FRAMING HEALTH MATTERS

Social Media and Suicide: A Public Health Perspective

David D. Luxton, PhD, Jennifer D. June, BA, and Jonathan M. Fairall, BS

a systematic Web search of 12 suicide-associ-

There is increasing evidence that the Internet and social media can influence
ated terms (e.g., suicide, suicide methods, how to
suicide-related behavior. Important questions are whether this influence poses
a significant risk to the public and how public health approaches might be used kill yourself, and best suicide methods) to simu-
to address the issue. To address these questions, we provide an overview of late the results of a typical search conducted
ways that social media can influence suicidal behavior, both negatively and by a person seeking information on suicide
positively, and we evaluate the evidence of the risk. We also discuss the legal methods. They analyzed the first 10 sites listed
complexities of this important topic and propose future directions for research for each search, for a total of 240 different
and prevention programs based on a public health perspective. (Am J Public sites. Approximately half were prosuicide
Health. 2012;102:S195–S200. doi:10.2105/AJPH.2011.300608) Web sites and sites that provided factual in-
formation about suicide. Prosuicide sites and
Social media is a relatively new phenomenon recent increase in highly publicized cases of chat rooms that discussed general issues asso-
ciated with suicide most often occurred within
that has swept the world during the past suicide that involve social media has drawn
the first few hits of a search. We should note
decade. Social media fuses technology with national attention to this topic.7---9 Researchers
that this study primarily focused on prosuicide
social interaction via Internet-based applica- are also interested in whether the Internet in
search terms and thus likely excluded many
tions that allow the creation and exchange of general primarily helps or hinders suicide pre-
suicide prevention and support resource sites.
user-generated content.1 Social media plat- vention. Attempts to assess the extent of the
Recupero et al.11 also conducted a study that
forms, such as chat rooms, blogging Web sites Internet’s influence on suicide behavior are
examined suicide-related sites that can be
(e.g., Blogspot), video sites (e.g., YouTube), difficult because of the indirect and complex
found using Internet search engines. Of 373
social networking sites (e.g., Facebook, My- association between Internet use and suicide.
Web site hits, 31% were suicide neutral, 29%
Space, Twitter, Google+), and electronic bulle- The myriad legal complexities involved, as well
were antisuicide, and 11% were prosuicide.
tin boards or forums, as well as e-mail, text as the important issues of freedom of speech
The remaining sites either did not load or
messaging, and video chat, have transformed and civil liberties, have also triggered debate.
included “suicide” in the title but were not
traditional methods of communication by Whether some of social media’s influence
suicide sites (e.g., sites for movies and novels
allowing the instantaneous and interactive on suicide behavior should be considered
with “suicide” in their title or music bands
sharing of information created and controlled a public health problem and how public health
whose names included “suicide”). Together,
by individuals, groups, organizations, and gov- approaches might be used to address this these studies have shown that obtaining pro-
ernments. At the end of 2004, the popular influence are relevant issues. In this article, we suicide information on the Internet, including
social networking site Facebook had close to discuss the role of social media in suicide-related detailed information on suicide methods, is
1 million users;2 by June 2011, that number behavior and frame the issue from a public very easy.
had risen to nearly 700 million users world- health perspective. We begin with discussion of A fundamental question is whether an as-
wide.3 Facebook2 has reported that an average the primary ways social media can have a nega- sociation exists between rates of Internet use,
of 30 billion pieces of content (e.g., Web links, tive influence on suicide-related behavior and including social media, and population suicide
news reports, photo albums, blog postings) we evaluate the evidence of this influence. We rates. Although limited, several preliminary
are shared every month via the social media then provide examples of how social media can studies have begun to address this question.
site. Social media has become fundamental in be used in the prevention of suicide. We also For example, Shah12 conducted a cross-na-
the way many people and organizations com- discuss the legal complexities of this important tional study that examined the association
municate and share opinions, ideas, and in- topic and propose future directions for research between general population suicide rates and
formation. and prevention programs that are based on the prevalence of Internet users, using data
Suicide is a considerable public health a public health perspective. from the World Health Organization’s and the
problem; more than 30 000 suicide deaths United Nations Development Program’s Web
in the United States and nearly 1 million SOCIAL MEDIA AND SUICIDE RISK sites. Shah showed that the prevalence of
suicide deaths worldwide occur every year.4,5 Internet users was positively correlated with
The role that the Internet, particularly social An immense quantity of information on the general population suicide rates. Multiple re-
media, might have in suicide-related behavior topic of suicide is available on the Internet and gression analysis indicated that the prevalence
is a topic of growing interest and debate.6 The via social media. Biddle et al.10 conducted of Internet use was independently associated

