Since 13 Reasons Why debuted on Netflix two years ago, some critics and social scientists have said the popular teen series glorifies suicide and puts impressionable young people at risk.
On Monday, they received perhaps their strongest evidence yet with the release of a study showing abnormally high rates of teen suicide in April 2017, the first month the show was available.
The study, which researchers from Nationwide Children's Hospital in Columbus, Ohio, conducted, to explore the 13 Reasons effect, found 58 additional suicide deaths among 10- to 17-year-olds that April than would have been expected given both the trend in the months leading up to the period and projections based on a host of scientific factors.
"I was disheartened when I saw the results," said Jeffrey A. Bridge, the lead author of the study, which will be published in the Journal of the American Academy of Child & Adolescent Psychiatry. "It confirmed our suspicions" of an association.
The study also found aberrantly high suicide numbers for that same demographic through the end of 2017 - a total of 195 deaths more than the models predicted. There was also at least a 35 percent increase in suicide deaths among 10- to 17-year-olds in April 2017 compared with the same month in each of the previous two years.
"April 2017 is an outlier in every way," Bridge said. The increase was concentrated among teen boys; there was no evidence of an increase among girls or anyone older than 17.
After debuting on March 31, 2017, 13 Reasons was heavily watched on Netflix in both the weeks following and through the end of the year, according to the company. Executives have called it one of the most binged shows on the service.
The study used several methods of research to examine suicide patterns in the five-year period beginning in January 2013, when the United States saw 180,655 deaths by suicide among people ages 10 to 64. Those figures included the suicide-death numbers leading up to the release - a "step-up" of 28.9 percent that April was detected - and expected results given historical and other trends. Bridge and several colleagues are with the Research Institute at Nationwide Children's Hospital and the Ohio State University College of Medicine in Columbus. Experts at Carnegie Mellon University, West Virginia University and the National Institute of Mental Health in Bethesda, Maryland, were also involved in the study.
The results touch on difficult questions about streaming and violence, coming at a time when Netflix has been under fire from experts for leaning on morbid content to attract subscribers. The service has developed a reputation for producing and promoting such content to a greater extent than many of its competitors. Its shows are also watched in intimate settings, often one person holding a screen closer than a traditional television, increasing concerns.
Created by Brian Yorkey, 13 Reasons examines the aftermath of the death of the teenage character Hannah, who killed herself for a complex set of reasons, which she communicates from beyond the grave with a series of audio diaries.
While Netflix and its supporters say the show is a hard-hitting looking at a difficult subject, critics have argued the series glamorizes suicide as an answer to life's challenges and a way to settle scores, gain attention and communicate unheard messages. They say this puts viewers at risk for "suicide contagion," in which certain types of media images about suicide increase the likelihood of suicide ideation and attempts. A second season debuted last year, and a third is in the works.
The study offers some of the most concrete numbers to date that the show's release period is associated with higher suicides among teenagers. Earlier studies had uncovered more circumstantial data, such as an increase in Google search queries in the months after the show's premiere. A study published last week by the Annenberg Public Policy Center at the University of Pennsylvania of some 700 people in an older demographic - ages 18 to 29 - involving a different season found a more mixed outcome.
Asked for comment about the Nationwide report, a Netflix spokesman said: "We've just seen this study and are looking into the research, which conflicts with last week's study from the University of Pennsylvania. This is a critically important topic and we have worked hard to ensure that we handle this sensitive issue responsibly," the spokesperson added.
The Penn survey found that respondents who specifically watched the second season were less likely to consider suicide if they watched it to the end, though more likely to do so if they didn't finish watching the season.
After the early criticism, Netflix added a cast message to the show saying that "if you are struggling with [mental-health] issues yourself, this series may not be right for you or you may want to watch it with a trusted adult." There are no known plans yet to change the messaging regarding the debut of the third season in the wake of the study.
The Nationwide researchers were careful to say they had found no causal link between Reasons and suicide, merely a correlation with the months the show was available. The study did not explore, for instance, how many of those teens who committed suicide watched the show.
Researchers said there was no definitive explanation for why the increase was higher among boys and not girls - an anomaly given 13 Reasons' female lead character - though Bridge noted that suicide deaths are generally more common for teen boys by a measure of more than 3 to 1. The study did not measure suicide attempts, which are historically higher for girls.
They also said that the book on which 13 Reasons is based was read widely by girls years before the show's release, possibly desensitizing them to suicide messages when the Netflix adaptation came on.
Dan Reidenberg, a psychologist who runs Suicide Awareness Voices of Education, a Minnesota-based mental-health organization, said that he found the results of the Nationwide study concerning.
"It is clear that for younger people and those vulnerable, especially those highly influenced by media, Season 1 had a serious impact on them, too many in negative ways," he told The Washington Post. Reidenberg consulted on the first season of the show but has offered a measured criticism of the show's effects in the time since.
In addition to supporting resources such as the National Suicide Prevention Hotline, authors of the study advocate that shows follow guidelines about how to discuss suicide - while acknowledging the inherent limitations in asking Hollywood producers to change their creative approach.
"Media and entertainment professionals understandably value freedom of expression and might equate responsible messaging with censorship," the study said. "Nevertheless, [the] study findings should encourage dialogue and reflection within the entertainment industry about balancing creative license and [the medical principle of] 'first do no harm.'"
It noted that Netflix in particular needed to be more vigilant - as did parents who subscribe to the service.
"The release of 13 Reasons Why was associated with a significant increase in monthly suicide rates among U.S. youth aged 10 to 17 years," it said. "Caution regarding the exposure of children and adolescents to the series is warranted."
Where you can get help:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call 111.
If you need to talk to someone, the following free helplines operate 24/7: