The first season of the Netflix drama 13 Reasons Why (13RW-1), which examined a 17-year-old girl’s reasons for death by suicide, took the world by storm. It garnered unprecedented levels of engagement across social media, becoming the most tweeted-about show ever in the history of streaming television [1]. It drew favorable reviews from critics and viewers (78% and 80%, respectively, on the Rotten Tomatoes website) and high-profile recognition, including an Emmy nomination, a Golden Globes nomination, and a National Association for the Advancement of Colored People Image Award win.

However, the subject matter of 13RW-1 also elicited speculation of possible harm to youth. It flouted several recommendations for suicide-themed stories, including the established injunction against graphically depicting suicidal acts and newer best practices of providing trigger warnings and recommending resource providers, such as Crisis Text Line or Rape, Abuse & Incest National Network. In doing so, some argued that Netflix put a target on its back and put young people at risk. Myriad public health experts and organizations published condemnations, warnings, and recommendations [2-4], whereas many researchers used diverse methods to study the impact of the show [5-16].

For example, Ayers et al [5] found higher than predicted suicide-related keyword search activity on Google, whereas Cooper et al [6] found higher than predicted admissions to a children’s hospital because of an intent to self-harm. Another study found a postexposure worsening in mood that was particularly pronounced among the most vulnerable adolescent viewers [7]. Other researchers found that, among adolescent viewers who had ever considered suicide, a minority reported increases in suicidal ideation, whereas more than twice as many reported decreases [8]. A large survey of young adults, adolescents, and parents across 4 countries reported positive outcomes from viewing 13RW-1, including higher rates of suicide awareness, empathy, information seeking, outreach, and interpersonal discussion [9].

This conflicting corpus suggests that more research is needed to understand how television shows like 13 Reasons Why (13RW) might affect adolescents. For example, despite numerous studies about the program, investigators had not conducted an experiment in real time, assigning adolescent participants to watch the show during its initial airing. Few studies investigated how viewers navigated show-related content. Finally, hardly any studies explored whether or how the show indirectly affected vulnerable youth by activating conversations in their networks, despite decades of research documenting how shows that spark interpersonal discussion are more likely to promote behavioral change [17,18].

Adolescence is a critical age for identity development, characterized by elevated social-affective engagement and goal flexibility [19]. Physiologically, it is also a time when the brain is most receptive to the environment [20]. The sheer number of hours that adolescents spend with screen media daily—7 hours and 22 minutes, not including the time spent using screens for school or homework [21]—demonstrates that media shapes adolescents’ lived experiences.

Since the emergence of COVID-19, the number of hours that youth spend with media has skyrocketed [22], whereas early data [23] and youths’ own testimonies [24,25] suggest that the pandemic’s immediate and long-term impacts on adolescent mental wellness may be considerable. Entertainment media can contribute to adolescents’ well-being by destigmatizing mental health issues, modeling help-seeking behavior, and helping vulnerable youth to feel less alone. Collectively, this suggests that media consumed during adolescence may be an especially powerful socializing agent and thus raises the stakes around global media franchises targeted to young people.

A panel-based research platform operated by the National Opinion Research Center (NORC) at the University of Chicago recruited adolescents aged 13 to 17 years from its nationally representative pool of participants. NORC solely retained participants’ personally identifiable information, submitting anonymized data to our research team (details on their recruitment practices are given in Multimedia Appendix 1).

Descriptive statistics and frequencies were used to analyze the demographic data of the participants. A combination of statistical tests, including t tests, one-way analysis of variance (ANOVA), chi-square tests, and logistic regressions, were used to analyze the impact of the intervention. Difference scores were calculated between measures at the two time points (representing increases or decreases in measures from T1 to T2) by subtracting T1 data from T2 data (T2−T1). Posthoc power analyses were conducted using G*Power [38]. Sets of analyses primarily using t tests and one-way ANOVA were conducted independently to compare (1) intervention versus control groups and (2) the intervention group only. For the intervention versus control analyses, the power analysis of our 2-tailed t tests, measuring the differences between the experimental and control groups, resulted in a power of β=.802 (control: N=89; intervention: N=68; Cohen d=0.455; α=.05). The power analysis of our one-way ANOVA, measuring fixed effects omnibus tests between our 2 groups, resulted in a power of β=.968 (N=157; Cohen f=0.306; α=.05). For the intervention-only analyses, the power analysis of our 2-tailed t tests, measuring a difference from a constant, resulted in a power of β=.896 (N=68; Cohen d=0.396; α=.05). SPSS version 26 was used for all analyses.

