not separate the impact of television from mixed media.

We excluded studies focused on internet media, such as social media or websites, given that this typically concerned individuals seeking pro-suicide information from websites or posting their own images or stories to the internet such as forums, blogs, social media and online communities.

Two authors independently conducted a risk of bias assessment using quality appraisal tools that corresponded to the study design of the included articles. Five appraisal tools were used to assess risk of bias: Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Control Studies; JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies; JBI Critical Appraisal Checklist for Cohort Studies, JBI Critical Appraisal Checklist for Quasi-Experimental Studies, JBI Critical Appraisal Checklist for Randomized Controlled Trials (Moola et al., 2017). The JBI tools required a response of the following four options: yes, no, unclear, not applicable. Any discrepancies between the two reviewers in checklist ratings were resolved by discussion to gain 100% consensus. The research team agreed on the follow-ing percentages for quality: 90%–100% exceptionally high quality, 80%–90% high quality, 70%–80% moderate to high quality.

A narrative synthesis method was used due to the heterogeneity of study contexts, study designs, samples, measures and outcome variables. Therefore, all relevant data from the studies that met in-clusion criteria and critical appraisal criteria have been descriptively summarised. The summarised findings relate to the reported key im-pacts of portraying suicide in moving-image media, on the consum-ers of that media.

3  | RESULTS

From initial database searching, a total of 4,277 publications were identified. After removing duplicates (n = 1,122) and articles that were clearly not relevant to the research question (n = 2,954), 201 articles were included for title and abstract screening. A total of 130 articles were excluded at this stage and full text screening was con-ducted on 71 articles. Of these, 16 articles met inclusion criteria and were deemed eligible for inclusion.

3.1 | Characteristics of included studies

Thirteen studies examined the impact of fictional portrayals of deaths by suicide, whereas four studies examined the impact of portraying deaths by suicide of non-fictional characters. The studies were conducted across five different countries. Sample sizes ranged from 60 to 21,062. However, one study (which analysed Google searches) did not state participant numbers but referred to search numbers (Ayers, Althouse, Leas, Dredze, & Allem, 2017). See Table 1 for study locations and sample sizes.

Six studies analysed the effect of suicidal content in a fiction film (Pouliot, Mishara, & Labelle, 2011; Stack, Kral, & Borowski, 2014; Till, Herberth, Sonneck, Vitouch, & Niederkrotenthaler, 2013; Till, Niederkrotenthaler, Herberth, Vitouch, & Sonneck, 2010; Till, Strauss,

F I G U R E 1   PRISMA flow diagram (Moher et al., 2009)

Records identified through database

searching (n = 4268)

Additional records identified

through other sources (n = 9)

Records after duplicates removed (n =3155)

Preliminary screening

(n = 3155) Records excluded (n = 2954)

Titles and abstracts

screened for eligibility

(n = 201)

17 Wrong intervention

3 Editorial

2 Wrong outcomes

31 Wrong study design

1 Conference paper, no FT

1 Does not compare

reporting to suicide rate

Full-text articles assessed

(n = 71)

Studies included (n = 16)

Records excluded (n = 130)

4  |     POSSELT ET aL.

TAB

LE 1

 Ke

y fe

atur

es o

f inc

lude

d st

udie

s

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

1A

rend

t, F.

, Sch

err,

S., P

asek

, J.

, Jam

ieso

n, P

. E.,

& R

omer

, D

. (20

19).

Inve

stig

atin

g ha

rmfu

l and

hel

pful

eff

ects

of

wat

chin

g se

ason

2 o

f 13

Reas

ons

Why

: Res

ults

of a

tw

o-w

ave

U.S

. pan

el s

urve

y.

Soci

al S

cien

ce &

Med

icin

e,

232,

489

–498

.

USA

TV s

erie

s— ‘1

3 Re

ason

s W

hy’—

Ser

ies

2Re

view

the

effe

cts

of‘1

3 Re

ason

s W

hy’—

Serie

s 2

n =

729

F =

81.

6%M

= 1

8.4%

(age

18

–29

year

s)1/

3 pa

rtic

ipan

ts

wer

e H

ispa

nic

Suic

ide

Prob

abili

ty S

cale

(S

PS);

Brie

f ver

sion

of B

eck'

s H

opel

essn

ess

Scal

e;N

on-s

uici

dal s

elf-

inju

ry;

Yout

h Ri

sk B

ehav

ior

Surv

ey;

Surv

ival

and

cop

ing

belie

fs s

ubsc

ale

of B

rief

Reas

ons

for L

ivin

g sc

ale;

thre

e ite

ms

from

Gen

eral

So

cial

Sur

vey;

Inte

ntio

n to

pro

vide

hel

p to

sui

cida

l ind

ivid

uals

(H

elp

scal

e);

Expo

sure

to ‘1

3 Re

ason

s W

hy’;

Expo

sure

to o

ther

sui

cide

st

orie

s;Ex

posu

re to

war

ning

m

essa

ge;

Hel

p M

essa

ge;

Did

the

show

spu

r di

scus

sion

with

frie

nds

Fict

iona

l sto

ries

with

con

tent

ab

out s

uici

de c

an h

ave

harm

ful

or h

elpf

ul e

ffec

ts

8/9

(89%

)

2Ay

ers,

J. W

., A

lthou

se, B

. M

., Le

as, E

. C.,

Dre

dze,

M

., &

Alle

m, J

. P. (

2017

). In

tern

et s

earc

hes

for s

uici

de

follo

win

g th

e re

leas

e of

‘13

Reas

ons

Why

’. JAM

A In

tern

al

Med

icin

e, 1

77, 1

527–

1529

.

Not

st

ated

; in

tern

et

base

d

TV s

erie

s—‘1

3 Re

ason

s W

hy’ S

erie

s 1

Com

pare

Inte

rnet

se

arch

es fo

r sui

cide

af

ter t

he p

rem

iere

of ‘

13

Reas

ons

Why

’, ser

ies

1,

with

ant

icip

ated

sea

rch

num

bers

Not

sta

ted;

inte

rnet

ba

sed

Sear

ch tr

ends

incl

udin

g th

e te

rm s

uici

de w

ere

anal

ysed

incl

udin

g th

e to

p 25

term

s an

d th

e ne

xt fi

ve m

ost r

elat

ed

term

s.Su

icid

e qu

erie

s w

ere

divi

ded

by th

e to

tal

num

ber o

f sea

rche

s fo

r ea

ch d

ay

Suic

ide

sear

ches

wer

e 19

% (9

5%

CI,

14%

–24%

) hig

her f

or 1

9 da

ys

follo

win

g th

e re

leas

e of

‘13

Reas

ons

Why

’/ (9

00,0

00–1

.5

mill

ion

mor

e se

arch

es th

an

expe

cted

.)Fo

r 12

of th

e 19

day

s st

udie

d,

suic

ide

quer

ies

wer

e si

gnifi

cant

ly g

reat

er th

an

expe

cted

. ‘13

Rea

sons

Why

’ ha

s bo

th in

crea

sed

suic

ide

awar

enes

s w

hile

incr

easi

ng

suic

idal

idea

tion

6/8

(75%

)

(Con

tinue

s)

     |  5POSSELT ET aL.

