They’re calling it the new must-see series on Netflix. But it’s giving pause to some schools, parents and mental health experts. 13 Reasons Why, whether you like it or not, has sparked a crucial – and perhaps overdue – conversation about youth suicide.

Based on a young adult (YA) novel of the same name, 13 Reasons Why is a story about a young woman, Hannah, who kills herself and creates 13 audio tapes to explain why for that many people.

Dr. Kristin Rager, an adolescent medicine specialist at The Children’s Hospital at TriStar Centennial in Nashville, who works with young people ages 10 to 25, read the book (which was published in 2007) and watched the show after patients of hers brought it up in discussion.

“Anytime there’s a book, show, song or whatever that adolescents are talking a lot about, I like to read it and watch it, too, so I can have meaningful conversations, and guide the parents,” Dr. Rager said.

13 Reasons Why is an interesting concept because it’s pretty universal after someone commits suicide that everyone around them wonders why, why, why, and what could they have done differently. The praise for the show, which I agree with, is that it has created a nationwide ‘buzz’ on a topic that people need to talk about. Suicide is a vital health issue that has too long been in the dark corners,” she added.

Clark Flatt, who lost his son, Jason to suicide at 16 years old, and later founded The Jason Foundation, which partners with HCA in 13 centers across the country, believes the series has its pros and cons.

“Overall, it is good that we are talking about suicide. It is now the second leading cause of death for youth ages 10 to 24 in our nation,” Flatt said. “However, the way in which it is presented in the series causes me some concern, especially if young people view it by themselves. Suicide is presented almost as a natural outcome of someone struggling as Hannah struggled (in the series).”

However, there is a way out. The Jason Foundation provides programs and resources that educates and equips individuals with tools to help students, educators and communities recognize “warning signs” and react responsibly.

If the goal of 13 Reasons Why is to talk openly about suicide, Dr. Rager is of the opinion that it has accomplished that very well. Now that we’ve started a conversation, what can we do differently so there is not another young person, in real life, who attempts or commits suicide?

Let’s get into it.

What’s the difference between the 13 Reasons Why novel and series?

The book is different in that 1) it’s in your imagination. You’re creating a visual of what suicide looks like and, in the book, Hannah, actually overdoses on pills. In the Netflix version she commits suicide by cutting and there’s a very, very graphic and prolonged scene of her death that’s difficult to watch. I know the creators did that on purpose. What I have read is that (Executive Producer) Selena Gomez (an American actress and singer) and the producers wanted to create and draw attention to the national public health crisis of youth suicide. So I appreciate their mission to create a visual, while unsettling, to draw attention to this vitally important issue.

Should parents watch this series?

My first piece of advice is to grown-ups – you need to watch this. Parents need to watch it because their teens are watching it and talking about it, and it is graphic. It also deals with issues that teenagers are faced with every day, beyond death.

An ideal situation would be that parents watch the series before their adolescent does. The reason I say this is because they need to decide if their teenager can handle it or not. There’s a graphic rape and graphic suicide scene. It’s hard to watch as an adult, but would be incredibly traumatic as a young person.

Second best would be if the parent and the young person watched it together.

Third, if the adolescent has already watched it, a parent needs to watch it as soon as possible and have a conversation. I would start the conversation with a question: “What do you think could have happened differently so at the end Hannah doesn’t kill herself?” “Can you think of one reason why NOT?”

As with many things, if you ask the adolescent how they might solve the problem, they come up with brilliant solutions. I think that’s the best way to go about this.

What concerns you about the series?

I have had people tell me that they purposely cannot binge watch it because it is so intense. Even as an adult who deals with these issues all day, every day – I have chosen to watch only one episode at a time. And I have watched all except the very last episode – the suicide. The reason I know about the graphic ending is because I’ve had many patients describe it to me and explain how traumatic it was for them.