The final sample consisted of 157 participants—68 in the intervention group and 89 in the control group (demographics broken down by conditions are given in Table 1). The mean age of the sample was 14.99 years. The sample was fairly well balanced in terms of gender, with 82 females and 75 males. Most of the sample 54.8% (86/157) was White and non-Hispanic, 18.5% (29/157) identified as Hispanic, 17.2% (27/157) identified as Black, non-Hispanic, 6.4% (10/157) identified as mixed race, and 3.2% (5/157) identified as Asian, non-Hispanic.

At T2, viewers of 13RW-3 (mean difference [M_diff] 0.368, SD 0.827) engaged in conversations around suicide significantly more frequently (t_124.580=–2.735; P=.007; Cohen d=0.455) than nonviewers (M_diff 0.034, SD 0.651). In addition, compared with T1, at T2, the viewers engaged in significantly more conversations (M_diff 0.368, SD 0.827) about social and mental health issues (t₆₆=3.243; P=.002; Cohen d=0.396), with the number of conversations about suicide (M_diff 0.367, SD 0.827), mental health (M_diff 0.324, SD 0.999), and bullying (M_diff 0.294, SD 0.915) increasing the most.

Two variables emerged as moderators of conversational frequency: depressive symptoms and knowing a survivor of sexual assault. Viewers with higher levels of depressive symptoms at T2 reported more frequent conversations about suicide from T1 to T2 than viewers with lower levels of depressive symptoms (F_8,59=2.265; between-groups mean square [MS]=1.345; P=.04; Cohen f=0.554). Knowing a survivor of sexual assault moderated how often viewers spoke about bullying and sexuality, respectively, from T1 to T2. Viewers who knew a survivor of sexual assault reported more frequent conversations about bullying (F_1,57=5.318; MS=3.813; P=.03; Cohen f=0.306) from T1 to T2 than viewers who did not. Viewers who knew a survivor of sexual assault spoke about sexuality less frequently from T1 to T2 (F_1,57=9.985; MS=10.161; P=.003; Cohen f=0.419) than viewers who did not know a survivor of sexual assault.

After watching 13RW-3, the scores of adolescent viewers on mental wellness self-efficacy measures (M_diff–0.152, SD 1.010) did not significantly differ (t₁₅₅=0.746; P=.46) from nonviewers’ scores (M_diff–0.041, SD 0.853). After watching 13RW-3, scores on masculine role pressure measures (M_diff 0.072, SD 0.613) did not significantly differ (t₁₅₁=–0.134; P=.89) from nonviewers’ scores (M_diff 0.058, SD 0.625).

After watching 13RW-3, nearly all viewers (58/63, 92%) sought information on social and mental health issues. Bullying and mental health were the most frequently searched issues.

Once again, depressive symptoms and experiences with sexual assault emerged as moderating variables, influencing the extent to which viewers sought information. Viewers who reported little interest or pleasure in doing things sought information about suicide more than those who did not (B=0.806, SE 0.319; df=1; Exp (B)=2.238; P=.01; frequencies and significant moderators are given in Table 2). Viewers who reported having trouble with sleep sought more information about rigid gender stereotypes than those who did not report such sleep issues (B=0.663, SE 0.326; df=1; Exp (B)=1.940; P=.04). Viewers who self-identified as being forced to do sexual things they did not want to (kissing, touching, etc) sought more information about sexual assault than those who did not (Fisher exact test, P=.047). Viewers who reported being close to a survivor of sexual assault sought out more information about rigid gender stereotypes than those who did not report such a relationship (Fisher exact test, P=.03).

