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Rapid Responses: Rapid Responses published:
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Big conclusion for small numbers
- Robert Varnam (9 April 1999)
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Influence of television drama on medical knowledge: a positive note
- Richard Wilson (9 April 1999)
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Sudden fall in suicide rates
- K Ian Johnson (10 April 1999)
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Life imitating the arts?
- Santanu Sen (10 April 1999)
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The Responsibility of Television
- Justin Stebbing (10 April 1999)
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Education about suicide
- Mark Lewis (11 April 1999)
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Effects of a drug overdose in a television drama
- Ben Green (19 April 1999)
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'The X-Files' and patient's delusions
- Oliver Howes (20 April 1999)
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An impressive study but one that raises methodological concerns
- Roger Denny (21 April 1999)
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Effect of publication in the BMJ on presentation to hospital for self poisoning
- Anthony O'Brien (3 June 1999)
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Robert Varnam, GP Registrar Rusholme, Manchester, UK
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I can't avoid the impression that some rather large leaps of faith are involved, to get from this study's results to its conclusions. Clearly, if life mirrors art as closely as is suggested here, this is a major public health issue. But how one can justify such conslusions on the basis of figures that, even at a glance, would surely disappoint most researchers, is something of a mystery to me. I appreciate the need for both this issue and this journal to retain a high public profile, and this edition has suceeded well in reaching the headlines today. However, may not "Wide Confidence Interval Science" ultimately weaken our credibility as policy-formers? |
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Richard Wilson, Research Fellow Department of Public Health and Epidemiology, University of Birmingham
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Hawton et al (1) reported the fine line between entertainment and negative influences on behaviour. However, there is also a positive side, television drama can be a source of public health information. Every year it is estimated that 50 people die (2) and a further 500 suffer acute accidental Carbon Monoxide poisoning in England and Wales.(3) Educating the public to the danger has so far proved challenging. However, an episode of the popular television soap opera Coronation Street may have proved a successful means of raising awareness. In July 1997, a major storyline was an incident of accidental Carbon Monoxide poisoning. This series is watched by 18 million in the United Kingdom. Throughout August and September a survey of gas appliance safety was carried out in Douglas, Isle of Man by an Environmental Health student. As part of this investigation respondents were asked if they could recall any incidents or adverts in the media relating to Carbon Monoxide poisoning. 60% (117/196) reported this episode of Coronation Street.(4) The storyline had been suggested to the producers of Coronation Street by Stephanie Trotter of the Carbon Monoxide and Gas Safety charity (CO-GAS Safety). It appears to have succeeded in raising public knowledge of Carbon Monoxide poisoning but it remains to be seen whether it will change people's habits regarding the maintenance of fuel burning appliances. For further information regarding Carbon Monoxide Poisoning you can contact CO-GAS Safety on (01372) 466135. Richard Wilson Research Fellow Division of Primary, Public and Occupational Health University of Birmingham Birmingham B15 2TT Tel:(0121) 414 7851 Fax:(0121) 414 7878 Email: r.c.wilson@bham.ac.uk Karen Leslie MSc Student School of Chemistry University of Birmingham Birmingham B15 2TT Email: Kleslie8@hotmail.com Pat Saunders Regional Environmental Health Advisor Division of Primary, Public and Occupational Health University of Birmingham Birmingham B15 2TT Tel:(0121) 414 3985 Fax:(0121) 414 7878 Email: p.j.saunders@bham.ac.uk Stephanie Trotter President Carbon Monoxide and Gas Safety charity Lorien House Common Lane Claygate Surrey KT10 0HY Tel:(01372) 466135 Fax:(01372) 468965 References 1. Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Philo G, Bulstrode C. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study. BMJ 1999;318:972-977. 2. Calman K, Moores Y. Carbon Monoxide: The Forgotten Killer - PL/CMO/98/5. London: Department of Health, 1998. 3. Wilson RC, Saunders PJ, Smith G. An epidemiological study of acute carbon monoxide poisoning in the West Midlands. OEM 1998;55:723-8. 4. Leslie K. Survey of non-intentional Carbon Monoxide poisoning awareness amongst occupants of the Isle of Man. School of Chemistry, University of Birmingham, 1998. |
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K Ian Johnson, Healthcare consultant Interphase