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

3C

oope

r, M

. T.,

Bard

, D.,

Wal

lace

, R.,

Gill

aspy

, S.,

&

Del

eon,

S. (

2018

). Su

icid

e at

tem

pt a

dmis

sion

s fr

om

a si

ngle

chi

ldre

n's

hosp

ital

befo

re a

nd a

fter

the

intr

oduc

tion

of N

etfli

x se

ries

‘13

Reas

ons

Why

’. Jou

rnal

of

Ado

lesc

ent H

ealth

, 63,

68

8–69

3.

USA

TV s

erie

s—‘1

3 Re

ason

s W

’—Se

ries

1Id

entif

y tr

ends

in s

elf-

harm

ad

mis

sion

s to

a c

hild

ren'

s ho

spita

l aft

er th

e re

leas

e ‘1

3 Re

ason

s W

hy’ S

erie

s 1

n =

775

F =

73%

M =

17%

(age

4–1

8 ye

ars;

m

ean

age

15.2

[SD

2.

1])

Patie

nt re

cord

s an

alys

is

for t

hose

pre

sent

ing

to

the

ED w

ith S

HID

/SI

-Sig

nific

ant i

ncre

ase

in S

HID

/SI

adm

issi

ons

afte

r the

scr

eeni

ng

of ‘1

3 Re

ason

s W

hy’ S

easo

n 1.

Pre

dict

ed (v

ersu

s ac

tual

) nu

mbe

r of a

dmis

sion

s fo

r SH

ID/

SI in

May

201

7 w

as 1

2 (v

ersu

s 31

)

6/8

(75%

)

4H

ong,

V.,

Ewel

l Fos

ter,

C. J

., M

agne

ss, C

. S.,

McG

uire

, T.

C.,

Smith

, P. K

., &

Kin

g,

C. A

., (2

018)

. ‘13

Rea

sons

W

hy’:

Vie

win

g pa

tter

ns a

nd

perc

eive

d im

pact

am

ong

yout

hs a

t ris

k of

sui

cide

. Ps

ychi

atric

Ser

vice

s, 70

, 10

7–11

4.

USA

TV s

erie

s –

‘13

Reas

ons

Why

’ — S

erie

s 1

Exam

ine

expo

sure

to a

nd

patt

erns

of e

ngag

emen

t w

ith th

e ‘1

3 Re

ason

s W

hy’

— S

erie

s 1

and

the

impa

ct

on y

outh

s pr

esen

ting

with

su

icid

e-re

late

d co

ncer

ns

to a

psy

chia

tric

ED

dur

ing

the

year

aft

er th

e se

ries'

prem

iere

n =

87

Pare

nt-y

outh

dya

dsYo

uth

—F

= 7

1%M

= 2

6%N

onbi

nary

= 2

%

(age

10–

17 y

ears

; m

ean

age

= 1

4.6

[SD

+ 1

.8])

Yout

h Q

uest

ionn

aire

;Re

ynol

ds A

dole

scen

t D

epre

ssio

n Sc

ale,

(R

AD

S−2)

;Su

icid

al Id

eatio

n Q

uest

ionn

aire

–—Ju

nior

(S

IQ-J

R) (2

9);

44-it

em q

uest

ionn

aire

to

asse

ss s

ever

al a

spec

ts o

f yo

uths

' int

erac

tions

with

‘1

3 Re

ason

s W

hy’;

Posi

tive

and

Neg

ativ

e A

ffec

t Sch

edul

e (P

AN

AS)

;Id

entif

icat

ion

with

fe

mal

e/m

ale

lead

act

ors;

Perc

eptio

ns o

f whe

ther

th

e se

ries

had

an im

pact

on

the

yout

h's

own

suic

ide

risk

and

on th

e lik

elih

ood

of e

ngag

ing

in s

uppo

rt-s

eeki

ng

beha

viou

rs;

open

-end

ed q

ualit

ativ

e qu

estio

nsPa

rent

Que

stio

nnai

re:

36-it

em;

Iden

tical

PA

NA

S re

spon

ses

to th

e se

ries

n =

21

(51%

) bel

ieve

d w

atch

ing

the

serie

s in

crea

sed

own

risk

of

suic

ide.

Iden

tifyi

ng w

ith c

hara

cter

re

sulte

d in

hig

her S

I (n

= 4

7,

df =

43,

p =

.001

) and

de

pres

sive

sym

ptom

s (n

= 4

3,

df =

43,

p =

.004

).Pa

rtic

ipan

ts d

o (v

ersu

s do

not

) be

lieve

the

serie

s gl

orifi

es o

r no

rmal

ises

sui

cide

and

men

tal

illne

ss n

= 1

3 (v

ersu

s n

= 1

2).

Part

icip

ants

repo

rted

the

serie

s m

ade

them

less

like

ly

(ver

sus

mor

e lik

ely)

to ta

lk to

ot

hers

n =

12%

–28%

(ver

sus

n =

12%

–28%

).51

% b

elie

ved

the

serie

s in

crea

sed

thei

r sui

cide

risk

to a

no

n-ze

ro d

egre

e;Pa

rtic

ipan

ts w

ith m

ore

depr

essi

ve s

ympt

oms

and

SI

wer

e m

ore

likel

y to

iden

tify

with

the

lead

cha

ract

ers

and

repo

rt n

egat

ive

affe

ct w

hile

vi

ewin

g.

10/1

0 (1

00%

)

TAB

LE 1

 (C

ontin

ued)

(Con

tinue

s)

6  |     POSSELT ET aL.

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

5K

ing,

K. E

., Sc

hlic

htho

rst,

M.,

Spitt

al, M

. J.,

Phel

ps,

A.,

& P

irkis

, J. (

2018

). C

an a

do

cum

enta

ry in

crea

se h

elp-

seek

ing

inte

ntio

ns in

men

? A

rand

omis

ed c

ontr

olle

d tr

ial.

Jour

nal o

f Epi

dem

iolo

gy

and

Com

mun

ity H

ealth

, 72,

86

–92.

Aus

tral

iaD

ocum

enta

ry- n

on-

fictio

n— ‘M

an U

p’D

oes

‘Man

Up’

incr

ease

m

en's

help

see

king

for

pers

onal

and

em

otio

nal

prob

lem

s?

n =

337

Inte

rven

tion

= 1

69C

ontr

ol =

168

(age

18

+ y

ears

)Pa

rtic

ipan

ts a

ll m

ale

Gen

eral

Hel

p Se

ekin

g Q

uest

ionn

aire

(GH

SQ)

This

stu

dy d

emon

stra

tes

that

m

edia

-bas

ed p

ublic

hea

lth

inte

rven

tions

that

focu

s on

tr

aditi

onal

mas

culin

ity a

ffec

ting

men

's he

alth

out

com

es

posi

tivel

y.Fo

r the

inte

rven

tion

grou

p,

help

see

king

sco

res

wer

e si

gnifi

cant

ly g

reat

er th

an th

e co

ntro

l gro

up.