Approximately one-third (21/63, 33%) of viewers engaged with informative resources produced by or affiliated with 13RW (the entire list is given in Table 3).

The vast majority of viewers (60/68, 88%) reported speaking about 13RW-3 and issues related to the show. Adolescent viewers most commonly chose friends (43/68, 63%) as their conversational partners, followed by parents (32/68, 47%); frequencies and significant moderators are given in Table 4).

In addition to depressive symptoms and knowing a survivor of sexual assault, race or ethnicity also moderated the extent to which viewers spoke about 13RW-3 and show-related issues with certain conversational partners. Viewers who reported higher levels of feeling down, depressed, irritable, or hopeless at T2 spoke to their parents less (B=–0.923, SE 0.373; df=1; Exp (B)=0.397; P=.01) than those who reported lower levels of depressive symptoms. Viewers who knew a survivor of sexual assault spoke to their friends more than those who did not know a sexual assault survivor (Fisher exact test, P=.047). Viewers who identified their race or ethnicity as Black, non-Hispanic and Mixed spoke with other family members (ie, neither parents nor siblings) more than viewers who identified with other races or ethnicities (χ²₄=13.8; P=.008).

As hypothesized, watching the show was associated with significantly more conversations about social and mental health issues. A vast majority (60/68, 88%) of viewers reported discussing the show and related issues. The potential wellness implications were significant. Story-driven conversations can raise awareness, reduce stigma, shift attitudes [39], normalize certain behaviors [40], and strengthen supportive relationships [41]. For example, in a study of a popular TV show with a public health storyline, viewers’ interpersonal discussions facilitated and amplified the show’s impact; when viewers discussed the show, they were more likely to demonstrate show-related shifts in knowledge, attitude, and behavior [42]. By supporting adolescents’ narrative-inspired conversations, parents, educators, and public health officials may reap these types of benefits.

As expected, adolescents most often reported friends as their conversational partner (43/68, 63%); more surprisingly, parents did not trail far behind. Almost half of the sample participants (32/68, 47%) chose to discuss the show and issues related to the show with parents, with no differences based on gender or age. Intrigued by this finding, we searched for other parent data. We found that 60% (36/60) of 13RW-3 viewers watched the show with a parent at least once, similar to a global study on 13RW-1 [9] wherein 39.1% (184/471) of its sample reported coviewing with a parent and 43% (123/286) of those who did not coview reported talking about the show with a parent. Collectively, these data present parents as important members of adolescents’ media ecologies, at least with respect to shows like 13RW. Despite adolescents’ engagement with individuation, a developmental imperative that has them turning away from parents and toward their peer group [43], adolescents seem to rely on parents’ support for processing this challenging content—even traditionally, harder-to-reach adolescents, such as males.

Supporting our hypothesis, nearly all viewers (58/63, 92%) tried to learn more about issues explored by the show, with bullying and mental health drawing the most searches. This high rate of engagement outstrips a recent research finding [44], in which approximately half of an adult sample sought more information about something they learned from a fictional movie or TV show. Approximately one-third (21/63, 33%) of viewers engaged with informative resources produced by or affiliated with 13RW. These findings suggest that providing credible, engaging resources is a worthwhile effort for content creators for reasons that are not simply performative.

We also aimed to identify moderator variables, particularly those that moderated the experiences of more vulnerable adolescent viewers. Our explorations of age, gender, race, and sexual orientation and relationships with suicidal ideation, depression, and sexual assault revealed that lived experience—rather than demographic characteristics—were most likely to significantly affect viewers’ decisions.

Depressive symptoms emerged as an important moderator. Two of our findings related to engaging with the topic of suicide, namely, viewers who reported higher levels of depression talked about suicide more frequently at T2 than those with lower levels of depression. In addition, viewers who reported that they had little interest or pleasure in doing things (a subscale of our depression measure) looked up information on suicide more frequently. It is important to note that the content of these conversations and searches is unknown. Although the popular press tended to frame similar findings from Ayers et al [5] as sinister, assuming or implying that suicide-related information seeking meant procuring strategies on how to end one’s life, this is not necessarily the case. Depressed youth might have sought information or broached a conversation about suicide to get help; for youth, talking about suicide can serve as a protective factor [45]. It is also possible that depressed adolescent viewers initiated conversations to reassure their support networks that, despite their affect, they were not contemplating death by suicide. Interestingly, teen suicide rates declined in 2019, the year in which the show came out [46].

