Content Notice: Guidelines to Discuss Suicide on Social Media

On January 30, 2022, Miss USA 2019 Cheslie Kryst died by suicide. The news of her untimely death spread quickly across all forms of media. Although well-researched media guidelines for safely reporting on suicide have existed for years, journalists broke important rules—such as detailing the method of suicide and including the contents of the note she left.^1,2 Social media activity further amplified this problem. While news outlets shared stories with images and triggering language, individual social media users amplified those stories and expressed shock, grief, and condolences via comments and posts of their own (Figure 1). Such social media activity is concerning because discussions about suicide on social media platforms can perpetuate old myths and stigma, and can potentially lead to suicide contagion.^3,4

Figure 1.

Content Notice: This figure includes some examples of what not to do when posting about suicide on social media.

These are example Twitter posts about Cheslie Kryst’s suicide a) A post from a verified account* for a journalist is an example of further amplifying a news story that does not follow media guidelines for reporting on suicide. While the tweet itself follows guidelines, like including the number for a suicide hotline, the news story does not. b) A post from a verified account that uses the phrase “committed suicide” in reference Cheslie’s death. Guidelines for reporting on suicide indicate that a phrase such as “died by suicide” should be used instead. c) A tweet by the New York Post that includes a graphic image. This image, which depicts the method and location of the suicide, is not in compliance with media guidelines for reporting on suicide and may be triggering. News organizations need to monitor their social media postings just as stringently as their articles, d) Unlike previous examples, a tweet by a verified journalist that follows recommended guidelines for the discussion of suicide and includes information about suicide prevention.

*a verified account lets people know that an account of public interest is authentic (i.e. not a bot or an automated program that simulates human behavior on social networks). Often, verified accounts are celebrities, journalists, government officials, or people with large followings

Suicide remains a major public health concern. Nearly half a million lives were lost to suicide between 2010 and 2020 in the United States alone, and the national age-adjusted suicide rate increased by 30% during that time.⁵ While the early period of the pandemic saw a 3% decline in the national suicide rate (in 2020), this improvement was not seen in youth and young adults. Suicide was the second leading cause of death among individuals between the ages of 10–14 and 25–34 and the third leading cause of death among individuals between the ages of 15–24 in 2020.⁵ Given that these populations use social media more frequently, social media can be utilized as a significant venue for psychoeducation and risk reduction.⁶

Several studies demonstrate an association between population suicide rates, and cultural beliefs about mental health and help seeking.⁷ The sheer volume of online discussions broadens the reach beyond one location or population and highlights the importance of safe conversations about suicide; there are 4.48 billion social media users worldwide, and many are not yet informed about how to responsibly communicate about suicide.⁸ While guidelines for general media exist, those for social media are limited and not widely known.^1,9 The answer is not to stop talking about suicide, since matters of critical public health concern warrant public education and destigmatization—especially as stigma related to mental illness is directly associated with less active help seeking.¹⁰ Instead, we must talk about suicide safely and effectively. Rather than elevating contagion risk, conversations may deepen mental health literacy, increase help seeking behaviors, and instill hope.^4,11

Why Guidelines Are Needed: The History of Suicide Contagion

Suicide contagion is not a new phenomenon. The Werther effect, as it is widely called, is named after a reported spike in suicides following the 1774 publication of Goethe’s The Sorrows of Young Werther.¹¹ More recent examples include upticks in suicide following media reports of celebrity deaths. According to a 2020 meta-analysis, reporting of celebrity suicides is correlated with an increase in the number of suicides by 8–18% in the months following the death, and detailing the method of suicide is associated with an 18–44% increase in the risk by the same method.¹² Though no studies have yet looked at Kryst’s death (since Centers for Disease Control and Prevention (CDC) reporting on suicide lags by 12–18 months), when Robin Williams died by suicide in 2014, suicides via the same method increased by 32% in the months following his death.¹³ There were concerns after William’s death that United States (U.S.) print media only moderately adhered to recommendations including providing details romanticizing suicide.¹⁴

