Dramatic portrayal of suicide: a critical analysis of Netflix's 13 Reasons Why

Aims The aims of this project were to assess how well the Netflix drama 13 Reasons Why portrayed suicide, in terms of both accuracy and safety, and to discuss the potential effect this could have on viewers. Background Psychiatric content within dramatic media can have measurable effects on the population, such as reinforcing stigma around mental illness. Given the show's focus on a character's suicide, the most serious effect here would be suicide contagion. Guidelines and regulations for the portrayal of suicide in media are in place to protect those who might be vulnerable to suicide contagion. Method We formed our own pro-forma of 42 criteria using existing guidelines written for both news and dramatic media. These criteria were formatted into positive and negative pairs; positive being instances of guidelines being followed, negative as guidelines being broken. These were further organised into 7 categories. Each episode of seasons 1-2 was then assessed against the criteria. Cumulative instances of guidelines being followed or broken were compared within and between seasons. Context of each instance was taken into account by the primary researcher, and we also highlighted instances of exceptional breach of these guidelines. Result The results showed an over-all breach of the guidelines, with no significant improvement between the seasons. Some categories of criteria, such as “asking for help” and “mental health”, were portrayed well overall. Other categories, such as “blame”, performed extremely badly. The most significant breach was the graphic suicide scene at the end of the first season, which completely disregarded Samaritans’ guidelines. Conclusion The breaching of guidelines in this show was overwhelming. In terms of severity, although there were some positive themes running through the seasons, there were also worrying instances of guidelines being completely disregarded. This led to the conclusion that the producers of the show did not take their responsibility to young, vulnerable viewers seriously regarding the dangers around portraying suicide. Suggestions from this study are that more guidelines around suicide are needed specifically for dramatic media, and that existing guidelines should be conflated and have stronger implementation by regulators. This implementation should potentially include overseas providers such as Netflix. Ethically, a significant challenge here is maintaining balance between safety and allowing artistic licence.

Psychiatric liaison referrals: a thematic analysis during peak  Kaj Svedberg*, William Hancox and Hugh Grant-Peterkin City and hackney Centre for Mental Health *Corresponding author. doi: 10.1192/bjo.2021.780 Aims. With the advent of the COVID-19 Pandemic the NHS long term Plan commitments of January 2019 to improve crisis care nationwide became all the more pressing. The aim of this study was to thematically investigate what mental health crisis presentations might be diverted from the Emergency department to external crisis hubs in order to reduce the COVID-19 contamination risks. Method. All referrals made to the Homerton University Hospital (HUH) mental health liaison service were looked at between 1/3/ 20-11/6/20 (n = 846), coinciding with the first peak of the COVID-19 Pandemic.
Referral data was anonymised and sorted independently into naturally emerging thematic classes by two junior liaison doctors.
Cases that did not clearly fit any of the 14 themes generated were further looked into to determine outcome of referral and discussed to try and match to an appropriate class. Result. 14 frequent themes for mental health crisis referrals were identified. The distribution of these ranged from most common (suicidality) to neurocognitive presentation and identified shifts in themes over the course of the pandemic peak such as increases of low mood, anxiety and intoxication requiring medical attention over the three month period. Conclusion. Although themes for presentations may be identified in acute referrals to mental health liaison services it is problematic determining how these may be parsed safely to crisis hubs without risking overlooking cases that may require medical attention. The most common theme that was identified and remained throughout the first wave of the COVID-19 Pandemic was acute suicidal presentation. The remaining themes would require careful consideration around risk thresholds for what a service may wish to accept in devolving the emergency department liaison and balance these against future risks of repeat COVID-19 waves.
Staff survey on using the new clinical risk assessment framework for teams (CRAFT) tool Pamela Swift 1 *, Brian Gillatt 2 , Emma Drysdale 2 , Hollie Walker 2 , Pamela Johnston 2 and Emma Jackson 2 1 Royal Alexandra Hospital and 2 Rowanbank Clinic *Corresponding author. doi: 10.1192/bjo.2021.781 Aims. Risk assessment and management are crucial elements of clinical practice in mental health. Healthcare Improvement Scotland identified risk management as a key area for change, with risk tools identified as one necessary component. In NHS Greater Glasgow and Clyde (GG&C) the CRAFT tool replaced the Glasgow Risk Screen (GRS) in October 2019. The CRAFT tool is a 2 page document that comprises a broad risk screen, details of historical risk events and prompts for family and carer involvement. The aim of this study was to assess staff attitudes to the CRAFT, 12 months after it had been rolled out. Looking at whether the CRAFT tool is used to inform decision making about risk in clinical settings and if patients were involved in the risk management process.
Method. An electronic staff survey was distributed to all clinical staff within NHS GG&C Mental Health Services. Clinical staff includes the following professional groups: Medical, Nursing, Psychology, Occupational Therapists and Allied Health Professionals. Contact details were accessed via the relevant managers and surveys were sent via secure global address lists. Questions were focused around the following areas: time taken to complete/update/frequency of use/contact and ease of use, role in decision making, patient and carer involvement/knowledge, view on the impact of the CRAFT.

