Experts warned '13 Reasons Why' could lead to suicides. A new study suggests they were right.

When the Netflix series 13 Reasons Why debuted in 2017, suicide prevention experts worried that the show's graphic depiction of suicide might make some vulnerable viewers more prone to increased suicidal thinking and behavior.

A new study of the suicide rate following the show's debut suggests those concerns were more than justified. Researchers found that, among adolescents and teens, 195 additional suicides occurred in the nine months after Netflix released the first season of 13 Reasons Why.

While the study, which was published in the Journal of the American Academy of Child and Adolescent Psychiatry, couldn't establish a causal link between the show and the increase, the researchers used approaches that helped them account for various factors that could affect the suicide rate. That included forecasting models to estimate suicide trends, controlling for seasonal variations in the suicide rate, and comparing the suicide and homicide rates, the latter of which is also influenced by social and environmental events.

The study's analysis looked at the existing and anticipated trends for the suicide rate and found an unexpected spike after the show launched. The finding was limited to only 10- to 17-year-olds; there was no significant association for those 18 and older. A separate study published in 2017 found an association between 13 Reasons Why and a spike in internet searches about suicide and suicide methods.

Critics who've questioned Netflix's decision to show the protagonist's suicide in detail point to research indicating that such portrayals can have a "contagion effect," leading to a temporary rise in the suicide rate. Published guidelines for the media are meant to help reduce this possibility by, in part, avoiding sensationalism.

"I think that any media depiction of suicide should follow the recommended guidelines," said Jeff Bridge, the study's lead author and director of the Center for Suicide Prevention and Research at Nationwide Children's Hospital. "The reason for that is to avoid any harm and, in particular, subsequent suicides."

Netflix has occasionally resisted criticism of its creative decisions, with some of the show's staff and supporters arguing — without scientific evidence — that a gory depiction can raise awareness and act as a deterrent. In the wake of the controversy, one of the show's writers defended the portrayal in a column for Vanity Fair about how his own experience with suicide, and having seen the outcome of a failed attempt firsthand, convinced him not to take his own life.

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In general, it took considerable outcry from experts, advocates, and viewers to persuade Netflix to include detailed content warnings at the beginning of each episode. For the second season of 13 Reasons Why, Netflix offered additional resources to help guide conversations about the show's difficult themes. The third season is currently in production.

"This is a critically important topic and we have worked hard to ensure that we handle this sensitive issue responsibly," a spokesperson for Netflix told the New York Times. The streaming service is looking into the new study.

In addition to the increased suicide rate amongst adolescents and teens, the study also found that boys were most affected. That may seem counter-intuitive given that the show's protagonist is a teenage girl, but suicide attempts made by boys and men are more frequently fatal than those made by girls and women. Though females are more likely to try to take their own lives, researchers did not have data on suicide attempt rates amongst girls during the study's time period.

Bridge said future research could look into those patterns, in addition to better understanding the effect of binge-watching content like 13 Reasons Why on the developing adolescent and teenage brain. It's possible that older viewers weren't similarly affected by the show's depiction of suicide because they possess more mature reasoning or coping skills.

Nicole Mavrides, medical director of the child psychiatry consultation service at the University of Miami Health System, said that while the new study should be taken with a "grain of salt" because it can't prove a causal connection between the show and higher suicide rate, it does provide clinicians like her with useful information.

She and her colleagues actually noticed a spike in the number of adolescents and teens admitted to their department for suicidal behavior following the show's first season; they wondered at the time if the two events were related.

Mavrides, who was not involved in the study, recommends that parents discuss 13 Reasons Why's themes with a child who's watched the show, and urges worried adults to ask kids and teens about whether they've had thoughts about suicide.

Mavrides said the study is an important reminder for clinicians to also talk to parents and patients about the media they're consuming, particularly if that includes 13 Reasons Why.

"This evidence does show us we need to be more cautious about what our kids and teenagers are watching," she said.

If you want to talk to someone or are experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call the National Suicide Prevention Lifeline at 1-800-273-8255. Here is a list of international resources.