We also found that viewers who reported feeling down or depressed spoke to their parents less than nondepressed peers. This is unsurprising, given the nature of depression, which commonly reduces individuals’ interest in social interaction. Depressed adolescents might have been particularly loath to speak with their parents, who may have been worried about or critical of their condition.

Being affected by sexual assault also moderated several relationships. Adolescent viewers who knew a survivor of sexual assault spoke about bullying more than their peers, whereas they talked about sexuality less. This might suggest viewers’ learning from 13RW-3, which framed sexual assault as oppression—a means for violent bullies to exert power—and not as intimacy. Owing to their knowledge of their friends’ experiences, these viewers might have been more receptive to such framing and/or more curious to learn more.

Indeed, viewers who knew survivors of sexual assault sought information about rigid gender stereotypes more than their peers. Again, this hints at learning from 13RW-3. Season 3 showed how rigid gender stereotypes, especially a set of male heterosexual stereotypes commonly known as toxic masculinity, shaped the home life of the show’s serial rapist. It is possible that, because of their friendship with sexual assault survivors, these viewers were particularly interested in discovering whether or how internalizing rigid gender stereotypes can lead to sexual assault. Similarly, viewers who reported having trouble with sleep (a subscale of our depression measure) sought more information about rigid gender stereotypes than those who did not report such sleep issues. This is consistent with international research that has identified an association between traditional gender role attitudes and poor mental health outcomes (eg, depression and suicidal ideation) [47-49]. Finally, viewers who reported surviving sexual assault sought more information about it than their peers. Owing to their lived experience, these viewers likely were more motivated to make sense of this scourge and work toward healing. Of note, healing from sexual assault was a significant storyline in 13RW-3.

Finally, viewers who identified their race or ethnicity as Black, non-Hispanic and Mixed spoke with other family members (ie, neither parents nor siblings) more than viewers who identified with other races or ethnicities. This aligns with the established research that has found that “the extended kin network is a more salient structure for Black families than it is for White families” [50] and a newer research finding that African Americans and Black Caribbeans give and receive support from extended networks (eg, fictive kin and fellow congregants) more than non-Hispanic White people [51].

By design, study participation was limited to adolescents who reported they had never seriously considered suicide; as such, we cannot answer whether or how 13RW-3 impacted suicidal youth. As we only recruited adolescents across the United States, our results are limited to this population.

We did not measure the valence of adolescents’ conversations and/or information seeking and thus cannot definitively claim that these actions were positive. Depending on how the conversations unfolded, the more vulnerable youth may have suffered or benefited. Our modest qualitative data suggest, however, that viewers embraced a prosocial message (eg, “The show made me think about the things that teens go through [sic] and then on top of that all the bullying and family problems. I can now say I am much more careful about the things I say. I was made aware of the language I use on a day to day basis”).

Other limitations emerged in process. Our sample size, although considerable, could have been larger. Some participants did not adhere to the randomized conditions, making the study a partially randomized preference trial rather than a randomized controlled trial. Adolescent nonadherence is common across clinical and social science research. For example, according to the Children’s Hospital of Philadelphia [52], adolescent transplant recipients disregard the protocol at a 60% higher rate than adults, although such behavior risks their lives. We found a significant difference between adherents and nonadherents on the mental health self-efficacy measure, which may have influenced our results. In addition, the 18 nonadherents originally assigned to the control condition did not receive T2 questions about 13RW-3.

Finally, some of our measures were not validated, and this may have affected our outcomes. To assess both mental health self-efficacy and masculine role pressure, we used the unvalidated scales that we developed for this study. Both outcomes also may suggest insufficient dosage—that is, perhaps the storyline of 13RW-3 met the threshold to raise consciousness and catalyze discussion around social and mental health issues but did not deliver (enough) content to impact specific constructs.

