Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7189.972 (Published 10 April 1999) Cite this as: BMJ 1999;318:972All rapid responses
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EDITOR - Hawton et al's examination of the effects of a medical
television drama on the incidence and nature of general hospital
presentations for deliberate self-poisoning1 has provoked considerable
interest in medical and popular media. The role of imitation in suicide
attempts is not a new phenomenon. It was named the Werther Effect after
an epidemic of copycat suicides in young men who read Goethe's Die Leiden
des jungen Werther. The effect has been described following television
films depicting fictional suicide2. Television is certainly a powerful
medium in contemporary society.
We have a methodological concern about Hawton's study that was not
addressed in the discussion: the study was not well controlled. They
compared overdose rates between a baseline period prior to the screening
of the drama with each of the three weeks following the index episode.
The authors acknowledge the possibility that an overdose depicted in
a second soap opera six days after the index episode may have had a minor
influence on results. We note that the end of British Summer Time also
coincided with the observed trend of increasing rates of overdoses that
began in the week before the drama was screened. The consequent reduction
in evening daylight represents an external stressor that could be
associated with parasuicide. Although Shapiro et al3 could not confirm
such an association, the temporal relationship of the return to "winter"
timings with the rise in overdose rates raises possibility of this being a
confounding factor that cannot be excluded given the methodology of the
study. Other potential confounding factors include seasonal changes in
weather and temperature and the impact of unrelated items in national and
international news.
A more robust study design would involve a comparison of the change
in overdose rates before and after the November 1996 screening to the
change over a similar period one year earlier or later. An alternative
would be an investigation of any change in overdose rates in a region or
state where the index episode was screened compared with an area where it
was not shown.
Hawton's study was certainly impressive in its co-ordination of data
from many sources. It will continue to stimulate valuable debate on the
responsibilities of media producers in portraying self- harming behaviour.
We believe the results must be interpreted with caution. The limitations
of the study design should be recognised.
Simon JC Davies, Senior House Officer
Mary Atherton, Senior House Officer
Timothy Williams, Senior House Officer
Jethro Purkis, Senior House Officer
Gillian Combe, Senior House Officer
Andrew J Brindley, Senior House Officer
Geraldine McCarthy, Specialist Registrar
Roger Denny, Specialist Registrar
Department of Mental Health, Gloucester House, Southmead Hospital,
Westbury-on-Trym, Bristol
1 Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Phil
G, Bulstrode C. Effects of a drug overdose in a television drama on
presentations to hospital for self poisoning: time series and
questionnaire study. BMJ 1999; 318:972-7.(10 April.)
2 Gould MS, Shaffer, D. The impact of suicide in television movies.
N Engl J Med 1986; 315:690-4.
3 Shapiro CM, Blake F, Fossey E, Adams B. Daylight saving time in
psychiatric illness. J Affect Disord 1990; 19:177-81.
Competing interests: No competing interests
EDITOR- The marked rise in paracetamol overdose following an episode
of Casualty found by Hawton et al. (1) highlights the effects that the
media in general have on health. The findings provide further evidence
that the Media should be more repsonsible in their presentation of health
related issues. It also indicates that their responsibilty extends beyond
factual reporting to all areas. This study suggests that individual
programme makers, for example, could be held accountable for the effects
of their programs. The Internet,
with its abscence of controls, presents even greater risks. I have seen a
number of patients who obtained detailed information about the most
effective suicide techniques from the WWW.
Finally, the effects of the media are often strikingly seen in (the
similarities between) the delusional systems of different psychotic
patients. Recently I have noticed that the plots of the popular American
television programme 'The X-Files' seem to be particularly common in the
content of many patients' delusions. Is there any scope for a prospective
study of delusions of 'alien infestation' following an episode of The X-
files?