13/1

3 (1

00%

)

6Po

ulio

t, L.

, Mis

hara

, B. L

., &

Lab

elle

, R. (

2011

). Th

e W

erth

er E

ffec

t rec

onsi

dere

d in

ligh

t of p

sych

olog

ical

vu

lner

abili

ties:

Res

ults

of

a pi

lot s

tudy

. Jou

rnal

of

Affe

ctiv

e D

isord

ers,

134,

48

8–49

6.

Can

ada

Fict

ion—

film

s (v

ario

us)

The

poss

ible

impa

ct to

yo

ung

peop

le o

f exp

osur

e to

a fi

lm w

ith s

uici

dal

cont

ent

F =

71

M =

29

Und

ergr

adua

tes

(mea

n ag

e 23

yea

rs

[SD

= 4

.27]

);

32 it

ems

expo

sure

to

*sui

cide

sto

ries;

*d

urat

ion

of d

istr

ess;

*n

egat

ive

affe

ctiv

e;

*cog

nitiv

e re

actio

ns.

IES-

R;Su

icid

e Pr

obab

ility

Sca

le,

(SPS

);Tr

ait D

isso

ciat

ion

Que

stio

nnai

re (T

DQ

);Th

e M

ehra

bian

’ Tra

it A

rous

abili

ty S

cale

(TA

S);

Whi

te B

ear T

houg

ht

Supp

ress

ion

Inve

ntor

y (W

BSI).

70%

repo

rted

bei

ng d

istr

esse

d by

the

port

raya

l of a

sui

cide

in a

fic

tiona

l film

.33

% fe

lt di

stre

ssed

for s

ever

al

days

to s

ever

al w

eeks

.M

ajor

ity (7

1%) s

tate

d be

ing

men

tally

pre

occu

pied

and

ex

perie

nced

intr

usiv

e m

emor

ies

(68%

).55

% o

f mal

es w

ere

dist

ress

ed

com

pare

d to

76%

of f

emal

es.

From

this

sub

-gro

up, 3

3%

stat

ed th

eir d

istr

ess

last

ed fr

om

a fe

w d

ays

to le

ss th

an a

mon

th.

13%

fear

ed th

ey w

ould

eng

age

in

the

sam

e su

icid

al b

ehav

iour

as

the

prot

agon

ist,

and

repo

rted

th

at th

e id

ea c

ross

ed th

eir m

ind

to a

ct o

n it.

8/8

(100

%)

7Re

tam

ero,

C.,

Wal

sh, L

., &

O

tero

-Per

ez, G

. (20

14).

Use

of t

he fi

lm ‘T

he B

ridge

’ to

aug

men

t the

sui

cide

cu

rric

ulum

in u

nder

grad

uate

m

edic

al e

duca

tion.

Aca

dem

ic

Psyc

hiat

ry, 3

8, 6

05–6

10.

Not

st

ated

, po

ssib

ly

USA

Doc

umen

tary

- non

-fic

tion—

‘The

Brid

ge’

Is th

e m

ovie

‘The

Brid

ge’

com

plem

enta

ry to

the

suic

ide

curr

icul

um fo

r m

edic

al s

tude

nts?

n =

180

Seco

nd-y

ear

med

ical

stu

dent

s

Surv

ey re

gard

ing

belie

fs

abou

t sui

cide

and

abo

ut

lear

ning

abo

ut s

uici

dal

conc

epts

in th

e fil

m

Stud

ents

repo

rted

‘The

Brid

ge’ i

s va

luab

le a

nd b

elie

ved

it sh

ould

be

sho

wn

to p

eopl

e in

the

med

ical

fiel

d; 8

0% o

f stu

dent

s co

mm

ente

d ab

out a

t lea

st o

ne

pers

on in

the

stor

y or

abo

ut th

e st

ory

in g

ener

al

7/9

(77%

)

TAB

LE 1

 (C

ontin

ued)

(Con

tinue

s)

     |  7POSSELT ET aL.

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

8Ro

sa, G

. S. D

., A

ndra

des,

G.

S., C

aye,

A.,

Hid

algo

, M. P

., O

livei

ra, M

. A. B

. D.,

& P

ilz, L

. K

. (20

19).

‘Thi

rtee

n Re

ason

s W

hy’:

The

impa

ct o

f sui

cide

po

rtra

yal o

n ad

oles

cent

s' m

enta

l hea

lth. J

ourn

al o

f Ps

ychi

atric

Res

earc

h, 1

08,

2–6.

Braz

ilTV

ser

ies—

‘13

Reas

ons

Why

’, Ser

ies

1To

inve

stig

ate

the

influ

ence

of

med

ia p

ortr

ayal

s of

su

icid

e on

ado

lesc

ents

' m

ood,

focu

sing

on

‘13

Reas

ons

Why

’

n =

7,0

04F

= 5

,870

(84%

)M

= 1

,134

(16%

)Su

icid

al id

eatio

n n

= 4

9%;

Suic

ide

atte

mpt

n

= 1

2% (a

ges

12–1

8 ye

ars)

Moo

d (s

adne

ss a

nd la

ck

of m

otiv

atio

n) p

rior t

o w

atch

ing

the

serie

s, a

nd

prev

alen

ce o

f sel

f-ha

rm,

suic

idal

idea

tion,

or

suic

ide

atte

mpt

s

23.7

% re

port

ed w

orse

ning

of

moo

d af

ter w

atch

ing

‘13

Reas

ons

Why

’. Tho

se p

rior t

o w

atch

ing

the

mov

ie w

ho h

ad

mor

e fr

eque

nt a

nd in

tens

e fe

elin

g of

sad

ness

and

lack

of

mot

ivat

ion

expe

rienc

ed

wor

seni

ng m

ood

or re

port

ed

suic

idal

idea

tion/

self-

harm

/su

icid

e at

tem

pt

6/8

(75%

)

9Sc

herr

, S.,

& R

eine

man

n, C

. (2

011)

. ‘Be

lief i

n a

Wer

ther

Ef

fect

: thi

rd-p

erso

n ef

fect

s in

the

perc

eptio

ns

of s

uici

de ri

sk fo

r oth

ers

and

the

mod

erat

ing

role

of

dep

ress

ion’

Sui

cide

&

Life

-thr

eate

ning

Beh

avio

r, 41

, 62

4–63

4.

