East Asian Arch Psychiatry 2024;34:115-21 | https://doi.org/10.12809/eaap2440

ORIGINAL ARTICLE

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Rameez Ali Mahesar, Department of Media Science, Iqra University, Karachi, Pakistan
Muneeba Mughal, Department of Linguistics and Social Sciences, The Begum Nusrat Bhutto Women University, Sukkur, Pakistan
Shakeela Abro, Department of English, Shaheed Benazir Bhutto University, Shaheed Benazirabad, Pakistan
Antonio Ventriglio, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
Syeda Ayat-e-Zainab Ali, Department of Clinical Psychology, Shifa Tameer-e- Millat University, Islamabad, Pakistan
Sheikh Shoib, Independent researcher, India

Address for correspondence: Dr Antonio Ventriglio, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy. Email: a.ventriglio@libero.it

Submitted: 13 August 2024; Accepted: 18 October 2024

In 2019, suicide claimed >700 000 lives globally; it was the fourth-leading cause of death among individuals aged 15 to 29 years; 77% of suicides occur in low- and middle-income countries.¹ Risk factors for suicide include mental health issues such as mood disorders, psychosis, and substance abuse, as well as social issues such as oppression and discrimination.¹ There is growing interest in the Werther effect, which refers to the spike in emulation of suicidal behaviours following their portrayal in news reporting.²

Similarly, the Werther effect is also observed in response to fictional portrayals in television and movie dramas. Additionally, there is the Papageno effect that exposure to suicidal behaviour through social media may also play a key role in shaping behaviours, especially among youth, potentially promoting both suicidal and non-suicidal self- harm as well as alternative behaviours to suicide.^3,4

Over 150 studies have explored the impact of media on suicidal behaviours among consumers.⁵ Two main theories have been proposed to explain the association between suicidal content in the media and suicidal behaviours among viewers. Social learning theory posits that new behaviours can be acquired by observing and imitating others, whereas identification theory suggests that observers may identify with portrayals of suicide in the media as a solution to personal and psychosocial issues. Both theories explain how individuals in Pakistan, especially those who are vulnerable, may adopt or learn suicidal behaviours by observing or identifying with those facing distress.⁵ In particular, identification occurs when individuals experiencing emotional states or crises similar to those portrayed in the media may seek to emulate the observed suicidal behaviours.

There is also the cultivation effect that long-term exposure to television programmes with violent content, including suicide or self-harm, may influence the perceptions of the general population.⁶ Therefore, the depiction of suicide in film or television may trigger suicidal behaviours in the general population.⁷ For example, the Netflix show 13 Reasons Why has raised public concern about the risk of suicide imitation among teenagers.⁸

Rates of both depression and suicide attempt are higher in adolescents exposed to two television suicide scenes than in those reporting lower exposure.⁹ Similarly, fictional and non-fictional suicide-related stories potentially increase the occurrence of suicide.^10,11 In 2017, the World Health Organization developed guidelines for newspaper reporting on suicide, and studies have been carried out to determine the level of compliance of newspapers with these recommendations.¹²

In Pakistan in 2019, the rate of suicide was 9 per 100 000 people^13,14; it was estimated that 15 to 35 people died by suicide per day (ie, approximately one suicide per hour).¹⁵ The complex interplay between socioeconomic, cultural, and psychological factors may trigger these suicidal behaviours. Although suicide is a major public health issue, it is often underreported owing to societal stigma and religious beliefs associated with suicide. We aimed to examine the effects of suicide depiction in Pakistani television dramas on their viewers.

Methods

In April 2023, we searched the YouTube website for Urdu- language television dramas released between 2011 and 2022 that contained scenes of suicidal behaviours (both attempts and completed suicides) using the keywords ‘suicide in Pakistani dramas’. Television dramas with ambiguous incidents of suicide, assisted suicide, or suicide bombings were excluded. We then used Google to gather more information on these selected dramas by reviewing blogs, newspaper articles, and commentaries. Additionally, we posted requests on social media platforms (eg, Instagram and Facebook), inviting followers to suggest other television dramas that depict suicidal behaviours. These channels were used because they are influential for public opinion, and time-sensitive contents (news updates, television dramas, and trending social media posts) can reach a wide range of audience.

We then viewed the complete series of episodes from each selected drama and extracted details of the characters involved including age group, sex, role, occupation, religion, and marital status, as well as details of the suicidal behaviours including method, reason/trigger, and place of suicide. Age groups were categorised as follows: young adolescent (13-14 years), middle adolescent (15-16 years), late adolescent (17-19 years), young adult (20-30 years), middle adult (31-45 years), and late adult (>45 years).¹⁶

Results

In total, 45 Urdu-language television dramas with scenes depicting suicidal behaviour were identified. Of these, five did not have the full series available and thus were excluded. Among the 40 dramas included in the analysis, 42.5% were released in 2021 and 2022, and 57.5% were released between 2011 and 2020. One drama portrayed a case of homicide-suicide, six dramas portrayed two suicide incidents in two characters, and one drama portrayed three suicide incidents in one character.