The fact that patients feel comfortable bringing it up to me is wonderful as a physician, and perhaps that’s the missing piece in the show. The professional in this young woman’s life (the school counselor) who she goes to with this discussion does not believe her. So my worry is that might discourage young people from coming to me or other professionals to talk about it. Also, I don’t think the series does a great job of is telling those of us out in the world what we could do differently to prevent this from happening to someone we know.

Talk about suicide contagion, or copycats, and what this series could trigger for young people…

People are always afraid to talk about suicide. I have countless people say they’re afraid to bring up the topic because it’s going to give someone the idea to commit suicide. There’s no evidence to support that having a discussion with a young person about suicide will cause them to do it.

However, when suicide is presented in a certain way, especially visual depictions of suicide, it could certainly create situations where young people might commit suicide. That’s the risk with this show, particularly, because the suicide scene is so dramatic.

Based on what I’ve read, they purposely made the scene graphic and drawn out, because they wanted people to see how horrifying suicide is. I worry that this visual depiction may produce the undesired effect of triggering people to potentially engage in that behavior. It’s a legitimate concern, and a concrete reason why parents need to watch it and talk to their teens about it.

After watching 13 Reasons Why, what’s the conversation that you would like to start?

The conversation that I would like to start, especially with young people, is asking the question: How could this story have ended differently? What could have transpired so that this young woman didn’t ultimately kill herself?  What could people around her have done, where at the end of the story, she lives? That’s the version of the story that I would like to see. And I think that’s the interesting conversation that needs to happen next.

What are the risk factors for suicide among teens?

  • Mental illness is the greatest risk factor. If an adolescent or young adult has a personal history of depression, anxiety, suicidality or assault, this should be incredibly triggering for them and quite devastating for them, actually. And that is why young people with mental illness watching this show concerns me.
  • People who have attempted suicide before are at incredibly high risk for attempting again.
  • Having easy access to lethal means;
  • A recent loss, like a break up;
  • Substance use, and,
  • having someone around them commit suicide, which goes back to that contagion theory – that’s a risk factor.

Also, the LBGT youth is a population that I serve and they are at incredibly high risk. Without family support, I would argue that they are the highest risk group for suicide attempts for young people. In our society, many of them do not feel free to be themselves, either within their families or their schools, and the inability to be oneself creates a lot of internalized negativity and places them at such high risk. The best predictor for them to not be high risk for suicide is a strong family support system. That’s well documented.

What are some signs to look for in someone who might be contemplating suicide?

It’s important to say that suicide attempts should never be viewed as something that’s simply attention seeking behavior. It should always be viewed in the context that could potentially end some young person’s life and needs to be taken seriously – period. Whether the person’s intention was to die or not, people who attempt with lethal means, die.

I’ve seen it quoted that four out of five people who committed suicide had outward behaviors that could’ve been recognized. Specifically someone who is:

  • talking, writing or drawing about death or listening to songs about death,
  • discussing how the world might be without them in it,
  • talking about a lack of hope for the future, and
  • withdrawing from things they used to love – family, friends, sports, activities – these are all red flags.

Social media is a place where a lot of these feelings or thoughts get posted. And if young people see things like this posted by their friends, they need to tell an adult. I’ve had patients say to me that they would rather their friend be alive and mad for telling somebody, than not alive. I think that’s a good philosophy to have.

Where can people go to get help?

  • The National Suicide Hotline is an amazing resource: 1-800-273-8255(TALK) or text 741-741
  • The Trevor Project is a suicide hotline for LGBT youth: 1-866-488-7386
  • The Jason Foundation: jasonfoundation.com.
  • National Sexual Assault Hotline: 1-800-656-4673 (HOPE)

Dr. Kristin Rager is an adolescent medicine specialist at The Children’s Hospital at TriStar Centennial, an affiliate of HCA.

HCA is a national community affiliate with The Jason Foundation, which has 13 affiliate offices in various markets across the nation. Together, HCA and The Jason Foundation provide programs and services at no-charge to schools, churches, youth organizations and communities.  For more information on The Jason Foundation visit www.jasonfoundation.com