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Whilst one cannot dispute the association between an increase in the incidence of self-poisoning and the Casualty case study, one wonders at the statistics for other suicide rates over this period: did the programme really precipitate an unprecendented increase in suicide or did it merely highlight a well documented safety issue over paracetamol? As Simon Weston recounted on a similarly influential programme last night: "It's not the fall that kills you, but the sudden stop at the end". |
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Santanu Sen, SHO Paediatrics Royal Oldham Hospital, Oldham OL1 2JH
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The very interesting article by Hawton et al (1)on the profound influence that television has on our lives was really captivating. Once again their results have shown that the arts which supposedly depict life do have a great influence on our subsequent behaivior. However whether we should really have a say on the advisibility of the media in portraying suicidal behaivior is open to question. Violence has unfortunately always been a part of human life. Whether it is television, radio, newspapers or even gossip on the streets we have always been fascinated by violence. The feeding frenzy on the coverage of the war in Kosovo just seems to prove the point even more. In this background I wonder whether any kind of censorship of the media would really lead to any changes in behaivior. And if we were to start making such changes, where can we really stop? By banning all depiction of violent behaivior? It does seem like shades of Big Brother to me. However I do agree that more information should be provided to the viewers in such serials if at all possible. The storyline doesn't make any mention of the fact that an effective treatment is available for paracetamol poisoning, though again I wonder whether such information even if included would really make any changes in subsequent behaivior. Paracetamol is now the most common drug used for self poisoning in the UK. Instead of going in for any changes or restrictions in the mass media I wonder whether the time has come to put some kind of restriction in the availability of this drug in the UK. As reported by Gunnel et al (2) fatality rates from paracetamol poisoning are four times as high in England and Wales as compared to France where such restrictions are in place. References 1. Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Philo G, Bulstrode C. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study. BMJ 1999;318:972-977 2. Gunnel D, Hawton K, Murray V, Garnier R, Bismuth C, Fagg J, Simkin S. Use of paracetamol for suicide and non fatal poisoning in the UK and France: are restrictions on availability justified? J Epidimiol Community Health 1997 Apr 51(2):175-179 |
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Justin Stebbing, Senior Resident in Internal Medicine The Johns Hopkins Hospital, Baltimore, MD 21201, USA
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EDITOR - The enjoyable articles by Bulstrode and colleagues (refs 1 and 2) highlighted the fact that many individuals base medical decisions on incomplete information obtained in television dramas. The information presented is easily misinterpreted and occurs with all types of television shows. In a recent episode of Fox TV's 'The Simpson's', the lead character, Bart, donated a kidney to his father. During the cartoon, Doctor Hibbard appropriately points out the long waiting list for cadaveric transplants is shortened with living related donors. Following the procedure, Bart's mother turned to him and calmly remarked "You've done a wonderful thing! You've significantly shortened your life so that someone could extend theirs for a short period." The cartoon then abruptly ended surely leaving many (including a patient that I cared for!) with the impression that there is a significant morbidity and mortality associated with donating a kidney. The evidence that mortality rates associated with kidney donation is similar to that of the general population (ref 3) was irrelevant. The producers of Casualty and The Simpson's know these shows draw a wide and varied audience but they are not accountable. Whether in a news story or in a cartoon, information about medical procedures needs to be accurate as it is clear that people base major life decisions on these sources. The unfortunate results of portraying suicidal behaviour in Casualty and harm from organ donation in an American cartoon are undoubtedly just two examples of many. Justin Stebbing MA MRCP Resident in Internal Medicine The Johns Hopkins Hospital Baltimore, Maryland 21205 USA Tel. 410-467-6188 jstebb@welchlink.welch.jhu.edu 1 O'Connor S, Deeks JJ, Hawton K, Simkin S, Keen A, Altman DG, Philo G, Bulstrode C. Effects of a drug overdose in a television drama on knowledge of specific dangers of self poisoning: population based surveys. BMJ 1999;318:978-979. 2 Hawton K, simkin S, Deeks JJ, O'Connor, Keen A, Altman DG, Philo G, Bulstrode C. Effects of drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionairre study. BMJ 1999;318:972-977. 3 Najarian JS, Chavers BM, McHugh LE, Matas AJ. 20 years of more of follow-up of living related donors. Lancet 1992;340:807-810. |
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Mark Lewis
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It's pretty absurd to make a fuss over a bit of publicity given to paracetamol
overdose when a comprehensive list of
suicide methods is freely available on the internet.