There were 46 characters displaying 49 incidents of suicidal behaviour (Table 1). Among the 46 characters with suicidal behaviour, 50% were male, 54.3% were young adults, 52.2% were married, 26.1% were housewives, 100% were Muslim, and 34.8% were in a leading role (Table 2).

Of the 49 incidents of suicidal behaviour, 29 were suicide, 19 were suicide attempts, and one was homicide- suicide. Common methods of suicidal behaviour depicted were gun shooting (30.6%), wrist cutting (18.3%), self- poisoning (12.2%), and jumping from height (12.2%). Common reasons for suicidal behaviour were failure in love (24.4%), familial issues (24.4%), and others (26.5%); 69.4% of suicidal behaviour occurred in home.

Discussion

In Urdu-language Pakistani television dramas, most suicidal behaviours involved young adults, consistent with the findings of a content analysis of Bangladeshi movies.¹⁷ Young adults are more vulnerable to suicidal behaviours, as reported in various studies in Pakistan and among medical students.^18-21 In the present study, 34.8% of characters with suicidal behaviour were in a leading role (hero/heroine). Viewers might misinterpret that suicide is intended to be a heroic behaviour or a bold action; indeed, the leading characters are often portrayed as heroic. These dramas typically focus on the protagonists as central figures, depicting them as relatable individuals whose actions are framed as meaningful or justified. They frequently face serious challenges, overcome obstacles, or make difficult decisions, all of which contribute to their portrayal as heroic.²⁰ Additionally, lead characters are often played by well-known celebrities, and the suicidal actions of celebrities can have a substantial impact, potentially leading to copycat behaviours.²⁰

Most of the characters with suicidal behaviour, especially males, appeared to suffer from a failure in love, consistent with the findings of a previous study.¹⁷ On the contrary, females often attempted suicide in response to harassment, betrayal in love, divorce, and discordance with their spouse. This reflects that family conflict is relevant and may lead to both homicide and suicide.²² Timely psychological interventions within families are crucial to mitigate familial discord and reduce suicidal behaviours among family members.²³ Dramas often reflect sociocultural issues, and the focus on familial problems in dramas is inspired by the community.

Other reasons for suicidal behaviours such as depression, divorce, job loss, and financial issues reflect the issues of psychiatric disorders, financial distress, and unemployment in the real world.^24,25 In Bangladesh, 91% of suicides were related to adverse life events; prevention in the family context may reduce the incidence of suicide by 86%.^26,27

In Pakistani television dramas, all characters with suicidal behaviours were Muslim; this rate is higher than that in Muslim populations in the real world.^28,29 Similarly, 52.2% of suicidal behaviours were portrayed in married characters, which is in contrast with findings from the real world where rates are lower.³⁰

The suicide methods of gun shooting and wrist cutting were most commonly portrayed, followed by self-poisoning and jumping from height; this was in line with real-world findings in Pakistan.^21,31 Portrayal of suicide methods may lead to imitation and thus details should be removed from the scenes.³² The suicidal behaviour commonly took place at home, consistent with real-world findings in Bangladesh.¹⁷

Television dramas with emotional content, such as in Pakistan.³³ However, national-level statistics on suicide rates are not available in Pakistan; therefore, comparison between television dramas and real life cannot be made.

Awareness of the potential impact of depictions of suicide in television dramas was low among the general population, particularly in young people who may be vulnerable to media messages. The specifics of portrayals of suicide were in line with the current social constructs and real-world background, as were family concerns, love affairs, harassment, and unemployment.³⁴ When suicide is presented in a realistic manner, there is a complex interaction between risk factors.³⁵ However, there is little regard for the guidelines and warnings set forth by the World Health Organization regarding suicide in the media. The content of television dramas, situation comedies, and cartoons, particularly those reaching young people, should be reviewed. It is of note that 13 Reasons Why, a drama depicting the suicide of a high school student, was condemned by mental health practitioners and psychiatrists in the United States.³⁶ Prevention of suicide among young people should include a careful review of stimuli that they are exposed to in both the school and the media. Television dramas should promote messages on help seeking and coping with issues as a solution, rather than suicide.^37,38 Suicides of idols or heroes/heroines are detrimental, as adolescents are likely to identify with their idols and may imitate the suicide (as a glorious action to behave as the loved character does).