Oliver Howes
Senior House Officer
The Maudsley Hospital
Denmark Hill
London SE5 8AX
Competing interests: No competing interests
Sir
I read Hawton et al's survey (BMJ 1999;318:972-7 with interest. The
hypothesis that viewing television drama can affect subsequent behaviour
is one which is difficult ot research and the attempt to do so is
laudable, but I would draw attention to a possible confounding factor in
this study.
Suicide rates are generally held to be seasonally dependent and
therefore looking at rates before and after any discrete point in time
should necessarily take into account natural variations through the year.
I do not think that this paper does that. Of course, such an effect may be
minor, but nevertheless a comparison to data for deliberate self harm
behaviour in the same weeks in previous years should have been performed
or at least discussed as a possibility for future research.
Yours sincerely
Dr Ben Green
Consultant Psychiatrist
Honorary Senior Lecturer
University of Liverpool
Competing interests: No competing interests
It's pretty absurd to make a fuss over a bit of publicity given to paracetamol
overdose when a comprehensive list of
suicide methods is freely available on the internet.
That list describes the effects of paracetamol overdose as "acute toxic
hepatitis, renal failure, cerebral oedema, intra-abdominal bleeding, aspiration
pneumonia, haemophilia". I cannot believe that any realistic depiction
on television of these effects would encourage anyone to choose it as a
method of suicide.
The best way to kill yourself is probably an overdose of heroin - readily
available from a drug dealer.
On that page it says "Heroin costs £20-£30 for half a gram" - which happens
to be the lethal dose recommended in the above list.
Knowledge about suicide methods should be regarded as similar to knowledge
about contraceptive methods. People have the right to sex education,
and they have the right to death education.
The authors do not make clear their general attitude to suicide or free
speech. With a social issue like this you really need an ethical
context to complement the objective analysis - the web provides the authors
with the ideal medium to provide that. I regard it as desirable that
people should question whether they want to live or die, and natural that
some should choose the latter. I believe in the absolute right to
free speech.
Competing interests: No competing interests
EDITOR - The enjoyable articles by Bulstrode and colleagues
(refs 1 and 2) highlighted the fact that many individuals base medical
decisions on incomplete information obtained in television dramas. The
information presented is easily misinterpreted and occurs with all types
of television shows.
In a recent episode of Fox TV's 'The Simpson's', the lead character,
Bart, donated a kidney to his father. During the cartoon, Doctor Hibbard
appropriately points out the long waiting list for cadaveric transplants
is shortened with living related donors. Following the procedure, Bart's
mother turned to him and calmly remarked "You've done a wonderful thing!
You've significantly shortened your life so that someone could extend
theirs for a short period." The cartoon then abruptly ended surely leaving
many (including a patient that I cared for!) with the impression that
there is a significant morbidity and mortality associated with donating a
kidney. The evidence that mortality rates associated with kidney donation
is similar to that of the general population (ref 3) was irrelevant.
The producers of Casualty and The Simpson's know these shows draw a
wide and varied audience but they are not accountable. Whether in a news
story or in a cartoon, information about medical procedures needs to be
accurate as it is clear that people base major life decisions on these
sources. The unfortunate results of portraying suicidal behaviour in
Casualty and harm from organ donation in an American cartoon are
undoubtedly just two examples of many.
Justin Stebbing MA MRCP
Resident in Internal Medicine
The Johns Hopkins Hospital
Baltimore, Maryland 21205
USA Tel. 410-467-6188
jstebb@welchlink.welch.jhu.edu
1 O'Connor S, Deeks JJ, Hawton K, Simkin S, Keen A, Altman DG, Philo
G, Bulstrode C. Effects of a drug overdose in a television drama on
knowledge of specific dangers of self poisoning: population based surveys.
BMJ 1999;318:978-979.
2 Hawton K, simkin S, Deeks JJ, O'Connor, Keen A, Altman DG, Philo G,
Bulstrode C. Effects of drug overdose in a television drama on
presentations to hospital for self poisoning: time series and
questionairre study. BMJ 1999;318:972-977.