USA

Mus

ic v

ideo

with

sui

cida

l co

nten

t: ‘Je

rem

y’ b

y Pe

arl J

am

To e

xam

ine

stud

ents

' ra

tes

of s

elf-

risk

of

depr

essi

on a

nd s

uici

de

and

perc

eptio

ns o

f oth

ers'

suic

ide

risk.

n =

133

F =

74

M =

59

Und

ergr

adua

tes

(Mea

n ag

e w

as

19.1

3 ye

ars

[SD

= 2

.35]

).C

ontr

ol =

66

Expe

rimen

tal =

67

Part

icip

ants

sel

f-re

port

ed

estim

ates

of t

he ri

sk o

f de

pres

sion

and

sui

cide

fo

r the

mse

lves

and

for

othe

rs

Part

icip

ants

repo

rted

risk

of

suic

ide

as h

ighe

r for

oth

ers

than

for t

hem

selv

es a

fter

bei

ng

expo

sed

10/1

2 (8

3%)

10Sc

hlic

htho

rst,

M.,

Kin

g, K

., Sp

ittal

, M.,

Reife

ls, L

., Ph

elps

, A

., &

Pirk

is, J

. (20

18).

Usi

ng

a te

levi

sion

doc

umen

tary

to

prev

ent s

uici

de in

men

and

bo

ys. A

ustr

alas

Psy

chia

try,

26,

160–

165.

Aus

tral

iaD

ocum

enta

ry- n

on-

fictio

n—‘M

an U

p’W

as th

e se

ries

‘Man

U

p’ e

ffec

tive

in ra

isin

g aw

aren

ess

for m

ales

' of

soc

ieta

l pre

ssur

es to

co

nfor

m to

mas

culin

e no

rms

and

affe

ct th

eir

likel

ihoo

d of

hel

p se

ekin

g an

d co

nnec

ting

with

thei

r m

ale

frie

nds?

n =

1,2

87A

ll m

ale

Gro

up

A =

476

(com

plet

ed th

e pr

e-sc

reen

ing

surv

ey);

Gro

up B

= 1

92

(com

plet

edth

e po

st-s

cree

ning

su

rvey

and

had

not

vi

ewed

‘Man

Up’

);G

roup

C =

619

(c

ompl

eted

the

post

-scr

eeni

ng

surv

ey a

nd h

ad

view

ed ‘M

an U

p’)

Hel

p-se

ekin

g be

havi

our

Vie

win

g M

an U

p di

d no

t inc

reas

e lik

elih

ood

of h

elp

seek

ing

8/8

(100

%)

11St

ack,

S.,

Kra

l, M

., &

Bor

owsk

i, T.

(201

4). E

xpos

ure

to s

uici

de

mov

ies

and

suic

ide

atte

mpt

s:

A re

sear

ch n

ote.

Soc

iolo

gica

l Fo

cus,

47, 6

1–70

.

USA

Fict

ion—

film

s (v

ario

us)

A re

tros

pect

ive

stud

y as

sess

ing

the

impa

ct o

f cu

mul

ativ

e, v

olun

tary

ex

posu

re to

sui

cide

m

ovie

s.

n =

260

Col

lege

stu

dent

s.

No

othe

r det

ails

gi

ven

rega

rdin

g ag

e or

gen

der

Relig

iosi

ty—

a si

ngle

-item

m

easu

re u

sed

in th

e W

orld

Val

ues

Surv

eys;

Dep

ress

ion—

Yout

h Ri

sk

Beha

vior

Sur

veys

;Bu

rden

som

enes

s—Jo

iner

s' ni

ne-it

em in

dex;

Risk

of a

ttem

pted

sui

cide

in

crea

sed

by 4

7.6%

with

eac

h ad

ditio

nal m

ovie

exp

osur

e

7/8

88%

TAB

LE 1

 (C

ontin

ued)

(Con

tinue

s)

8  |     POSSELT ET aL.

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

12Ti

ll, B

., St

raus

s, M

., So

nnec

k,

G.,

& N

iede

rkro

tent

hale

r, T.

(201

5). D

eter

min

ing

the

effe

cts

of fi

lms

with

sui

cida

l co

nten

t: A

labo

rato

ry

expe

rimen

t. Br

itish

Jour

nal o

f Ps

ychi

atry

, 207

, 72–

78.

Aus

tria

Fict

ion—

film

s‘N

ight

, Mot

her’,

‘A S

ingl

e M

an’ o

r ‘El

izab

eth-

tow

n’.

To e

xam

ine

the

impa

ct o

f th

ree

dram

a fil

ms

with

su

icid

al c

onte

nt th

at

with

var

ying

out

com

es

and

test

ing

the

base

line

suic

idal

ity o

f the

pa

rtic

ipan

ts.

n =

95

F =

65

M =

30

(mea

n ag

e w

as

27.3

2 ye

ars

[SD

10

.43]

)H

igh

scho

ol

grad

uate

(ave

rage

le

vel o

f edu

catio

n)

Aff

ectiv

e St

ate

Scal

e (m

ood)

;Er

lang

er D

epre

ssio

n Sc

ale;

Satis

fact

ion

with

Life

Sc

ale;

Self-

wor

th s

ubsc

ale

of

Wor

ld A

ssum

ptio

ns

Scal

e;Re

ason

s fo

r Liv

ing

Scal

e;Be

nevo

lenc

e of

the

wor

ld

subs

cale

of t

he W

orld

A

ssum

ptio

ns S

cale

;C

ohen

's Id

entif

icat

ion

Scal

e (s

uici

dalit

y)

Whe

n ex

pose

d to

a fi

lm

disp

layi

ng s

uici

de, p

artic

ipan

ts

with

low

er v

ulne

rabi

lity

expe

rienc

ed m

ore

emot

iona

l re

actio

ns. P

artic

ipan

ts w

ith

high

er v

ulne

rabi

lity

expe

rienc

ed

high

er S

I—pa

rtic

ular

ly if

they

id

entif

ied

with

pro

tago

nist

. Po

rtra

yals

of m

aste

ry o

f a c

risis

m

ay h

ave

bene

ficia

l eff

ects

for

thos

e w

ho a

re m

ore

vuln

erab

le

10/1

2 (8

3%)

13Ti

ll, B

., H

erbe

rth,

A.,

Sonn

eck,

G.,

Vito

uch,

P.,

& N

iede

rkro

tent

hale

r, T.

(2

013)

. ‘W

ho id

entif

ies

with

su

icid

al fi

lm c

hara

cter

s?

Det

erm

inan

ts o

f id

entif

icat

ion

with

sui

cida

l pr

otag

onis

ts o

f dra

ma

film

s'.

Psyc

hiat

ria D

anub

ina,

25,

15

8–16

2.

Aus

tria

Fict

ion

– fil

ms

‘It's

My

Part

y’ o

r ‘Th

e Fi

re

With

in’

How

influ

entia

l is

sim

ilar

iden

tific

atio

n (i.

e. s

ex,

age,

and

edu

catio

n) b

y a

part

icip

ant w

ith a

sui

cida

l pr

otag

onis

t of a

film

as

wel

l as

by th

e pa

rtic

ipan

ts'

empa

thy

and

suic

idal

ity?

n =

60

M =

23

(38.

3%),

(mea

n ag

e of

37

.65

year

s [S

D =

18.

78]);

F =

37

(61.

7%),

(mea

n ag

e of

43

.32

year

s[S

D =

23.

06]).

