A new study indicates that youth suicides spiked nationwide following the 2017 release of the controversial Netflix series "13 Reasons Why" about a girl who dies by suicide, leaving behind cassette tapes to explain the reasons she decided to end her life.

The study, led by researchers at Nationwide Children's Hospital in Columbus, says there were 195 more suicides than expected among youth ages 10 to 17 in the United States in the nine months after the show's release on March 31, 2017.

Of those 195 suicides, 58 were in April 2017, said the study's lead author, Jeff Bridge, who directs the Center for Suicide Prevention and Research at Nationwide Children's.

That's about 30 percent of the total, with the rest averaging about 17 suicides per month.

April 2017 also had the highest suicide rate among the age group in the five-year period analyzed (2013-2017), according to the study, accepted last week for publication by the Journal of the American Academy of Child & Adolescent Psychiatry. Bridge said data not included in the report indicate it was the highest rate in at least 19 years.

While suicides increased among both boys and girls, they were only statistically significant among boys, but it is unclear why, Bridge said.

The study did not examine whether the youth had been exposed to the series and cannot link the show to the deaths. Bridge said researchers did account for the increasing trend in suicides and for seasonal differences.

A second season of "13 Reasons Why" was released in 2018, and a third is expected this year.

Study authors recommend caution in allowing children and adolescents to watch the show, and Dr. John Ackerman, study co-author and suicide prevention coordinator at the Center for Suicide Prevention and Research, wrote a cautionary blog post for parents in 2017.

Youth are particularly vulnerable to suicide "contagion," or imitation, which can be fostered by stories that "sensationalize or promote simplistic explanations of suicidal behavior, glorify or romanticize the decedent, present suicide as a means of accomplishing a goal or offer potential prescriptions of how to die by suicide,” Bridge said.

Among problems with the first season, Bridge said, is that all episodes were released at once, allowing it to be one of the most binged-watched shows on Netflix in 2017. Further, he said, it gives an inaccurate depiction of suicide as a natural consequence of life events, glosses over mental-health issues and portrays nearly all adults as out-of-touch, leaving youth with nowhere to turn for help.

A number of mental-health professionals have expressed concern over the series, and Netflix incorporates graphic-content warnings and offers series-related programming in which mental-health professionals, cast members and others discuss suicide, bullying and other issues. Netflix also has a website with numbers to crisis text and phone lines, a discussion guide, links to several mental-health resources and topic videos.

In a statement, Netflix said, "We've just seen the study and are looking into the research, which conflicts with last week's study from the University of Pennsylvania. It’s a critically important topic and we have worked hard to ensure that we handle this sensitive issue responsibly."

The study referenced in the statement focused on young adults 18 to 29, not children, and the second season, not season one. Based on surveys of the adults, it showed that, overall, viewers who watched only part of the season had greater suicide risk that those who watched to the end; however, among those surveyed who were currently enrolled in school, those who watched the entire season reported a drop in suicide ideation compared with those who did not watch the show.

In March, the National Action Alliance for Suicide Prevention released what it called the first-ever national recommendations for depicting suicide in entertainment, developed with the federal Substance Abuse and Mental Health Services Administration and the Entertainment Industries Council. They are aimed at content creators, script writers and producers.

"Studies have found that the way the media covers suicide can influence behavior negatively, by contributing to increased suicidal behavior among viewers, or positively, by encouraging help-seeking and recovery," according to a March 12 statement from the Alliance.

The study analyzed suicides reported to the Centers for Disease Control and Prevention through a web-based system from Jan. 1, 2013 to Dec. 31, 2017.

Researchers say there was no correlation between the series release and suicides among people 18 and older.

Bridge suggests that parents have open dialogue with children about mental health.

"If a child is depressed or showing warning signs about suicide, it's OK to ask your child directly 'Are you thinking of killing yourself?'" Bridge said. "Research has shown that asking a child about suicide is not going to put the thought in their head."

For help, reach someone at Ohio's 24/7 Crisis Text Line, by texting 4HOPE to 741741. By phone, contact the Franklin County Suicide Prevention Hotline at 614-221-5445; the Teen Suicide Prevention Hotline at 614-294-3300; or the national Suicide Prevention Lifeline at 1-800-273-8255/TALK (or 1-888-628-9454 for Spanish speakers).

jviviano@dispatch.com

@JoAnneViviano