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 FRAMING HEALTH MATTERS

with general population suicide rates in men developed in some way through the use of resulted in the deaths of 208 people.32 This
(P = .001) and approached statistical signifi- the Internet has been referred to as a cybersui- suicide outbreak was blamed on the introduc-
cance for women (P = .074). Hagihara et al.13 cide pact.23 Traditional suicide pacts have tion of the gas-related method on message
conducted a time-series analysis with data typically developed among individuals who boards via the Internet. Family members,
from 1987 to 2005 and reported a statistically know each other, such as a couple or friends.23 paramedics, and caregivers were reported to
reliable positive correlation between general A primary characteristic that differentiates have been injured or even killed in attempts to
population male suicide rates in Japan and the cybersuicide pacts from traditional suicide save suicide victims because of the toxic gas
prevalence of households using the Internet pacts is that these pacts are usually formed methods used.32
(P < .05). We should note that the results of among complete strangers.21 The use of Another concern is the media contagion
these studies cannot be considered conclusive online chat rooms and virtual bulletin boards effect.33---36 The media’s influence on suicidal
because of cross-sectional designs and the and forums can provide an unmediated avenue behavior, especially suicide methods used, has
possibility of ecological fallacy. to share one’s feelings with other like-minded been well documented,37---43 and social media
There are several specific ways that social individuals, which can be easier than talking may possibly increase the risk of the media
media can increase risk for prosuicide behav- about such thoughts and feelings in person.24---26 contagion effect, especially among young peo-
ior. Cyberbullying and cyber harassment, for The first documented use of the Internet to ple. A recent study by Dunlop et al.24 specifi-
example, are serious and prevalent prob- form a suicide pact was reported in Japan in cally examined possible contagion effects on
lems.14---19 Cyberbullying typically refers to 2000. It has now become a more common suicidal behavior via the Internet and social
when a child or adolescent is intentionally and form of suicide in Japan,27 where the suicide media. Of 719 individuals aged 14 to 24
repeatedly targeted by another child or teen in rate increased from 34 suicides in 2003 to years, 79% reported being exposed to suicide-
the form of threats or harassments or humili- 91 suicides in 2005.28 South Korea now related content through family, friends, and
ated or embarrassed by means of cellular has one of the world’s highest suicide rates traditional news media such as newspapers,
phones or Internet technologies such as e-mail, (24.7/100 000 in 2005), and evidence exists and 59% found such content through Internet
texting, social networking sites, or instant that cybersuicide pacts may account for almost sources. Additional analysis revealed no link
messaging.17 Cyber harassment and cyber one third of suicides in that country.29 Cur- between social networking sites (e.g., Face-
stalking typically refer to these same actions rently, a dearth of published information is book) and suicidal ideation, but it did find
when they involve adults. A review of data available regarding the number of cybersuicide a connection between suicidal ideation and