3 Najarian JS, Chavers BM, McHugh LE, Matas AJ. 20 years of more of
follow-up of living related donors. Lancet 1992;340:807-810.
Competing interests: No competing interests
Whilst one cannot dispute the association between an increase in the
incidence of self-poisoning and the Casualty case study, one wonders at
the statistics for other suicide rates over this period: did the programme
really precipitate an unprecendented increase in suicide or did it merely
highlight a well documented safety issue over paracetamol? As Simon Weston
recounted on a similarly influential programme last night: "It's not the
fall that kills you, but the sudden stop at the end".
Competing interests: No competing interests
The very interesting article by Hawton et al (1)on the profound
influence that television has on our lives was really captivating. Once
again their results have shown that the arts which supposedly depict life
do have a great influence on our subsequent behaivior. However whether we
should really have a say on the advisibility of the media in portraying
suicidal behaivior is open to question.
Violence has unfortunately always been a part of human life. Whether
it is television, radio, newspapers or even gossip on the streets we have
always been fascinated by violence. The feeding frenzy on the coverage of
the war in Kosovo just seems to prove the point even more. In this
background I wonder whether any kind of censorship of the media would
really lead to any changes in behaivior. And if we were to start making
such changes, where can we really stop? By banning all depiction of
violent behaivior? It does seem like shades of Big Brother to me.
However I do agree that more information should be provided to the
viewers in such serials if at all possible. The storyline doesn't make any
mention of the fact that an effective treatment is available for
paracetamol poisoning, though again I wonder whether such information even
if included would really make any changes in subsequent behaivior.
Paracetamol is now the most common drug used for self poisoning in
the UK. Instead of going in for any changes or restrictions in the mass
media I wonder whether the time has come to put some kind of restriction
in the availability of this drug in the UK. As reported by Gunnel et al
(2) fatality rates from paracetamol poisoning are four times as high in
England and Wales as compared to France where such restrictions are in
place.
References
1. Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Philo
G, Bulstrode C. Effects of a drug overdose in a television drama on
presentations to hospital for self poisoning: time series and
questionnaire study. BMJ 1999;318:972-977
2. Gunnel D, Hawton K, Murray V, Garnier R, Bismuth C, Fagg J, Simkin
S. Use of paracetamol for suicide and non fatal poisoning in the UK and
France: are restrictions on availability justified? J Epidimiol Community
Health 1997 Apr 51(2):175-179
Competing interests: No competing interests
Hawton et al (1) reported the fine line between entertainment and
negative influences on behaviour. However, there is also a positive side,
television drama can be a source of public health information. Every year
it is estimated that 50 people die (2) and a further 500 suffer acute
accidental Carbon Monoxide poisoning in England and Wales.(3) Educating
the public to the danger has so far proved challenging. However, an
episode of the popular television soap opera Coronation Street may have
proved a successful means of raising awareness. In July 1997, a major
storyline was an incident of accidental Carbon Monoxide poisoning. This
series is watched by 18 million in the United Kingdom.
Throughout August and September a survey of gas appliance safety was
carried out in Douglas, Isle of Man by an Environmental Health student.
As part of this investigation respondents were asked if they could recall
any incidents or adverts in the media relating to Carbon Monoxide
poisoning. 60% (117/196) reported this episode of Coronation Street.(4)
The storyline had been suggested to the producers of Coronation Street by
Stephanie Trotter of the Carbon Monoxide and Gas Safety charity (CO-GAS
Safety). It appears to have succeeded in raising public knowledge of
Carbon Monoxide poisoning but it remains to be seen whether it will change
people's habits regarding the maintenance of fuel burning appliances.
For further information regarding Carbon Monoxide Poisoning you can
contact CO-GAS Safety on (01372) 466135.