Producers of television dramas should consider their moral responsibility and reduce the potentially harmful impact on viewers.⁸ Movies and television dramas on YouTube should be properly censored. Advice such as ‘restricted to an adult audience’ should be provided; the use of the suicide helpline should be encouraged, as should be provision of a brief psychoeducational introduction. Television dramas should promote open dialogue on adolescent issues, encourage help-seeking behaviours, and aim to improve the wellbeing of viewers and their approaches to real-world issues.

In television dramas, suicide is often dramatised to elicit an emotional impact. Suicides are frequently portrayed as spontaneous, without thorough exploration of the underlying mental health issues, struggles, or available support systems. However, in reality, suicides rarely unfold in such a dramatic or impulsive manner; they are more commonly the result of long-term mental health challenges such as anxiety, depression, addiction, or trauma. Real-life cases often exhibit warning signs such as behavioural changes, hopelessness, and social withdrawal. Stigmatisation, lack of support, and systemic barriers (eg, limited access to healthcare) also contribute to real- life suicidal behaviour. In television dramas, the context surrounding suicide often revolves around external factors such as relationship breakdowns, revenge, or bullying, leading to narrative closure. This emphasis on external triggers can overshadow the internal psychological struggles of individuals. In reality, suicide is deeply connected to complex sociobiological and psychological factors. Chronic illness, financial stress, or substance abuse can also trigger suicidal ideation. Dramatic portrayals of suicide frequently fail to address the long-term psychological, emotional, and social effects on the deceased individual’s loved ones. Oversimplification or glamorisation of suicide raises concerns about copycat behaviours. In real-life suicides, families, friends, and communities often face long-term grief, trauma, and guilt.

The present study has some limitations. The findings are based on a specific selection of television dramas. The portrayal of suicidal behaviour was observed in those translated from Urdu. Television dramas related to suicide bombing and terrorist activities were excluded. Television dramas were selected without focusing on any specific vulnerable cohort such as adolescents. Some variables of characters with suicidal behaviour were not available such as economic position and education level. Data regarding context, outcomes, or interpretations of the suicidal acts were not collected.

Conclusion

Television dramas with scenes involving suicidal behaviours may negatively affect the general population, particularly adolescents. These scenes should be censored to prevent imitation or identification among vulnerable young people. Television dramas should provide psychoeducational messages to promote help-seeking rather than suicide for emotional problems. Our findings may increase the awareness on the relevance of television dramas contents and the adoption of World Health Organization guidelines.

Contributors

RAM, AV, SAA designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. MM and SA acquired and analysed the data. SS drafted the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding / support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Acknowledgement

We thank SM Yasir Arafat for his feedback on improving the manuscript.