collected between 2004 and 2010 via survey pacts in the United States. The problem of suicide-related content found on online forums.
studies indicated that lifetime cyberbullying cybersuicide pacts has gained international Video-sharing Web sites have also gained
victimization rates ranged from 20.8% to attention, however, and more research is in presence and popularity on the Internet,
40.6% and offending rates ranged from 11.5% needed to understand social media’s impact on especially since the creation of YouTube in
to 20.1%.18 the formation of Internet-based suicide pacts. 2005.44 A primary concern with suicide or
Cyberbullying, when directly or indirectly The Internet has also provided a way for self-harm videos is that they may normalize
linked to suicide, has been referred to as cyber- people to obtain how-to descriptions of suicide and reinforce self-injurious behaviors or cause
bullicide.14 Hinduja and Patchin19 reported re- as well as lethal means to kill themselves. disinhibition.45,46 Lewis et al.45 examined the
sults from a survey given to approximately 2000 Unregulated online pharmacies outside of the accessibility and content of the most popular
middle school children that indicated that vic- United States have posed a significant risk to YouTube videos associated with nonsuicidal
tims of cyberbullying were almost 2 times as the public.30 For example, Beatson et al.31 self-injury, such as self-cutting, burning, and
likely to attempt suicide than those who were described the case of a man in his 30s who hitting oneself. In 2009, they conducted
not. These results also indicated that cyberbul- committed suicide by overdosing on clomipr- a search on the keywords “self-injury” and
lying offenders were 1.5 times as likely to report amine bought from an online pharmacy out- “self-harm” via YouTube’s search option and
having attempted suicide than children who side the United States that did not require rated and analyzed the 50 most-viewed char-
were not offenders or victims of cyberbullying. a prescription. Unfortunately, despite the de- acter videos (featuring live individuals) and 50
Although cyberbullying cannot be identified as velopment over the past decade of increased most-viewed noncharacter videos. Their results
a sole predictor of suicide in adolescents and regulations and accreditation of Internet phar- showed that the top videos had more than 2
young adults, it can increase risk of suicide by macies through organizations such as the Na- million viewers and more than half (58%) had
amplifying feelings of isolation, instability, and tional Association of Boards of Pharmacy, the no viewer restrictions, such as requiring
hopelessness for those with preexisting emo- fight against unregulated online pharmacies viewers to validate that they are aged 18 years
tional, psychological, or environmental that distribute unapproved or counterfeit drugs or older. Lewis et al. reported that of the videos
stressors.20 continues worldwide.30 that were retrievable during coding, 42 were
A suicide pact is an agreement between 2 or Message boards or forums have been used neutral (neither promoted nor discouraged
more people to die by suicide at a particular to spread information on how to die by suicide. nonsuicidal self-injury, 26 were against self-
time and often by the same lethal means.21,22 In Japan in 2008, 220 cases of people injury, 23 provided a mixed message (both
A suicide pact that has been formed or attempting suicide via hydrogen sulfide gas for and against self-injury), and 7 were