Because of the very real dangers of particular messaging about suicide, media guidelines for reporting were developed by several government agencies and health organizations, including WHO, CDC, the American Foundation for Suicide Prevention, the American Association of Suicidology, and the Annenberg Public Policy Center in 2001.¹⁵ While adherence to these guidelines is voluntary in the U.S., it is considered so important that the Columbia University School of Journalism has a center devoted to reporting on suicide and the Poynter Institute has also led on this.^16,17 Still, a recent comparison of major news outlets for initial reporting on celebrity suicide found that while articles frequently adhered to guidelines for what not to do when reporting on suicide (86%), they rarely adhered to guidelines for what to do (26%).¹⁸ It is just as important that guidelines are in place to prevent untoward outcomes, as they are to help promote good ones. For example, news articles that educate readers on risk factors, warning signs, and coping with suicidal struggles have been shown to decrease suicidal thoughts and increase knowledge about suicide prevention, without harmful effects.¹⁹ This is in line with another concept, the Papageno effect, named after the main character in Mozart’s 18^th century opera The Magic Flute.¹¹ Papageno feels the only way out of the pain of losing his love is suicide, but before he can act on it, three characters show him other ways to solve his problems. The media, in this sense, can act as the other characters by highlighting stories of resilience, survival, and encouraging help seeking. Currently, guidelines largely focus on traditional forms of news and print media. As the use of social media has risen sharply, the content of posts about suicide on these platforms must be considered as well.⁸

How Information Is Spread: Suicide and Social Media

Social media has become fundamental in the way we share opinions, ideas, and information. News on social media platforms surpassed print newspapers as a form of news consumption in the U.S.²⁰ Similarly, social media is becoming integral to the way we communicate about mental health. As of June 2022, the #MentalHealth hashtag has generated nearly 40 million public Instagram posts and has been used in millions of TikTok videos, amassing 36 billion views.^21,22 This influx of mental health-related posts undoubtedly helps normalize the discussion of mental illness. Celebrities, influencers, and members of the general public are opening up about their mental health and sharing content that addresses their experiences. But, unlike discussions or disclosures about anxiety (or almost any other health issue), discussions about suicide can lead to serious consequences due to the unique risk of contagion. Social media sites and online forums are common sources of information about suicide, and participation in particular online forums is strongly related to increases in suicidal ideation.²³ However, similar to other forms of media, while inappropriate social media discussions about suicide can be harmful, appropriate conversations can lead to shared knowledge, offerings of support, and a sense of connection—a known protective factor against suicide risk.²⁴ The difference is a matter of informing the public how to post safely and informatively.

Of note, various policies about suicide exist on common social media platforms. In a recent study titled “Self-Harm Policies and Internet Platforms,” Stanford researchers ranked 39 online platforms, including social networks, to identify the clarity in public-facing policies relating to self-harming behavior.²⁵ They noted considerable variability in the comprehensiveness of public-facing policies. For example, Facebook policies address not only suicide but also suicide notes and live streaming suicide attempts. In contrast, other sites such as Reddit have no policies related to suicide in their primary policy documents. This large variability leaves individual’s responsible for providing correct and safe information to the public. Also, as regulations can limit helpful and educational content, it is important to be aware of these policies and adapt. For example, on TikTok, posts that discuss death, dying, or suicide are often removed.²⁶ To circumvent this, creators use the word “unalive” to raise awareness instead.

As healthcare providers on social media, we must set an example with appropriate messaging. Through role-modeling specific language and providing resources, health professionals can help raise awareness and create change in the evolving discussion about suicide. We can also identify posts that are well written and educational, while gently pointing out problems in others. Our role is perhaps even more important in cases where the person who died is a healthcare worker, such as Lorna Breen, MD, a New York emergency medicine physician who died by suicide in 2020. Dr. Breen’s story was featured in news outlets worldwide and healthcare professionals reacted on social media. While this case led to more conversation about, and normalization of, the pandemic’s impact on healthcare professionals’ mental health, the news was discussed dangerously in the media. In fact, a 2021 study found limited adherence to suicide reporting guidelines in the coverage of Dr. Breen’s death by top media outlets.²⁷ Healthcare workers are responsible for accurately and sensitively sharing information about suicide. In this case a more positive focus could be messaging about the systemic issues surrounding physicians during the pandemic and the importance of proactive approaches to physicians’ mental health, including suicide prevention efforts and the importance of accessing support and treatment. This shifts the lens from the individual suicide and instead focuses on the broader narrative about suicide prevention.

Proposed Guidelines for Social Media Discussions about Suicide

As far as the authors are aware, there are no formally vetted guidelines created for social media. Guidelines can help ground conversations and lead professionals and creators to discuss suicide safely and more easily. As such, we propose these key strategies to encourage people to responsibly report and discuss suicide on social media (Figure 2).

Figure 2.

Summary of social media suicide reporting guidelines a) Do’s of social media posting about suicide b) Don’ts of social media posting about suicide c) A noncomprehensive list of resources to provide on social media that direct people to help.

1. Include a Content Notice

“Triggering” occurs when a person considering suicide or self-harm views material related to someone else engaging in these behaviors and is subsequently drawn closer to their suicidal feelings or acts on their thoughts.⁴ A trigger warning (TW), also known as a content notice (CN), is a statement at the beginning of a post that alerts other users to potentially distressing content. Such warnings give space for the reader to “scroll away” or otherwise avoid the content of the post. It also allows users who may have certain words “muted” not to have those posts show up on their feed at all.