The neutral and positive outcomes documented in our study align with a growing collection of studies that have found salubrious effects associated with watching 13RW [9,10,14,26-29]. These effects include lower depressive symptoms [27], decline in incidences of suicidal ideation and self-harm [14], decreases in stigmatized beliefs about suicide [27], increased sense of mental illness being socially acceptable [26], increased knowledge of suicide risk factors [28], engagement in prosocial mental health–related behaviors [26], and increased likelihood of expressing interest in helping a suicidal person [14]. It also strengthens another group of methodologically driven studies that problematize claims of 13RW viewership, leading to harm [11,29]. Of note, a reanalysis [11] of the data presented by Bridge et al [29] repudiated (widely reported) claims that suicide rates increased in the months following the debut of 13RW.

Our findings suggest that globally watched television shows featuring social and mental health issues drive conversation and that social media are regarded as a promising avenue to support adolescents’ well-being [53-55]. Thus, we are currently exploring whether second-screen content (ie, content appearing on a phone, tablet, or laptop that does not simultaneously exhibit a television show) can amplify the impacts of a narrative by facilitating conversations and information seeking around the topics raised within the show.

As noted, we do not know the content of adolescents’ conversations. Future research should examine the impact and valence of narrative-inspired conversations on vulnerable youth. For example, scornful conversations might deliver a boomerang effect, intensifying mental health stigma. Appreciative conversations might enrich vulnerable adolescents’ social context, normalizing challenges around mental wellness and improving peers’ abilities to identify warning signs. Future research might also investigate narrative-inspired information seeking. Are adolescents more likely to seek information about topics featured in popular media than adults? Do narratives like 13RW drive more information seeking than other types of narratives?

Understanding whether and how parents’ media choices impact adolescents—for example, whether subscribing to streaming services such as Netflix or whether enforcing media rules is associated with adolescents’ mental wellness—would be another fruitful arena of investigation. Similarly, researchers could query whether and how adolescents’ media choices affect parents (known as the child effect [56]). A recent study found that children actively mediate their parents’ television use [57], a phenomenon attested by our own study and a global study on 13RW-1 [9]. Therefore, it would be interesting to examine how parent-child engagement with adolescent-selected media might affect the parent-child relationship and parenting practices.

Finally, it is important for future research to examine the more vulnerable minority—youth with a history of suicidal ideation—and whether and how narrative affects their ideation.

Our findings should have implications for diverse stakeholders, including entertainment content creators, studios, public health experts, parents, and adolescents seeking to support adolescent mental health. Previous research has documented popular film and television’s tendency to stigmatize and trivialize mental health [58], stoking some creators’ resolve to correct mental health’s representation or misrepresentation. This study suggests that such efforts do not just improve the optics; they can facilitate meaningful outcomes in viewers’ lives. It complements recently released data on narratives’ capacity to shift viewers’ mindsets, “which can transform the way Americans think about health and influence policy” [44]. Therefore, executives can use this research to emphasize how stories matter and further inspire entertainment content creators’ efforts to enrich representation. As their content can drive conversations and information seeking, studios could also create resources that amplify these outcomes, including mini documentaries like Beyond the Reasons (the most used resource in our sample) and omnichannel promotion of companion content. Companion content might include conversational toolkits created by public health experts, designed to support the two most common types of dialogues: peer-to-peer and adolescent-parent. Clinicians and advocacy organizations can leverage the insight that adolescents who are most sensitive to this content are those who cope with depressive symptoms and/or are affected by sexual assault. First, they can seek to proactively identify adolescents who meet these criteria. Second, they can tailor programming to account for their lived experiences.

Most importantly, this investigation suggests that when all stakeholders work together well in advance of a global franchise’s release, they can better harness the content’s potential to enrich adolescent wellness. In fact, several entertainment outlets (eg, MTV, Comedy Central, VH1, and Paramount Plus) recently committed to representing mental health with greater frequency, accuracy, and empathy [59]. Indeed, this study’s lead author is speaking to this group about how the findings can enhance the resources for content creators.