Empa

thy

(Inte

rper

sona

l Re

activ

e In

dex)

;Id

entif

icat

ion;

Suic

idal

ity;

Soci

o-de

mog

raph

ics

Part

icip

ants

' ide

ntifi

catio

n w

as

not a

ssoc

iate

d w

ith s

ocio

-de

mog

raph

ic s

imila

rity

or th

e vi

ewer

's su

icid

ality

10/1

2 (8

3%)

14Ti

ll, B

., V

itouc

h, P

., H

erbe

rth,

A.,

Sonn

eck,

G

., &

Nie

derk

rote

ntha

ler,

T. (2

013b

). ‘P

erso

nal

suic

idal

ity in

rece

ptio

n an

d id

entif

icat

ion

with

sui

cida

l fil

m c

hara

cter

s’. D

eath

St

udie

s, 37

, 383

–392

.

Aus

tria

Fict

ion

– fil

ms

‘It's

My

Part

y’ o

r ‘Th

e Fi

re

With

in’.

Ana

lyse

per

sona

l sui

cida

lity

on id

entit

y w

ork

and

iden

tific

atio

n du

ring

film

s w

ith s

uici

dal c

onte

nt w

ith

part

icip

ants

with

low

su

icid

ality

sco

res.

n =

150

F =

95

M =

55

(Mea

n ag

e 36

.05

year

s)C

auca

sian

30 p

artic

ipan

ts p

er

grou

p

Suic

idal

ity Id

entif

icat

ion;

Iden

tific

atio

n w

ith a

sp

ecifi

c ch

arac

ter;

Suic

idal

itySo

cio-

dem

ogra

phic

s;Id

entif

icat

ion;

Iden

tity

No

rela

tions

hip

betw

een

suic

idal

ity a

nd id

entif

icat

ion.

Pe

rson

al s

uici

dalit

y di

d no

t co

rrel

ate

sign

ifica

ntly

with

th

ose

wat

chin

g ce

nsor

ed

vers

ions

of t

he fi

lm b

ut d

id

with

thos

e w

atch

ing

the

orig

inal

(sui

cide

) ver

sion

s of

the

film

s. H

ighe

r SI i

n th

e gr

oups

w

atch

ing

the

orig

inal

film

s.

Part

icip

ants

use

d th

e fil

m fo

r th

eir o

wn

prob

lem

sol

ving

9/12

(75%

)

TAB

LE 1

 (C

ontin

ued)

(Con

tinue

s)

     |  9POSSELT ET aL.

No.

Stud

y/re

fere

nce

Coun

try

Med

ia ty

pe: e

.g.

docu

men

tary

, film

; fic

tion/

non

-fic

tion

Stud

y ai

ms

Sam

ple

size

and

ch

arac

teris

tics

Rele

vant

out

com

e m

easu

res

Key

findi

ngs r

elat

ed to

impa

ct

on s

uici

de re

late

d va

riabl

es

Criti

cal

appr

aisa

l sc

ore

15Ti

ll, B

., N

iede

rkro

tent

hale

r, T.

, Her

bert

h, A

., V

itouc

h,

P., &

Son

neck

, G. (

2010

). Su

icid

e in

film

s: T

he im

pact

of

sui

cide

por

tray

als

on

nons

uici

dal v

iew

ers'

wel

l-be

ing

and

the

effe

ctiv

enes

s of

cen

sors

hip.

Sui

cide

&

Life

-thr

eate

ning

Beh

avio

r, 40

, 31

9–32

7.

Aus

tria

Fict

ion

- film

s‘It

's M

y Pa

rty’

or ‘

The

Fire

W

ithin

’ or ‘

Phen

omen

on’

Wha

t is

the

effe

ct o

f sui

cide

fil

ms

and

cens

ored

film

s on

vie

wer

s' em

otio

nal a

nd

men

tal s

tate

?

n =

150

F =

95

M =

55

(Mea

n ag

e 36

.05

year

s)C

auca

sian

30 p

artic

ipan

ts p

er

grou

p

Beck

er m

ood

scal

e;A

djec

tive

chec

k lis

t (a

ctiv

atio

n an

d in

ner

tens

ion)

;Se

lf-es

teem

sca

le;

Satis

fact

ion

with

life

sc

ale;

Dep

ress

ion

scal

e;Su

icid

ality

;A

ttitu

des

to s

uici

de;

Empa

thy

(Inte

rper

sona

l Re

activ

e In

dex)

;Id

entif

icat

ion;

Qua

lity

of re

latio

nshi

p w

ith p

aren

ts.

Det

erio

ratio

n of

moo

d an

d an

in

crea

se in

inne

r ten

sion

and

de

pres

sion

sco

res

afte

r vie

win

g th

e fil

ms,

follo

wed

by

a ris

e in

se

lf-es

teem

and

life

sat

isfa

ctio

n an

d a

drop

in s

uici

dalit

y.N

o si

gnifi

cant

diff

eren

ces

betw

een

film

gro

ups.

Neg

ativ

e ef

fect

s w

ere

grea

ter t

he m

ore

a su

bjec

t ide

ntifi

ed w

ith th

e pr

otag

onis

t

10/1

2 (8

3%)

16Zi

mer

man

, A.,

Cay

e, A

., Zi

mer

man

, A.,

Salu

m, G

. A

., Pa

ssos

, I. C

., &

Kie

ling,

C

. (20

18).

Revi

sitin

g th

e W

erth

er E

ffec

t in

the

21st

Cen

tury

: Bul

lyin

g an

d su

icid

ality

am

ong

adol

esce

nts

who

wat

ched

‘1

3 Re

ason

s W

hy’. J

ourn

al o

f Am

eric

an A

cade

my

of C

hild

&

Adol

esce

nt P

sych

iatr

y, 57

, 61

0–61

2.

Braz

ilFi

ctio

n –

web

ser

ies—

‘13

Reas

ons

Why

’, firs

t se

ries

Doe

s w

atch

ing

‘13

Reas

ons

Why

’ inc

reas

e SI

?n

= 2

1,06

2C

ontr

ol g

roup

: n

= 2

,323

Recr

uitm

ent

thro

ugh

Face

book

fo

r Uni

ted

Stat

es

or B

razi

lA

ge =

12–

19 y

ears

Mos

tly fe

mal

e an

d 15

–17

year

s

Surv

ey re

-bul

lyin

g an

d SI

;Pa

tient

Hea

lth

Que

stio

nairr

e−2

(PH

Q−2

)—de

pres

sion

, su

icid

al id

eatio

n.

Thos

e w

ith h

isto

ries

of p

ast S

I ex

perie

nced

16.

5% m

ore

SI;

59.2

% le

ss S

I; 24

.2%

no

chan

ge.

Thos

e w

ithou

t a h

isto

ry o

f SI

had

a 6.

4% in

crea

se in

sui

cida

l th

ough

ts.

Dec

reas

es in

SI w

ere

mor

e pr

onou

nced

in th

ose

with

no

depr

essi

ve s

ympt

oms.