References

1. World Health Organization. Suicide: facts and figures globally. Accessed 13 August 2024. Available from: https://iris.who.int/ bitstream/handle/10665/360460/WHO-MSD-UCN-MHE-22.03-eng. pdf?sequence=1.
2. Phillips DP. The influence of suggestion on suicide: substantive and theoretical implications of the Werther effect. Am Sociol Rev 1974;39:340-54.
3. Niederkrotenthaler T, Braun M, Pirkis J, et al. Association between suicide reporting in the media and suicide: systematic review and meta-analysis. BMJ 2020;368:m575.
4. Niederkrotenthaler T, Voracek M, Herberth A, et al. Role of media reports in completed and prevented suicide: Werther v. Papageno effects. Br J Psychiatry 2010;197:234-43.
5. Niederkrotenthaler T, Stack S. Media and Suicide: International Perspectives on Research, Theory, and Policy. Routledge; 2017.
6. Gerbner G, Gross L, Morgan M, Signorielli N. The “mainstreaming” of America: violence profile No. 11. J Commun 1980;30:10-29.
7. Till B, Tran US, Voracek M, Sonneck G, Niederkrotenthaler T. Associations between film preferences and risk factors for suicide: an online survey. PLoS One 2014;9:e102293.
8. Scalvini M. 13 Reasons Why: can a TV show about suicide be ‘dangerous’? What are the moral obligations of a producer? Media Cult Soc 2020;42:1564-74.
9. Martin G. The influence of television suicide in a normal adolescent population. Arch Suicide Res 1996;2:103-17.
10. Hagihara A, Tarumi K, Abe T. Media suicide-reports, internet use and the occurrence of suicides between 1987 and 2005 in Japan. BMC Public Health 2007;7:321.
11. Stack S. Media coverage as a risk factor in suicide. J Epidemiol Community Health 2003;57:238-40.
12. World Health Organization. Preventing suicide: a resource for media professionals, update 2023. Accessed 13 August 2024. Available from: https://iris.who.int/bitstream/handle/10665/372691/9789240076846- eng.pdf?sequence=1.
13. World Population Review. Pakistan Population 2023. Accessed 13 August 2024. Available from: https://worldpopulationreview.com/ countries/pakistan.
14. World Health Organization. Global Health Observatory. Accessed 13 August 2024. Available from: https://www.who.int/data/gho.
15. Rehman A, Haque J. Pakistan’s silent suicide problem. Daily Dawn. 2020.
16. Trewavas C, Hasking P, McAllister M. Representations of non-suicidal self-injury in motion pictures. Arch Suicide Res 2010;14:89-103.
17. Arafat SMY, Jalil SB, Alam MS, et al. Suicide in Bangla movie and drama: a content analysis. Omega (Westport) 2022:302228221148286.
18. Osama M, Islam MY, Hussain SA, et al. Suicidal ideation among medical students of Pakistan: a cross-sectional study. J Forensic Leg Med 2014;27:65-8.
19. Saaiq M, Ashraf B. Epidemiology and outcome of self-inflicted burns at Pakistan Institute of Medical Sciences, Islamabad. World J Plast Surg 2014;3:107-14.
20. Tahir MN, Akbar AH, Naseer R, Khan QO, Khan F, Yaqub I. Suicide and attempted suicide trends in Mianwali, Pakistan: social perspective. East Mediterr Health J 2014;19 Suppl 3:S111-4.
21. Saeed A, Bashir MZ, Khan D, Iqbal J, Raja KS, Rehman A. Epidemiology of suicide in Faisalabad. J Ayub Med Coll Abbottabad 2002;14:34-7.
22. Al Helal MA. Extra marital affair and family discord: way-out in Islam. Bangladesh Institute of Islamic Thought 2013;35.
23. Mahesar RA, Chandio DA, Latif M, Abbas S, Shabbir T. Demography and risk factors of suicide deaths in Pakistan: a twelve-month content analysis study. Asian J Psychiatr 2023;80:103364.
24. Khan MM, Mahmud S, Karim MS, Zaman M, Prince M. Case-control study of suicide in Karachi, Pakistan. Br J Psychiatry 2008;193:402-5.
25. Abdullah M, Khalily MT, Ahmad I, Hallahan B. Psychological autopsy review on mental health crises and suicide among youth in Pakistan. Asia Pac Psychiatry 2018;10:e12338.
26. Arafat SMY, Mohit MA, Mullick MSI, Kabir R, Khan MM. Risk factors for suicide in Bangladesh: case-control psychological autopsy study. BJPsych Open 2021;7:e18.
27. Arafat SMY, Khan MAS, Knipe D, Khan MM. Population attributable fractions of clinical and social risk factors for suicide in Bangladesh: finding from a case-control psychological autopsy study. Brain Behav 2021;11:e2409.
28. Kamal Z, Loewenthal KM. Suicide beliefs and behaviour among young Muslims and Hindus in the UK. Ment Health Relig Cult 2002;5:111-8.
29. Abdel-Khalek AM. Neither altruistic suicide, nor terrorism but martyrdom: a Muslim perspective. Arch Suicide Res 2004;8:99-113.
30. Naveed S, Tahir SM, Imran N, et al. Sociodemographic characteristics and patterns of suicide in Pakistan: an analysis of current trends. Community Ment Health J 2023;59:1064-70.
31. Farooq U, Majeed M, Bhatti JA, Khan JS, Razzak JA, Khan MM. Differences in reporting of violence and deliberate self harm related injuries to health and police authorities, Rawalpindi, Pakistan. PLoS One 2010;5:e9373.
32. Leonard EC Jr. Confidential death to prevent suicidal contagion: an accepted, but never implemented, nineteenth-century idea. Suicide Life Threat Behav 2001;31:460-6.
33. Sisask M, Värnik A. Media roles in suicide prevention: a systematic review. Int J Environ Res Public Health 2012;9:123-38.
34. Shahid M, Hyder AA. Deliberate self-harm and suicide: a review from Pakistan. Int J Inj Contr Saf Promot 2008;15:233-41.
35. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 2016;3:646-59.
36. Bridge JA, Greenhouse JB, Ruch D, et al. Association between the release of Netflix’s 13 Reasons Why and suicide rates in the United States: an interrupted time series analysis. J Am Acad Child Adolesc Psychiatry 2020;59:236-43.
37. Rosa GSD, Andrades GS, Caye A, Hidalgo MP, Oliveira MAB, Pilz LK. Thirteen Reasons Why: the impact of suicide portrayal on adolescents’ mental health. J Psychiatr Res 2019;108:2-6.
38. Arendt F, Scherr S, Pasek J, Jamieson PE, Romer D. Investigating harmful and helpful effects of watching season 2 of 13 Reasons Why: results of a two-wave U.S. panel survey. Soc Sci Med 2019;232:489-98.