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pro---self-injury. Sixty-four percent had visual awareness of prevention programs, crisis help Google’s Internet search engine has a feature
representations (such as photographs) of self- lines, and other support and educational re- that displays a link and message about the
harming, specifically cutting. Lewis et al. sug- sources.52 For example, the National Suicide National Suicide Prevention Lifeline at the top
gested that these results represent an alarming Prevention Lifeline Facebook page53 had more of the search page when keyword searches
trend that may foster communities in which than 29 300 fans as of November 2011, and suggest suicidal ideation or intent (e.g., “I want
nonsuicidal self-injury is encouraged and there- the American Foundation of Suicide Preven- to die”). We found similar suicide prevention
fore increase the risk for self-injurious behavior. tion54 Facebook page had more than 77 200 links when we conducted the same search on
Social media platforms such as chat rooms fans. Both of these Facebook pages provide Yahoo. However, prosuicide sites were the first
and discussion forums may also pose a risk for links to suicide prevention Web sites and hot- to appear when we used some other popular
vulnerable groups by influencing decisions to lines, as well as information about the warning search engines. We also found a public Face-
die by suicide.10,24,47 In particular, interactions signs of suicide. We also found 580 groups on book page called “Report and Eliminate From
via chat rooms or discussion forums may foster Twitter and 385 blog profiles on Blogger.com Facebook Pro-Suicide Groups”58 that is
peer pressure to die by suicide, encourage designated as suicide prevention. These social intended to help facilitate the removal of links
users to idolize those who have completed media sites allow users to interact and share to prosuicide sites on Facebook.
suicide, or facilitate suicide pacts.34 Ultimately, relevant information, stories, and events in their Social networking sites Facebook, MySpace,
these interactions may reduce the doubts or local areas. and Bebo have collaborated with the United
fears of people who are ambivalent about YouTube also has many videos devoted to Kingdom Child Exploitation and Online Pro-
suicide. A trend also appears to be emerging in suicide prevention, including those in the form tection Centre (CEOP) to provide a panic-but-
which people use social media to leave suicide of public service announcements. For example, ton application to give users an easy way to
notes.34,48,49 Suicide notes left by individuals the Department of Veterans Affairs55 pro- report cyberbullying.59 A ClickCEOP applica-
via social media are shared with the public duced suicide prevention public service an- tion can be used to report postings that explic-
instantaneously and may influence the deci- nouncements that encourage veterans and itly target an individual or individuals with
sions of other vulnerable people who encoun- service members to seek help. We also found harassing, threatening, and hateful comments.
ter them. announcements from nonprofit organizations The ClickCEOP application had more than
Social media may also pose a hazard to and universities that promote suicide preven- 1500 active Facebook users as of July 2011.60
vulnerable people through the formation and tion awareness programs at both the institu- The ClickCEOP Facebook page61 includes in-
influence of “extreme communities”50—online tional and the national level. Other videos formative surveys, resources, and resource
groups that promote and provide support for were created by individual users and feature links to increase awareness of the cyberbully-
beliefs and behaviors normally unacceptable support and prevention content such as me- ing problem.
by the social mainstream such as anorexia, morials for loved ones who died by suicide and Facebook has also teamed up with the
suicide, and deliberate amputation.50,51 Similar personal stories of getting help.56 United Kingdom- and Ireland-based Samari-
to users of pro---eating disorder sites, users of The National Suicide Prevention Lifeline’s tans charity organization to launch a suicide
prosuicide sites may find support and accep- lifeline-gallery.org Web site57 features an in- alert reporting system so that Facebook users
tance that they have not found through other novative social media platform in which suicide can report individuals who they believe are
means.50Although these online groups may survivor stories are presented by animated expressing suicidal thoughts or intent.62,63
provide the benefit of support, they may avatars (a graphical representation of the user Users can access a Report Suicidal Content
present a risk to the public by encouraging or the user’s alter ego or character). Site users page 64 through the Help Center link on their
vulnerable individuals to harm themselves. can create and design the appearance of their profile page. The Report Suicidal Content page
In sum, evidence is growing that social media avatars, write a description about their per- is used to collect data on the content, such as
can influence prosuicide behavior. Because the sonal experiences with suicide, and then record the Web address (URL) of the Facebook page,
Internet eliminates geographic barriers to their voices or choose a computer-generated the full name of the user posting the content,
communication between people, the emer- voiceover to narrate their stories. The site also and the date of the posting, as well as additional
gence of prosuicide social media sites may provides contact information for the National information. These suicide-related alerts are
present a new risk to vulnerable people who Suicide Prevention Lifeline and links to other purported to be given top priority by Face-
might otherwise not have been exposed to suicide prevention organizations. As of No- book’s operation staff, who then connect the
these potential hazards. vember 2011, users had shared more than person who reported the postings with the
880 stories. The use of this form of social Samaritan team to help give guidance and
SOCIAL MEDIA AND SUICIDE media provides an anonymous, personalized, support.63
PREVENTION and interactive experience geared toward sui- The US military has also used social media
cide prevention. to address the problem of suicide. For example,
Social networking sites for suicide preven- We also found examples of features on Web the site Afterdeployment.org 65 provides
tion can facilitate social connections among and social media sites that allowed for pro- psychoeducation and suicide outreach infor-
peers with similar experiences and increase active prevention capabilities. For example, mation via social networking sites and blogs

