13 Reasons Why, Netflix’s controversial show about teen suicide, has been hit with a new wave of bad press.

Since before the show premiered, experts have warned that its premise, which revolves around the suicide of a 16-year-old girl and depicts it in graphic detail, could lead to an increase in teen suicide attempts. Now a new study suggests that the theoretical increase may have come to pass. The study’s authors say they have found an association between the release of 13 Reasons Why and a nearly 30 percent jump in suicide rates among US youths.

On social media, people have been quick to herald the study as proof that 13 Reasons Why is just as dangerous as experts have feared. But it’s a little more complicated than it seems.

The study, which lists Nationwide Children’s Hospital’s Jeff Bridge as its lead author, was conducted by multiple institutions, including the National Institute of Mental Health, and published April 29 in the Journal of the American Academy of Child and Adolescent Psychiatry. And while the association it finds is fairly damning, it does not definitively establish a causal link between 13 Reasons Why and the rise in suicide rates.

So when I talked to academics about the study, all of them said that they continue to be wary of shows like 13 Reasons Why — but they also said the study is nowhere near proof that 13 Reasons Why is actually responsible for the death of teenagers. And in part that’s because, regardless of whether such a relationship might exist, it’s nearly impossible to prove.

The worries about 13 Reasons Why stem from the phenomenon of suicide contagion

Before Netflix premiered 13 Reasons Why in 2017, it consulted suicide prevention expert Dan Reidenberg. The show centered on a touchy subject, and Netflix wanted to roll it out responsibly.

Reidenberg told the Syracuse Post-Standard in 2017 that he was worried about 13 Reasons Why. He feared, he said, that it was exactly the kind of show that would convince vulnerable kids to act on suicidal impulses. So he advised Netflix that it shouldn’t release the show at all.

“But that wasn’t an option,” Reidenberg said. “That was made very clear to me.”

His fears sprang from the problem of suicide contagion, which is what it’s called when media attention focused on one prominent suicide leads other people who are struggling with suicidal ideation to try to kill themselves. It’s a danger that young people are especially vulnerable to.

As I wrote for Vox in 2018, the theory among experts is that shows like 13 Reasons Why encourage people with suicidal ideation to keep returning to the idea of suicide, and to continually engage with it and become comfortable with it. And because 13 Reasons Why in particular treats its heroine’s death as a victory of sorts, a way for her to achieve popular immortality and triumph over her enemies, it’s thought to be especially dangerous.

There’s a lot of data documenting the problem of suicide contagion when it comes to media coverage of real suicides. But there’s much less data about whether suicide contagion is quite so common when it comes to fictional depictions of suicides, like 13 Reasons Why. And according to the experts I talked to, while the new study from Bridge and company is suggestive, it doesn’t quite make the case that suicide contagion is what’s happening with the show.

“The findings should be interpreted with caution,” says one expert

Bridge’s study analyzed data from the Centers for Disease Control and Prevention on suicide rates from 2013 to 2017. While suicide rates among young people have been trending upwards for years, the study found that in April 2017, the month that 13 Reasons Why premiered, suicide rates increased by 28.9 percent among US youths between the ages of 10 and 17. (The spike was mostly driven by boys; the shift among girls was not statistically significant.) All told, the study estimates that the spike was responsible for about 195 “extra” deaths by suicide between April and December 2017, beyond what the existing trends suggested.

“The findings should be interpreted with caution,” says Regina Miranda, a psychology professor at Hunter College, CUNY, and director of the Youth Suicide Research Consortium. She told me in an email that she thought the study was “compelling and concerning,” but that she also has numerous questions about its results.

Miranda notes that besides the rise in suicide rates in April 2017, the study also found a spike in suicide rates in March 2017, before 13 Reasons Why debuted. The study’s authors attribute that rise to the release of the show’s trailer, but, Miranda points out, Netflix actually announced 13 Reasons Why in January 2017, with a teaser trailer.

She also points to the fact that boys were driving the spike, even though Hannah, 13 Reasons Why’s tortured teen heroine, is a girl. “This was contrary to what the authors expected,” Miranda says, “but it is consistent with boys being at higher risk of suicide death than girls and girls being at higher risk of suicide attempts than boys.”

Finally, she points out, it’s possible that it wasn’t the show itself that created the spike, but instead coverage of the show. “If the effect was driven by the premiere of the show,” she asks, “was it actually watching the show or was it increased media attention to suicide generated by the show?”

Part of the ambiguity here is because it’s difficult to conduct any kind of study that could establish a causal link between a show like 13 Reasons Why and an increase in suicide rates, says Megan Chesin, an associate professor of psychology at William Paterson University and member of the YSRC who has run studies on 13 Reasons Why herself.

Ideally, Chesin says, researchers would expose one group of people to 13 Reasons Why and keep a control group away from the show, and then track suicide rates within the two groups. An experiment where 13 Reasons Why was the only variable could absolutely establish a causal link between the show and increases in rates of suicide. But practically, no one’s been able to build such a study.

Chesin points to the way Netflix released the show. It came out as one bingeable 13-episode unit, so that by the time researchers were able to set up a study for it, most of their potential subjects had already watched the whole thing. “It’s hard to get people before they watch it and then follow them after they watch it,” she explains.

Both Chesin and Miranda say it would be consistent with the current best theory on suicide ideation for 13 Reasons Why to lead to increased suicides among young people watching the show.

“We know from past research that adolescents are particularly vulnerable to depictions of suicide in the media. Past research also suggests that a substantial proportion of parents of suicidal adolescents are unlikely to know that their children have been thinking about suicide,” says Miranda. “If you combine this with unsupervised viewing of a show depicting a suicide death, there is potential for harm among suicidal teenagers.”

“Any realistic depiction of suicide in a way that engages young audiences might increase risk among young people who have already been thinking about suicide,” she adds.

Chesin agrees.

“I think for some people, who are vulnerable to suicide or can identify with the character, there’s enough risk based on the theory that it’s worth being concerned,” she says.

But Chesin also suggested that there’s value in a show like 13 Reasons Why. The study she ran last year found that among college students who watched 13 Reasons Why, suicidal ideation didn’t seem to increase. Instead, knowledge of the risk factors for suicide did. Another study at Northwestern, funded by Netflix, suggested that the show might be a good platform for starting conversations about the risk of suicide.

“It’s important to weigh,” says Chesin.

Shows about suicide are almost certainly always going to exist, Chesin added. The question then becomes, she says, “How can we portray it in the way that is least harmful?”