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Result. There were 209 responses. This represents a response rate of approximately 10%. 89% of respondents had completed a CRAFT tool at some point but only 38% had received training. 15% reported that the CRAFT did not aid decision making about risk in clinical settings, whereas 37% said it did and 42% said it did sometimes. 46% report patients are consulted most of the time (34%) or always (12%). The qualitative impression was that the CRAFT was an improvement on its predecessor. However common themes from responders highlighted a lack of clinical relevance or impact decision making, lack of training in filling it out and cumbersome integration with the electronic case notes.
Conclusion. Staff perceptions of the CRAFT tool were generally negative with many feeling it was a box ticking exercise that had minimal real world impact on patient risk and its management. However many felt it was an improvement over the previous risk tool and the majority used it at some point to aid clinical decision making.
Medical comorbidities of patients presenting to an adult neurodevelopmental new case clinic in Singapore Patients with neurodevelopmental disorders had higher rates of epilepsy (12.2% vs 4.9%), cerebral palsy (3.2% vs 0%) but lower rates of having other neurological conditions (1.4% vs 7.3%) compared to those with no neurodevelopmental disorders.
In terms of other medical comorbidities, patients with neurodevelopmental disorders had higher rates of thyroid abnormalities (4.7% vs 2.4%), respiratory problems (7.6% vs 2.4%), musculoskeletal conditions (5.8% vs 0%), eye issues (5% vs 2.4%) and hearing problems (2.9% vs 0%) but similar rates of dermatological conditions (10.1% vs 9.8%) and gastrointestinal conditions (4.7% vs 4.9%) compared to those with no neurodevelopmental disorders. Conclusion. Patients with neurodevelopmental disorders have significantly highly rates of medical comorbidity than those without any neurodevelopmental disorders. This study highlights the need to raise awareness of the common medical comorbidities in patients with neurodevelopmental disorders and to ensure adequate screening and referral for follow-up medical care for them.
Interview skillspsychiatry reel to reality Aims. This reel analysis identifies quotes and actions of fictional characters from TV shows, namely: Hercules Poirot, Sherlock Holmes and House who can demonstrate learning points for clinical students to use within real psychiatric practice, using scientific theories such as the Hypothetico-deductive model, Empirical falsification and Occam's razor. This analysis explores what an ideal psychiatric interview consists of and what can be learnt from these characters and implemented within medical education. Method. Each show was watched by one researcher over the period of March to August 2020. The researcher noted insightful quotes which were relevant to one of the three philosophical theories. Quotes were included if they demonstrated deduction skills, revealed a character's ethos and supported the Calgary-Cambridge model of interviewing such as building rapport. 32 quotations were collected in total and narrowed to 6 quotations. These were then analysed, learning points were made and linked to the Calgary Cambridge model. Result. Dr House demonstrates objectivity when taking a patient's history. He utilises empirical falsification when diagnosing to avoid missing a differential diagnosis. Detective Poirot displays how empathic listening allows disclosure of details in the history, which would have otherwise been omitted. Additionally, he illustrates the importance of collateral interviewing which allows one to identify misinterpretations and inconsistencies. Sherlock teaches us the importance of perception regarding mismatching information which can help to gather new facts. All three characters interview beginning with open questions to more closed questions, supplementing with deductive reasoning in order to solve cases. Objectivity, empirical falsification, empathetic listening and deductive reasoning are the key skills displayed by these characters, that medical students can most use in their own practices. Conclusion. The perfect interview discovers new information through synchronised collaboration, whilst adhering to the Hypothetico-deductive model of thought. A combination of the Calgary-Cambridge model of interviewing and skillset of the TV characters should be considered for implementation in some aspects of psychiatric interviewing. Medical education can utilise these TV shows to teach students how to conduct history-taking.