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 FRAMING HEALTH MATTERS

accessible from the site. Other military sites depressed women to discuss suicide or self- speech and expression. Restrictions on Internet
that provide suicide awareness and support harm via blogs. Ultimately, additional research content may possibly present a slippery-slope
information through social media platforms in this area will help to inform public health--- problem that can lead to additional restrictions
include Suicideoutreach.org,66 Realwarriors. based approaches to suicide prevention. of these rights.
net,67 and Science.dodlive.mil.68 Videos on Several significant difficulties emerge, how- The role of social media and its potential
targeted topics, including suicide prevention, ever, when conducting research on this topic. influence on suicide-related behavior is a rela-
are also hosted and dispersed via popular First, conducting research with suicide rates as tively new and evolving phenomenon that
media outlets (YouTube) and other Web sites. an outcome variable is difficult because of society is only beginning to assess and un-
There is, however, a dearth of published data suicide’s low base rate. Moreover, the variabil- derstand. The emerging data regarding the
to date regarding the effectiveness of these ity in social media format, use patterns, and influence of the Internet and social media on
platforms and the aforementioned social me- other influences on suicidal behavior makes suicide behavior have suggested that these
dia---based suicide prevention programs. it very difficult to test social media as a variable forms of technology may introduce new threats
that predicts suicidal behavior. For example, to the public as well as new opportunities for
CONCLUSIONS an increased prevalence of other risk factors, assistance and prevention. Because social me-
such as alcohol use and availability of firearms dia are mostly created and controlled by end
Public health is concerned with protecting among teens, might also explain the rise in users, the opportunity for surveillance and
and improving the health of entire populations, suicide rates among this vulnerable group.73 prevention can be extended to all users. To
whether those populations are small commu- Moreover, the causal role of social media in help facilitate this user-driven approach to
nities or large nations. Social media, as we a person’s decision to die by suicide or to surveillance and prevention, all social media
understand it today, has created virtual com- acquire the means to do so may not be direct. sites could adopt simple-to-use methods for
munities without physical borders. We have That is, whether an at-risk person is more users to report malicious Web sites and activ-
presented evidence showing that social media likely to die by suicide because he or she can ities of other users. Moreover, the public pro-
may pose a risk to vulnerable groups who are obtain information about it via the Internet motion of direct and easy avenues for people to
part of these virtual communities. We have also cannot be easily demonstrated. access help through social media sites should
provided some examples of extant social me- Legal issues must also be considered when be a priority. Public health campaigns that
dia---based prevention applications and pro- contemplating public health approaches to leverage the Internet and social media to raise
grams that follow from a public health---based addressing some of the problems of social awareness of the issue in schools, colleges,
approach. Framing the topic of social media media and suicide. In particular are the legal and other settings might also be beneficial.
and suicide from a public health perspective to complexities associated with the monitoring Those administrating suicide prevention and
address the issue and guide prevention pro- and filtering of content on the Internet. Al- outreach public health campaigns must also
grams makes sense. though some countries are able to control stay current with social media trends and user
More research is needed on the degree and Internet Web sites created within their borders, preferences, as well as pertinent legal issues.
extent of social media’s negative and positive international jurisprudence makes it difficult to Ultimately, proactively using social media to
influences, as are evaluations of the effective- obtain jurisdiction over sites that originate increase public awareness of and education
ness of social media---based suicide prevention outside the United States. 74,75 Debate has also on mental health issues is a logical modern
programs. Further examination of subgroups arisen as to whether the public sector or the public health approach that can potentially
that might be most vulnerable to suicide-pro- private sector should be responsible for save lives. j
moting influences of social media is also war- restricting content on the Internet and how
ranted. A focus on adolescents and young much restriction should be allowed.75 In gen- About the Authors
adults is intuitive given that suicide is the third eral, the Internet is less regulated than other David D. Luxton, Jennifer D. June, and Jonathan M. Fairall
are with the National Center for Telehealth and Technology,
leading cause of death among these groups and forms of media. Fiedorowicz and Chigurupati6
Joint Base Lewis-McChord, WA.
that these groups have a high likelihood of pointed out that when radio, television, and Correspondence should be sent to David D. Luxton, PhD,
encountering suicide-associated content on the newspapers broadcast or publish material of National Center for Telehealth and Technology (T2), 9933
West Hayes Street, Joint Base Lewis-McChord, WA 98431
Internet.24,33,69,70 Moreover, people with questionable intent or accuracy, they may be
(e-mail: david.luxton@us.army.mil). Reprints can be or-
mental illness and alcohol and substance abuse scrutinized by regulators or possibly lose rat- dered at http://www.ajph.org by clicking on the ‘‘Reprints’’
problems, who may already be at high risk ings as a consequence. The generation and link.
This article was accepted November 28, 2011.
for suicide,71 may be more likely than others to transmission of information via the Internet
Note. The opinions or assertions contained herein are
use the Internet to discuss and learn about and social media, however, are decentralized the private views of the authors and are not to be construed
suicide methods.6 Preliminary data have also and constantly being changed and updated by as official or as reflecting the views of the Department of the
Army or the Department of Defense.
been gathered regarding gender-based risk. end users. Thus, the Internet is an open
Clarke and van Amerom72 examined blogs gateway with few restrictions on content.
Contributors
created by depressed people and found that Ultimately, the control of Internet content in- D. D. Luxton originated the idea for this article. All
depressed men were more likely than volves First Amendment rights of freedom of authors contributed to research and writing of the article.

S198 | Framing Health Matters | Peer Reviewed | Luxton et al. American Journal of Public Health | Supplement 2, 2012, Vol 102, No. S2
 FRAMING HEALTH MATTERS

Acknowledgments bullying and victimization. Comput Human Behav. challenges and opportunities explored. Early Interv Psy-
We thank Mark A. Reger, PhD, Julie T. Kinn PhD, and 2011;28(1):226---232. chiatry. 2008;2(2):108---113.
Trisha A. Fintel for their comments on an earlier version 17. Kowalski RM, Limber SP, Agatston PW. Cyber 36. Williams J. The effect on young people of suicide
of this article. Bullying: Bullying in the Digital Age. Malden, MA: Black- reports in the media. Ment Health Pract. 2011(8);14:
well PublishingLtd; 2008. 34---36.
Human Participant Protection 18. Hinduja S, Patchin JW. Cyberbullying Research 37. Coleman L. The Copycat Effect: How the Media and
No protocol approval was needed for this study because Center: Research. Available at: http://www.cyberbullying. Popular Culture Trigger the Mayhem in Tomorrow’s
no human participants were involved. us/research.php. Accessed August 1, 2011. Headlines. New York, NY: Pocket Books; 2004.
19. Hinduja S, Patchin JW. Bullying, cyberbullying, and 38. Etzersdorfer E, Voracek M, Sonnech G. A dose-
suicide. Arch Suicide Res. 2010;14(3):206---221. response relationship between irrational suicides and
References
1. Kaplan AM, Haenlein M. Users of the world, unite! 20. Hinduja S, Patchin JW. High-Tech Cruelty. Educ newspaper distribution. Arch Suicide Res. 2004;8
The challenges and opportunities of social media. Bus Leadersh. 2011;68(5):48---52. (2):137---145.
Horiz. 2010;53(1):59---68 . 21. Rajagopal S. Suicide pacts and the Internet: complete 39. Jeong J, Shin SD, Kim H, Hong YC, Hwang SS, Lee EJ.
2. Facebook. Statistics. Available at: http://www.face- strangers may take cyberspace pacts. BMJ. 2004;329 The effects of celebrity suicide on copycat suicide
book.com/press/info.php?statistics. Accessed June 8, 2011. (7478):1298---1299. attempt: a multi-center observational study. Soc Psychia-
try Psychiatr Epidemiol. 2011; Epub ahead of print.
3. Socialbakers. Facebook statistics by country. Avail- 22. Brown M, Barraclough B. Epidemiology of suicide
able at: http://www.socialbakers.com/facebook-statistics. pacts in England and Wales, 1988-92. BMJ. 1997;315 40. Pirkis J, Blood RW. Suicide and the media. Part I:
Accessed July 18, 2011. (7103):286---287. reportage in nonfictional media. Crisis. 2001;22(4):146---
154.
4. Centers for Disease Control and Prevention. Suicide 23. Rajagopal S. The Internet and suicide pacts. In: Sher
and self-inflicted injury. Available at: http://www.cdc. L, Vilens A, eds. Internet and Suicide. New York, NY: Nova 41. Seno A, Mutsuko M. Isolated in their grief. Asiaweek.
gov/nchs/fastats/suicide.htm. Updated January 27, Science Publishers; 2009:185---196. Available at: http://quiz.cnn.com/ASIANOW/asiaweek/
2012. Accessed November 9, 2011. 98/0522/feat1.html. Accessed July 1, 2011.
24. Dunlop SM, More E, Romer D. Where do youth
5. World Health Organization. Mental health: suicide learn about suicides on the Internet, and what influence 42. Stack S. Media impact on suicide a quantitative
prevention. Available at: http://www.who.int/mental_ does this have on suicidal ideation? J Child Psychol review of 293 findings. Soc Sci Q. 2000;81(4):957---971.
health/prevention/en. Accessed November 9, 2011. Psychiatry. 2011;52(10):1073---1080. 43. Hawton K, Williams K. Influences of the media on
6. Fiedorowicz JG, Chigurupati RB. The Internet in 25. Johnstone C. How and why do the suicidal go suicide researchers, policy makers and media: personal
suicide prevention and promotion. In: Sher L, Vilens A, online? We need more research. Available at: http:// need to collaborate on guidelines. BMJ. 2002;325
eds. Internet and Suicide. New York, NY: Nova Science www.guardian.co.uk/commentisfree/2011/mar/25/sui- (7377):1374---1375.
Publishers; 2009:1---12. cidal-online-research-internet-suicide. Accessed June 27, 44. Website Monitoring Blog. YouTube facts & figures
7. Jones T. A deadly web of deceit. The Washington Post. 2011. (history & statistics). Available at: http://www.website-
January 10, 2008. http://www.washingtonpost.com/wp- 26. Narang P, Lippmann SB. The Internet: its role in the monitoring.com/blog/2010/05/17/youtube-facts-and-
dyn/content/article/2008/01/09/AR2008010903367_ occurrence and prevention of suicide. In: Sher L, Vilens figures-history-statistics. Published May 17, 2010. Ac-
pf.html. Accessed August 1, 2011. A, eds. Internet and Suicide. New York, NY: Nova Science cessed June 13, 2011.

8. Holladay J. Cyberbullying: The stakes have never Publishers; 2009:13---20. 45. Lewis SP, Heath NL, St Denis JM, Noble R. The scope
been higher for students—or schools. Teach Tolerance. 27. Naito A. Internet suicide in Japan. Clin Child Psychol of nonsuicidal self-injury on YouTube. Pediatrics.
2010;38:42---45. Psychiatry. 2007;12(4):583---597. 2011;127(3):e552---e557.

9. Duke A. Demi Moore responds to Twitter suicide 28. Hitosugi M, Nagai T, Tokudome S. A voluntary 46. Suler J. The online disinhibition effect. Cyberpsychol
threat. Available at: http://articles.cnn.com/2009-04- effort to save the youth suicide via the Internet in Japan. Behav. 2004;7(3):321---326.
03/entertainment/moore.twitter.threat_1_tweet-twitter- Int J Nurs Stud. 2007;44(1):157. 47. Becker K, Schmidt MH. Internet chat rooms and
message?_s=PM: SHOWBIZ. Accessed June 6, 2011. 29. Elusive, but not always unstoppable: people end suicide. J Am Acad Child Adolesc Psychiatry. 2004;43
10. Biddle L, Donovan J, Hawton K, Kapur N, Gunnell D. their own lives for many reasons, only some of which are (3):246---247.
Suicide and the Internet. BMJ. 2008;336(7648):800--- understood—but governments should not simply shrug 48. Ruder TD, Hatch GM, Ampanozi G, Thali MJ,
802. their shoulders. Economist. Available at http://www. Fischer N. Suicide announcement on Facebook. Crisis.
11. Recupero R, Harmss E, Noble JM. Googling suicide: economist.com/node/9370744. Published June 23, 2011;32(5):280---282.
surfing for suicide information on the internet. J Clin 2007. Accessed July 18, 2011. 49. South Korean man posts suicide note on Twitter.
Psychiatry. 2008;69(6):878---888. 30. National Association of Boards of Pharmacy. 5,000 Telegraph. Available at: http://www.telegraph.co.uk/
12. Shah A. The relationship between general popula- Web sites selling prescription drugs outside of pharmacy technology/twitter/7831684/South-Korean-man-posts-
tion suicide rates and the Internet: a cross-national study. laws and practice standards. Available at: http://www. suicide-note-on-Twitter.html. Published June 16, 2010.
Suicide Life Threat Behav. 2010;40(2):146---150. nabp.net/news/5000-web-sites-selling-prescription- Accessed July 7, 2011.
drugs-outside-of-pharmacy-laws-and-practice-standards. 50. Bell V. Online information, extreme communities
13. Hagihara A, Tarumi K, Abe T. Media suicide-reports,
Published December 28, 2009. Accessed July 7, 2011. and internet therapy: is the Internet good for our mental
Internet use and the occurrence of suicides between 1987
and 2005 in Japan. BMC Public Health. 2007;7:321. 31. Beatson S, Hosty GS, Smith S. Suicide and the health? J Ment Health. 2007;16(4):445---457.
Internet. Psychiatr Bull. 2000;24:434. 51. Davies P, Lipsey Z. Ana’s gone surfing. Psychologist.
14. Hinduja S, Patchin JW. Bullying Beyond the School-
yard: Preventing and Responding to Cyberbullying. Thou- 32. Morii D, Yasusuke M, Nakamae N, Murao M, 2003;16(pt 8):424---425.
sand Oaks, CA: Sage Publications; 2009. Taniyama K. Japanese experience of hydrogen sulfide: the 52. Luxton DD, June JD, Kinn JT. Technology-based
suicide craze in 2008. J Occup Med Toxicol. 2011;5:28. suicide prevention: current applications and future di-
15. Hinduja S, Patchin JW. Cyberbullying: identifica-
tion, prevention, and response. Available at: http:// 33. Whitlock JL, Powers JL, Eckenrode J. The virtual rections. Telemed J E Health. 2011;17(1):50---54.
www.cyberbullying.us/Cyberbullying_Identification_ cutting edge. Dev Psychol. 2006;42(3):407---417. 53. Facebook. National Suicide Prevention Lifeline “1-
Prevention_Response_Fact_Sheet.pdf. Accessed June 34. Baume P, Cantor CH, Rolfe A. Cybersuicide: the role 800-273-TALK (8255).” Available at: http://www.
20, 2011. of interactive suicide notes on the Internet. Crisis. facebook.com/home.php#!/800273TALK. Accessed
16. Law DM, Shapka JD, Hymel S, Olson BF, 1997;18(2):73---79. November 9, 2011.
Waterhouse T. The changing face of bullying: an em- 35. Webb M, Burns J, Collin P. Providing online support 54. Facebook. American Foundation for Suicide Pre-
pirical comparison between traditional and Internet for young people with mental health difficulties: vention. Available at: http://www.facebook.com/search.

Supplement 2, 2012, Vol 102, No. S2 | American Journal of Public Health Luxton et al. | Peer Reviewed | Framing Health Matters | S199
 FRAMING HEALTH MATTERS

php?q=suicide+awareness+and+prevention&type=all& 71. Harris EC, Barraclough B. Suicide as an outcome

init=srp#!/AFSPnational. Accessed November 9, 2011. for mental disorders. A meta-analysis. Br J Psychiatry.
1997;170:205---228.
55. Maslow Media Group Inc., US Department of
Veteran Affairs. Public service announcement on suicide 72. Clarke J, van Amerom G. A comparison of blogs by
prevention with Gary Sinise. Available at: http://www. depressed men and women. Issues Ment Health Nurs.
youtube.com/watch?v=bDj62nccYYc. Accessed August 2008;29(3):243---264.
1, 2011. 73. Gould M, Greenberg T, Velting D, Shaffer D. Youth
56. National Suicide Prevention Lifeline. The Terry suicide risk and preventive interventions: a review of the
past 10 years. J Am Acad Child Adolesc Psychiatry.
Wise story: a suicide attempt survivor. Available at:
2003;42(4):386---405.
http://www.youtube.com/800273TALK. Stories of
hope and recovery series. Accessed August 1, 2011. 74. Mishara BL, Weisstub DN. Ethical, legal and prac-
tical issues in the control and regulation of suicide
57. National Suicide Prevention Lifeline. Lifeline Gal-
promotion and assistance over the Internet. Suicide Life
lery. Available at: http://www.lifeline-gallery.org. Threat Behav. 2007;37(1):58---65.
Accessed August 1, 2011.
75. Bambauer D, Palfrey JG, Zittrain JL. A starting point:
58. Facebook. Report and eliminate from Facebook pro- legal implication of Internet filtering. Available at: http://
suicide groups. Available: http://www.facebook.com/ opennet.net/docs/Legal_Implications.pdf. Published
help/?faq=216817991675637&ref_query=suicide#!/ September 2004. Accessed November 9, 2011.
group.php?gid=61740703798&v=info. Accessed Au-
gust 1, 2011.
59. Sweney M. Facebook ClickCeop app to offer op-
tional “panic button.” Guardian. Available at: http://
www.guardian.co.uk/technology/2010/jul/12/face-
book-clickceop-app-optional-panic-button. Published July
11, 2010. Accessed July 22, 2011.
60. Facebook. ClickCEOP [application]. Available at:
http://apps.facebook.com/clickceop. Accessed July 22,
2011.
61. Facebook. ClickCEOP. Available at: http://www.
facebook.com/home.php#!/clickceop. Accessed Novem-
ber 9, 2011.
62. News BBC. Facebook adds Samaritans suicide risk
alert system. Available at: http://www.bbc.co.uk/news/
technology-12667343. Updated March 7, 2011.
Accessed November 15, 2011.
63. Samaritans. Samaritans launches Facebook drive to
encourage support for friends struggling to cope. Avail-
able at: http://www.samaritans.org/default.aspx?page=
8359. Accessed June 14, 2011.
64. Facebook. Report suicidal content. Available at: http://
www.facebook.com/help/contact.php?show_form=suicidal_
content. Accessed August 1, 2011.
65. National Center for Telehealth and Technology.
Available at: http://www.afterdeployment.org. Accessed
November 9, 2011.
66. National Center for Telehealth and Technology.
DoD/VA suicide outreach: resources for suicide pre-
vention. Available at: http://www.suicideoutreach.org.
Accessed August 1, 2011.
67. Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury. Real warriors, real
battles, real strength. Available at: http://realwarriors.
net. Accessed August 1, 2011.
68. US Department of Defense. Armed with science.
Available at: http://science.dodlive.mil. Accessed August
1, 2011.
69. Dobson R. Internet sites may encourage suicide.
BMJ. 1999;319(7206):337.
70. Messias E, Castro J, Saini A, Usman M, Peeples D.
Sadness, suicide, and their association with video game
and internet overuse among teens: results from the Youth
Risk Behavior Survey 2007 and 2009. Suicide Life
Threat Behav. 2011;41(3):307---315.

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