Richard Wilson
Research Fellow
Division of Primary, Public and Occupational Health
University of Birmingham
Birmingham
B15 2TT
Tel:(0121) 414 7851
Fax:(0121) 414 7878
Email: r.c.wilson@bham.ac.uk
Karen Leslie
MSc Student
School of Chemistry
University of Birmingham
Birmingham
B15 2TT
Email: Kleslie8@hotmail.com
Pat Saunders
Regional Environmental Health Advisor
Division of Primary, Public and Occupational Health
University of Birmingham
Birmingham
B15 2TT
Tel:(0121) 414 3985
Fax:(0121) 414 7878
Email: p.j.saunders@bham.ac.uk
Stephanie Trotter
President
Carbon Monoxide and Gas Safety charity
Lorien House
Common Lane
Claygate
Surrey
KT10 0HY
Tel:(01372) 466135
Fax:(01372) 468965
References
1. Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Philo G,
Bulstrode C. Effects of a drug overdose in a television drama on
presentations to hospital for self poisoning: time series and
questionnaire study. BMJ 1999;318:972-977.
2. Calman K, Moores Y. Carbon Monoxide: The Forgotten Killer -
PL/CMO/98/5. London: Department of Health, 1998.
3. Wilson RC, Saunders PJ, Smith G. An epidemiological study of acute
carbon monoxide poisoning in the West Midlands. OEM 1998;55:723-8.
4. Leslie K. Survey of non-intentional Carbon Monoxide poisoning awareness
amongst occupants of the Isle of Man. School of Chemistry, University of
Birmingham, 1998.
Competing interests: No competing interests
I can't avoid the impression that some rather large leaps of faith
are involved, to get from this study's results to its conclusions.
Clearly, if life mirrors art as closely as is suggested here, this is a
major public health issue. But how one can justify such conslusions on
the basis of figures that, even at a glance, would surely disappoint most
researchers, is something of a mystery to me.
I appreciate the need for both this issue and this journal to retain
a high public profile, and this edition has suceeded well in reaching the
headlines today. However, may not "Wide Confidence Interval Science"
ultimately weaken our credibility as policy-formers?
Competing interests: No competing interests
Effect of publication in the BMJ on presentation to hospital for self poisoning
Dear BMJ
Shortly after publication of a study in the BMJ claiming TV portrayal
of self poisioning may increase hospital admission for overdose (1), a
patient presented to us with a paracetamol overdose. Without prompting he
said he had
been influenced by media reporting of the results of the study. Since
this information was obtained without use of a questionnaire or leading
questions, we suggest that this study of one has more face validity than
the published
paper which appears to have significant potential for bias in data
collection.
Further interpretation of data collected by Hawton et al could infer
that being a 'Casualty' viewer is a protective factor against taking an
overdose! (22% general population watch Casualty vs 17% overdose
population).
Noting the BMJ's recent enthusiasm to publish papers involving TV
drama (1,2,3), we are currently conducting our own audit entitled "effect
of technical linguistics in a TV drama on conversations in Emergency
Departments". We have just recruited our first subject; a handsome,
tanned
specialist registrar who managed to cram "Cross-table-C-spine, BP 60 palp,
Chem 7, CBC", and "Urgent Psych consult", into a single sentence whilst
drinking a Diet Coke and perspiring heavily beneath surgical blues.
Yours etc.
Anthony O'Brien,
SHO in Psychiatry
Sian Hughes,
SPR in Psychiatry
Hillview Lodge,
Royal United Hospital,
Bath
1 Hawton et al. Effects of portrayal in a TV drama on presentation
to hospital for self poisoning. BMJ 1998;318: 972-7.
2 Gordon PN, Williamson S, Lawler PG. As seen on TV; observational study
of CPR in British mediacl dramas. BMJ 1998;317:780-3.
3 Tim Cranford, Richard Hooper, Sarah Evans. Death rates of characters
in soap operas on British television. BMJ 1998;315: 1649-52.
Competing interests: No competing interests