2. Limit Details

Details surrounding suicidal behavior may intensify thoughts of suicide in others. For example, sharing personal information or the content of a suicide note can lead to over-identification with the individual who attempted or died by suicide and oversimplification of the events leading to the suicide attempt. This may also lead vulnerable individuals to, consciously or unconsciously, view suicide as a way to draw positive attention to themselves or secure their legacy. Moreover, information about the method of suicide may suggest a viable means to others. Beyond these more overt cognitive mechanisms for contagion, it’s important to remember that on a neurosynaptic level, humans are social creatures that are hard-wired with mirror neurons leading to unconsciously imitative behavior.²⁸ For individuals with suicide risk factors, detailed descriptions of other’s suicidal behavior can draw them closer to their suicidal urges via these neurological and cognitive mechanisms. Therefore, it is best to keep information about the suicide general.

3. Images

Most social media platforms encourage the use of images, photos, and videos. However, images can have unintended consequences, particularly if they portray a person who has died by suicide. Such images may give rise to thoughts of suicide in others via triggering and may make suicide seem more realistic by suggesting viable methods of self-harm. Thus, posting—or reposting—images, photos, video content, or animations that depict the method of suicide or the location where it occurred should be avoided completely.

4. Language

Certain words and phrases can be hurtful, harmful, and further stigmatize suicide. For example, saying that a person “committed” suicide references a time when suicide was considered a crime or a sin. Instead, say that someone “died by suicide”—a recommendation made in the Associated Press Stylebook.¹⁷ Also, consider that suicide should not be described as a desirable outcome. For example, words or phrases such as “successful,” “unsuccessful,” or “failed attempt” when describing suicidal behavior should be avoided. Avoid inaccurate phrases like “suicide epidemic,” since it is not only inaccurate in terms of the rate of increase but implies a prevalence that makes suicide seem like a common behavioral response to stress. Finally, while it may be comforting for loved ones to say that a person lost to suicide is “finally at peace” this can prove dangerous to those who are experiencing suicidal thoughts as such phrasing frames suicide as a solution to a problem.

5. Don't Sensationalize

Acknowledging that there have been numerous suicide attempts at a particular location or “hotspot” can make self-harm seem like a regular, unavoidable, or effective coping strategy for distress. Instead, consider quoting, retweeting, or linking to suicide prevention experts on causes and treatments or linking to the national crisis resources. This may be a way for your account to amplify those who can talk about the issue more in-depth. The goal is to communicate the importance of the issue and encourage coping behaviors without normalizing suicide.

6. Do Not Assume You Know Why Someone Died by Suicide

Suicide is complex and research shows there are always multiple causes, including psychiatric illnesses—that may or may not have been recognized or treated.²⁹ Other contributing factors include physical illness, financial hardships, loss of relationships, academic performance, substance use, peer influence, and numerous other stressful life events. Avoid stating that suicide was preceded by a single event, like a divorce or job change or even the pandemic. Instead, indicate that many factors, including mental health, physical health, and psychosocial factors may contribute to a person ending their life. Additionally, in situations involving a school, do not resort to blaming the administrators. They are often struggling, too, and may even feel responsible for the suicide despite its multifactorial nature.

7. Comments

Comments on social media posts should be monitored for hurtful remarks and indications that others are considering suicide. Inappropriate and/or insensitive posts should be removed. Users and social media platforms together can monitor posts for inappropriate content and replies can even be limited (for example, allowing replies from followers or “friends” only) when discussing these topics.

8. Provide Messages of Hope

Inform others that suicide can be prevented and link to resources for seeking help, such as crisis lines and websites that contain information about suicide prevention. Promote the universal nature of facing challenges, the importance of opening up about mental health experiences, and connecting with others for support. Providing access to good information in a sea of misinformation is extremely helpful to people.

Conclusion

Suicide is a national public health crisis, and social media is a powerful tool that can be used to educate the public about it. People may believe that suicide should not be discussed because the topic is “dangerous.” However, talking about suicide properly can normalize help-seeking and deepen the public’s knowledge about mental health and suicide. Social media guidelines can shape the conversation and allow for accurate, safe, and hopeful messages related to suicide—such as living through struggles and connecting to support or treatment—rather than dangerous posts that can lead to contagion. Physicians and other health professionals can play a leadership role by following guidelines and amplifying experts. As conversations about celebrities—and even healthcare worker’s deaths—populate social media sites, guidelines can help us talk about suicide without endangering the public.