In 2016, a half million people were treated in U.S. emergency departments (EDs) as a result of self-harm. 1 Not only is self-harm a major cause of morbidity in the U.S., but it is also one of the best predictors of suicide. Given that approximately 40% of suicide decedents visited an ED in the year prior to their death and that the majority of medically-serious self-harm patients are treated in EDs2, EDs serve as a critical setting in which to monitor rates and trends of suicidal behavior. To date, the majority of ED data for self-harm are generally two to three years old and thereby can only be used to describe historical patterns in suicidal behavior. Thus, in 2018, a syndrome definition for suicide attempts and suicidal ideation (SA/SI) was developed by the International Society for Disease Surveillance (ISDS) Syndrome Definition Committee in conjunction with Centers for Disease Control and Prevention (CDC) staff, allowing researchers to better monitor recent trends in medically treated suicidal behavior using data from the CDC's National Syndromic Surveillance Program (NSSP). These data serve as a valuable resource to help detect deviations from typical patterns of SA/SI and can help drive public health response if atypical activity, such as geospatial or temporal clusters of SA/SI, is observed. Such patterns may be indicative of suicide contagion (i.e., exposure to the suicide or suicidal behavior of a friend or loved one, or through media content, that may put individuals at increased risk of suicidal behavior). Research has demonstrated that suicide contagion is a real phenomenon. 3 13 Reasons Why is a Netflix series focused on social, school, and family-related challenges experienced by a high school sophomore; each episode in the 13-episode series describes a problem faced by the main character, which she indicates contributed to her decision to die by suicide. The series premiered March 31, 2017 and is rated TV-MA by TV Parental Guidelines4 (may be unsuitable for those under age 18 years due to graphic content). Nevertheless, the series has become popular among youth under 18 years of age. Of note, in the final episode, the main character's suicide by wrist laceration is graphically depicted. Following the premiere of the series, researchers and psychologists across the U.S. expressed concern that this graphic depiction of suicide could result in a contagion effect, potentially exacerbating suicidal thoughts and behavior among vulnerable youth viewers. To date, the only empirical data demonstrating the potential iatrogenic effects of this graphic portrayal of suicide comes from a study of Google Trends data demonstrating an increase in online suicide queries in the weeks following the show, with most of the queries focusing on suicidal ideation (e.g., how to commit suicide, how to kill yourself).5 However, there has been no study to examine changes in nonfatal self-harm trends following the series debut.
Objective: To describe national-level trends in nonfatal self-harm and suicidal ideation among 10-19 year old youth from January 2016 through December 2017 and examine the impact of popular entertainment on suicidal behavior.