Part

icip

ants

with

dep

ress

ion

and/

or p

rior s

uici

dal i

deat

ion,

co

uld

be m

ore

nega

tivel

y af

fect

ed b

y w

atch

ing

the

show

. Th

ere

was

a n

egat

ive

affe

ct fo

r hi

gh ri

sk in

divi

dual

s.Pr

e-ex

istin

g ps

ycho

path

olog

y is

a c

ausa

l cha

ract

eris

tic fo

r SI

afte

r wat

chin

g th

e sh

ow.

4.7%

of t

hose

with

out S

I fel

t m

ore

SI a

fter

wat

chin

g th

e sh

ow.

6/8

(75%

)

Abb

revi

atio

ns: E

D: e

mer

genc

y de

part

men

t; SH

ID: S

elf-

harm

with

inte

nt to

die

; SI:

Suic

idal

idea

tion.

TAB

LE 1

 (C

ontin

ued)

10  |     POSSELT ET aL.

Sonneck, & Niederkrotenthaler, 2015; Till, Vitouch, Vitouch, Herberth, Sonneck, & Niederkrotenthaler, 2013), six studies analysed the effect of watching the web series 13 Reasons Why (Arendt, Scherr, Pasek, Jamieson, & Romer, 2019; Ayers et al., 2017; Cooper, Bard, Wallace, Gillaspy, & Deleon, 2018; Hong et al., 2018; Rosa et al., 2019; Zimerman et al., 2018), three studies analysed documentaries (King et al., 2018; Retamero, Walsh, & Otero-Perez, 2014; Schlichthorst et al., 2018) and one study looked at the suicidal content of a music video (Scherr & Reinemann, 2011).

3.2 | Participant characteristics

Out of the 16 studies, 11 focussed on adults (Arendt et al., 2019; King et al., 2018; Pouliot et al., 2011; Retamero et al., 2014; Scherr & Reinemann, 2011; Schlichthorst et al., 2018; Stack et al., 2014; Till et al., 2010, 2015; Till, Vitouch, et al., 2013; Till, Vitouch, et al., 2013), two on adolescents and young adults (Rosa et al., 2019; Zimerman et al., 2018), one on children and young adults (Cooper et al., 2018), one on children, young adults and parents (Hong et al., 2018) and one study focussed on internet searches (Ayers et al., 2017).

Participant gender was reported in 13 studies. Combining stud-ies that reported participant gender reveals a sample of 31,630 participants and shows that the gender distribution was overwhelm-ingly female (83% females, 17% males). Two studies included male participants only (King et al., 2018; Schlichthorst et al., 2018) and two large scale surveys reported that the majority of their partici-pants were female (89.4% female in Zimerman et al., 2018 and 84% female in Rosa et al., 2019).

3.3 | Study methods

Six studies were randomised control trials (RCTs; King et al., 2018; King et al., 2018; Scherr & Reinemann, 2011; Till et al., 2010, 2015; Till, Vitouch, et al., 2013; Till, Vitouch, et al., 2013), five studies were quasi-experimen-tal (Arendt et al., 2019; Ayers et al., 2017; Cooper et al., 2018; Retamero et al., 2014; Schlichthorst et al., 2018), four studies were cross-sectional (Pouliot et al., 2011; Rosa et al., 2019; Stack et al., 2014; Zimerman et al., 2018) and one study was a case series (Hong et al., 2018).

3.4 | Critical appraisal

Critical appraisal revealed four studies with ‘exceptionally high quality’ (100%) scores as determined by the tool checklists (Hong et al., 2018; King et al., 2018; Pouliot et al., 2011; Schlichthorst et al., 2018). Six studies scored ‘high quality’ (80%–90%) (Arendt et al., 2019; Scherr & Reinemann, 2011; Stack et al., 2014; Till et al., 2010, 2015; Till, Vitouch, et al., 2013). Six studies scored ‘moderate to high quality’ (70%–80%) (Ayers et al., 2017; Cooper et al., 2018; Retamero et al., 2014; Rosa et al., 2019; Till, Vitouch, et al., 2013; Zimerman et al., 2018).

3.5 | Key findings

The key potential impacts of moving-image media portrayals of sui-cide on the viewer included suicidal ideation and behaviour; suicide literacy (knowledge/awareness, help-seeking, attitudes); and emo-tional distress and psychological impacts. Table 1 outlines key infor-mation of the included studies.

3.6 | Suicidal ideation and behaviour

Overall, nine studies (53%) found evidence for potential increases in suicidal ideation and behaviour following exposure. Four studies (24%) found no change in suicidal ideation and behaviour follow-ing exposure. Three studies (18%) found evidence for potential de-creases in suicidal ideation and behaviour following exposure.

Cross-sectional data suggested that exposure to films portray-ing suicide can lead to increased consideration of imitating the suicidal behaviour, or actual suicide attempts (Pouliot et al., 2011; Stack et al., 2014; Zimerman et al., 2018). This included individuals reporting that they had considered imitating the suicidal act of a protagonist in a film (Pouliot et al., 2011), evidence that cumula-tive exposure to films portraying suicide could increase likelihood of a suicide attempt being reported by nearly 50% with each ad-ditional movie exposure (Stack et al., 2014) and increased suicidal ideation reported after watching 13 Reasons Why (Zimerman et al., 2018).

Characteristics found to influence these relationships in-cluded histories of suicidal ideation (Pouliot et al., 2011; Zimerman et al., 2018), and greater dissociation and thought suppression levels (Pouliot et al., 2011).

A case series analysis also found evidence of increased suicidal risk among young people following 13 Reasons Why (Hong et al., 2018). Among this sample (n = 87) 13 participants believed the series glori-fied or normalised suicide, however, 12 participants did not.

Several quasi-experimental studies (Arendt et al., 2019; Ayers et al., 2017; Cooper et al., 2018) also reported evidence of increased suicidal ideation and behaviour associated with the Netflix web se-ries 13 Reasons Why. For example, hospital admissions for suicidal ideation and self-harm with intent to die were found to be signifi-cantly higher than predicted (based on a 5-year prediction model) following the release of the series (Cooper et al., 2018). Increased numbers of people searching the internet for ways to die by sui-cide such as using search terms ‘how to commit suicide’ and ‘how to kill yourself’ were also observed following the release of the series (Ayers et al., 2017).

Finally, in a study where participants completed surveys pre- and post-viewing the second season of the series, increased suicidal ide-ation and risk of suicide was observed among those who reported being exposed to only some or part of the second season when com-pared to those who watched the entire series (Arendt et al., 2019). In this study, participant characteristics that were reported to influ-ence the relationship included those with lower levels of education

     |  11POSSELT ET aL.

and those who were current students. These groups were more likely to exhibit increased suicide risk (Arendt et al., 2019).

Identification with the protagonist was found to be a relevant factor by several researchers. Hong et al. (2018) found that par-ticipants who more strongly identified with the protagonist in 13 Reasons Why, reported higher levels of suicidal ideation and more strongly believed that the series contributed to their increased risk. Regarding film media, there is some inconsistency in findings re-garding whether identification with the protagonist is an influencing factor in the relationship between media portrayal of suicide and outcome. Across the three RCTs conducted by Till and colleagues where participants were randomised to different film conditions, two of the studies found no relationship between identification with the protagonist and viewer suicidality, however, the most recent of these studies (Till et al., 2015) found that identification was signifi-cantly associated with baseline suicidality and those with a stron-ger identification with the protagonist experienced the greatest increase in suicidality after exposure to the film which contained the protagonist's suicide.

3.6.1 | No observed changes in suicidal behaviour

Not all studies found evidence of increased suicidality among viewers and several studies have found either no increase in sui-cidal ideation or behaviour as a result of the media portrayal. For example, the study conducted by Scherr and Reinemann (2011) found no differences between the two groups on self-reported su-icide risk following one group viewing a music video that ended in a graphic depiction of a suicide, however, they did find that partici-pants in the experimental group rated the suicide risk for others as higher than those in the control group, suggesting a ‘presumed Werther effect’.

3.7 | Suicide literacy: knowledge, awareness, attitudes, help-seeking and helping others

Five studies (30%) found evidence for positive impacts such as in-creased suicide literacy (suicide awareness, stigma reduction, more positive attitudes and help-seeking behaviour) following exposure.

Some researchers found evidence of beneficial effects of view-ing the 13 Reasons Why series, particularly among certain viewers such as those who watched the entire second season, female view-ers and those who reported greater suicidal ideation and who sub-sequently reported increased help-offering behaviour. For example, in addition to increased internet searching of ways to die by suicide, Ayers et al. (2017) found the release of 13 Reasons Why to lead to increases in numbers of people searching for ‘suicide prevention’ and ‘suicide hotlines’. Arendt et al. (2019) found that those who watched the entire second season of 13 Reasons Why experienced higher lev-els of optimism, and females who watched the series reported re-duced suicide acceptance. Exposure to other suicidal stories among

viewers was associated with visiting the help-site which accompa-nied the second season. Finally, those viewers who reported greater suicidal ideation were more likely to report helping suicidal others (Arendt et al., 2019).

Increased help-seeking among young people and adults was reported in some of the literature regarding documentaries and television series. Significant increases (from baseline to follow-up) in help-seeking were observed in an RCT (n = 337) where the intervention group watched a documentary (Man Up) regarding masculinity, mental health and suicidality, which portrayed men speaking about their experiences of mental distress and suicid-ality (King et al., 2018). However, in another study by the same researchers (Schlichthorst et al., 2018), found that viewing Man Up did not increase likelihood of help-seeking. It should, however, be noted that although this study had a greater sample size (n = 476 pre-viewing and n = 619 post-viewing), it was less methodologi-cally rigorous than the RCT and rather than surveying the same individuals before and after viewing the documentary as King et al. (2018) did, Schlichthorst et al. (2018) did not follow the same participants over time.

In the Hong et al. (2018) study of young people presenting to emergency departments, they found that equal proportions of par-ticipants reported that 13 Reasons Why made them both more (28%) and less (28%) likely to talk to others about their mental health and suicidal thoughts (Hong et al., 2018). However, 80% reported discuss-ing the series with their friends, 34% reported discussing with their parents and of the participants who spoke with their parents about the series, n = 7 reported discussing the topic of suicide. Therefore, the series clearly prompted some discussion and depending on how this conversation was received, might determine whether such dis-cussion could lead to desirable outcomes, for example, help-seeking attitudes or stigma reduction (Hong et al., 2018).

In another study of a documentary portraying suicide, The Bridge was found to increase understanding of suicide and significantly reduce the belief that there is nothing one can do to help if some-one has a suicide plan, among a group of medical students (n = 180; Retamero et al., 2014).

3.8 | Emotional and psychological changes

Emotional distress and other psychological impacts of suicide por-trayals were reported in several studies; however, emotional distress and these other constructs did not necessarily correspond to sui-cidal ideation or behaviour.

In a large cross-sectional survey of young people (n = 7,004) who were asked questions about changes in mood and suicidality resulting from viewing 13 Reasons Why, it was found that 23.7% re-ported a worsening of mood after viewing. Importantly, worsening of mood was related to increased risk of suicide among this sample (Rosa et al., 2019). Those participants who reported past suicidal ide-ation, self-harm and suicide attempts reported a greater worsening of mood.

12  |     POSSELT ET aL.

4  | DISCUSSION

This review examined the evidence regarding the impact of por-traying suicide in moving-image fiction and non-fiction media on the consumer/viewer of that media. Given that the emphasis of previous reviews has been on looking at the impact of mixed and varied forms of media portrayals of suicide, we deemed it impor-tant to consider the specific impacts of screen/ moving-image portrayals of suicide on viewers. This was considered to be of im-portance in contemporary society given the increased availability of moving-image media through internet screening of television, movies and documentaries, and given changes in the ways in which viewers engage with this media, for example, by so called ‘binge watching’.

From a total of 16 articles that were identified in the literature from the past 10 years, the majority of these were in relation to fictional media (n = 13) versus non-fiction (n = 3). The literature highlighted that the portrayal of suicide in moving-image media can impact on a viewer's suicidal ideation and behaviour, suicide literacy, such as knowledge/awareness and help-seeking attitudes and be-haviour leading to emotional distress and psychological impacts. Key individual differences that may influence the relationship between viewing a screen portrayal of suicide and subsequent suicidality in-clude level of identification with the protagonist in terms of social demographic similarities and levels of empathy that the viewer has towards the protagonist. Pre-existing histories of suicidal ideation and suicidal behaviour also appear to be important considerations as these viewers may be more vulnerable to the negative impacts, however, depending on the way in which suicide is portrayed (e.g. a protagonist overcoming a suicidal crisis and seeking help), may also increase the possible beneficial effects of the portrayal such as in-creased help-offering to suicidal others.

It is important to note that the relationship between exposure and outcome is clearly not a simple one, as some studies found that portrayals of suicide could lead to both increases and decreases in suicidal ideation and behaviour depending on several factors including the individual characteristics of the viewer. Individuals with histories of past suicidal ideation and suicide attempts may be more affected by portrayals of suicide in screen media. For exam-ple, Till et al. (2015) found that a fictional film with a suicide scene increased suicidality among those with higher baseline vulnera-bility and suicidal ideation, versus no change in overall suicidality for the sample when considered as a whole. However, there were inconsistencies in this finding. For example, for participants with histories of suicidal ideation in the study by Zimerman et al. (2018), 59.2% reported a reduction in suicidal ideation after watching 13 Reasons Why (season 1). The survey by Zimerman et al. (2018) is limited by the cross-sectional design making us unable to draw conclusions about causal directions and by retrospective report-ing (after having watched the series). The sample was also mostly female (89.4%) and had a mean age of 15 years, so the findings may be mostly relevant to young females with histories of suicidal ideation.

The findings regarding identification, although inconsistent, may add to the understanding of how characteristics of the viewer influ-ence the relationship between portrayal and outcome. Some find-ings reported that stronger identification with the protagonist leads to increased likelihood of experiencing adversity as a result of the exposure. While Till, Vitouch, et al. (2013) found no association be-tween identification and suicidality, they did find that identification is not always in relation to socio-demographic similarity but can relate to the level of empathy that the viewer possesses. Till et al. (2015) found that baseline suicidal ideation was strongly associated with level of identification with the protagonist and that those who more strongly identified with the protagonist, experienced a greater in-crease in suicidality resulting from the exposure. Viewer similarity to the protagonist and viewers' depression level has been previously found to influence interest in the story (print media) with depression in the viewer increasing intention to read similar material in the fu-ture through identification with the role model (Niederkrotenthaler, Arendt, & Till, 2015).

In the study by Scherr and Reinemann (2011), no direct im-pact of the graphic depiction of suicide in the music video was found. The lack of a direct adverse impact could be time-related, given that the length of exposure was relatively short. However, previous research has found that exposure to media reporting of suicide, including through television news stories can lead to con-tagion effects, and presumably these news stories can be relatively short. Of the studies included in this review, consideration of the duration of the exposure to suicidal content was not adequately explored.

The heterogeneity of types of suicide portrayals is an import-ant limitation of this review and of the evidence in general. This is beyond length of exposure and whether there are Papageno effects or positive messages embedded within the film/series/documentary. Outcome of the protagonist is also an important factor to consider as evidenced by the studies by Till et al. (2015) and Arendt et al. (2019). Past research has found that news sto-ries about completed suicides rather than ideation and attempts were associated with greater subsequent suicidal behaviour (Pirkis et al., 2006).

The research also examines potential positive impacts of por-trayal of suicide in media in terms of suicide awareness, stigma re-duction, modelling of preferred language to use when talking about suicide and help-seeking behaviour. The findings that those who viewed the entire second season of 13 Reasons Why experienced benefits and were at lower risk of suicide than those who viewed only some of the season suggests that there was an element that counteracted the suicidal content that could be accessed by watch-ing the season in its entirety or the end part of the season. Arendt et al. (2019) considered whether the positive message of the protag-onist's mother saying that ‘staying alive is always better than ending it’, which appeared to help another key character overcome his own suicidal thoughts, was an important protective element. This the-ory is also consistent with the findings from Till et al. (2015) that for those randomised to view the film featuring the protagonist

     |  13POSSELT ET aL.

positively coping with a suicidal crisis, those with higher suicidal tendencies experienced more beneficial effects such as increased satisfaction with life.

There is evidence that fictional stories portraying suicide result in less imitation effects than non-fiction (Stack, 2005). Interestingly, of the non-fiction studies included, the results did not find evidence of negative impacts of portrayals of suicide, however, given the large body of work that has found non-fic-tion television or internet news reporting of deaths by suicide to be associated and followed by increases in imitative suicidal behaviour, the finding regarding non-fiction media in this re-view is more likely due to the low numbers of studies examining moving-image media on its own (and within the last 10 years) than any real differences between fiction and non-fiction. Furthermore, the studies by King et al. (2018) and Schlichthorst et al. (2018), although robust, did not measure personal suicid-ality and the findings relevant to this review were limited to suicide literacy, specifically, help-seeking behaviour. It should also be noted that given that a large proportion of the evidence included in this review related to the series 13 Reasons Why, for which the study participants were generally adolescents and majority female, our findings might be particularly pertinent to young females.

4.1 | Implications and future research

There is evidence for imitation and contagion effects arising from moving-image media portraying suicide which appears to be stronger under certain conditions. Taken together, these studies highlight that for some people and for some types of ex-posure, the risk of these portrayals leading to harmful outcomes are higher. Every viewer engages differently with media and this alters the potential outcomes. For individuals with higher lev-els (or histories) of depression, suicidality, dissociation, thought suppression and levels of identification with the protagonist, the potential harmful effects of viewing such media may be greater. In some instances, and for some people, narratives of hope, seeking help and portrayals of an individual overcoming or positively coping with a suicidal crisis can lead to positive outcomes. However, it remains unclear whether these potential benefits are enough to outweigh the potential harmful effects, for which there appears to be a larger evidence base. The WHO have recently published a resource regarding screen and stage portrayals of suicide which identifies ways in which positive im-pacts of portrayals of suicide in such media can be increased, and the potential negative impacts can be minimised (World Health Organization, 2019). Consistent with our findings, they suggest portrayals emphasise the importance of seeking help, looking after oneself and others, and shares a message of hope. More research is clearly needed on the impact of portraying suicide in non-fiction screen media such as documentaries. The current evidence makes it difficult to determine the impact of

documentary portrayals of suicide on viewer suicidality due to the current studies regarding non-fiction documentaries not di-rectly measuring suicidal ideation or behaviour in the viewers and instead only measuring suicide literacy outcomes (aware-ness, attitudes, help seeking).

4.2 | Strengths and limitations

The strengths of this review include the comprehensiveness of the searches conducted, the specific focus on this type of media and the rigorous study selection process. The review team were inde-pendent researchers with no conflict of interest in the topic. The articles included in this review were of varying methodological qual-ity and therefore the findings need to be considered in light of this. The reliance on self-reported outcome measures in almost all the studies included may be seen as a limitation, however, the self-re-port measures used were almost all reliable and valid measures of the outcomes of interest, for example, suicidality. Because of the rapid review methodology enabling a more efficient search, the nar-rowed date range and exclusion of studies not published in English or grey literature may mean that some relevant studies may have been excluded.

5  | CONCLUSION

The literature reported varying impacts of portrayals of suicide through moving-image media such as increased suicidal ideation and behaviour, as well as positive impacts such as increased help-seeking behaviour. While there is limited evidence which focuses specifically on the impact of moving-image media, the studies included in this review highlight concerning trends regarding the impact of media portraying deaths by suicide on subsequent suicidality. However, positive impacts on suicide awareness, literacy and help-seeking be-haviour were also identified.

ACKNOWLEDG EMENTThis work was supported by the South Australian Premier's Advocate for Suicide Prevention and the Government of South Australia.

CONFLIC TS OF INTERE S TThe authors have no conflicts of interest.

ORCIDMiriam Posselt https://orcid.org/0000-0003-1668-9933 Heather McIntyre https://orcid.org/0000-0001-8475-769X Nicholas Procter https://orcid.org/0000-0002-7289-3165

T WIT TERMiriam Posselt @MiriamPosselt Heather McIntyre @HeatherEaton01 Nicholas Procter @MHReasearchUniSA

14  |     POSSELT ET aL.

R E FE R E N C E SArendt, F., Scherr, S., Pasek, J., Jamieson, P. E., & Romer, D. (2019). Investigating

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How to cite this article: Posselt M, McIntyre H, Procter N. The impact of screen media portrayals of suicide on viewers: A rapid review of the evidence. Health Soc Care Community. 2020;00:1–14. https://doi.org/10.1111/hsc.13112