That list describes the effects of paracetamol overdose as "acute toxic hepatitis, renal failure, cerebral oedema, intra-abdominal bleeding, aspiration pneumonia, haemophilia". I cannot believe that any realistic depiction on television of these effects would encourage anyone to choose it as a method of suicide. The best way to kill yourself is probably an overdose of heroin - readily available from a drug dealer. On that page it says "Heroin costs £20-£30 for half a gram" - which happens to be the lethal dose recommended in the above list. Knowledge about suicide methods should be regarded as similar to knowledge about contraceptive methods. People have the right to sex education, and they have the right to death education. The authors do not make clear their general attitude to suicide or free speech. With a social issue like this you really need an ethical context to complement the objective analysis - the web provides the authors with the ideal medium to provide that. I regard it as desirable that people should question whether they want to live or die, and natural that some should choose the latter. I believe in the absolute right to free speech. |
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Ben Green
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Sir I read Hawton et al's survey (BMJ 1999;318:972-7 with interest. The hypothesis that viewing television drama can affect subsequent behaviour is one which is difficult ot research and the attempt to do so is laudable, but I would draw attention to a possible confounding factor in this study. Suicide rates are generally held to be seasonally dependent and therefore looking at rates before and after any discrete point in time should necessarily take into account natural variations through the year. I do not think that this paper does that. Of course, such an effect may be minor, but nevertheless a comparison to data for deliberate self harm behaviour in the same weeks in previous years should have been performed or at least discussed as a possibility for future research. Yours sincerely Dr Ben Green Consultant Psychiatrist Honorary Senior Lecturer University of Liverpool |
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Oliver Howes
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EDITOR- The marked rise in paracetamol overdose following an episode of Casualty found by Hawton et al. (1) highlights the effects that the media in general have on health. The findings provide further evidence that the Media should be more repsonsible in their presentation of health related issues. It also indicates that their responsibilty extends beyond factual reporting to all areas. This study suggests that individual programme makers, for example, could be held accountable for the effects of their programs. The Internet, with its abscence of controls, presents even greater risks. I have seen a number of patients who obtained detailed information about the most effective suicide techniques from the WWW. Finally, the effects of the media are often strikingly seen in (the similarities between) the delusional systems of different psychotic patients. Recently I have noticed that the plots of the popular American television programme 'The X-Files' seem to be particularly common in the content of many patients' delusions. Is there any scope for a prospective study of delusions of 'alien infestation' following an episode of The X- files? Oliver Howes Senior House Officer The Maudsley Hospital Denmark Hill London SE5 8AX |
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Roger Denny, Specialist Registrar in General Psychiatry Southmead Hospital Bristol
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EDITOR - Hawton et al's examination of the effects of a medical television drama on the incidence and nature of general hospital presentations for deliberate self-poisoning1 has provoked considerable interest in medical and popular media. The role of imitation in suicide attempts is not a new phenomenon. It was named the Werther Effect after an epidemic of copycat suicides in young men who read Goethe's Die Leiden des jungen Werther. The effect has been described following television films depicting fictional suicide2. Television is certainly a powerful medium in contemporary society. We have a methodological concern about Hawton's study that was not addressed in the discussion: the study was not well controlled. They compared overdose rates between a baseline period prior to the screening of the drama with each of the three weeks following the index episode. The authors acknowledge the possibility that an overdose depicted in a second soap opera six days after the index episode may have had a minor influence on results. We note that the end of British Summer Time also coincided with the observed trend of increasing rates of overdoses that began in the week before the drama was screened. The consequent reduction in evening daylight represents an external stressor that could be associated with parasuicide. Although Shapiro et al3 could not confirm such an association, the temporal relationship of the return to "winter" timings with the rise in overdose rates raises possibility of this being a confounding factor that cannot be excluded given the methodology of the study. Other potential confounding factors include seasonal changes in weather and temperature and the impact of unrelated items in national and international news. A more robust study design would involve a comparison of the change in overdose rates before and after the November 1996 screening to the change over a similar period one year earlier or later. An alternative would be an investigation of any change in overdose rates in a region or state where the index episode was screened compared with an area where it was not shown. Hawton's study was certainly impressive in its co-ordination of data from many sources. It will continue to stimulate valuable debate on the responsibilities of media producers in portraying self- harming behaviour. We believe the results must be interpreted with caution. The limitations of the study design should be recognised. Simon JC Davies, Senior House Officer Mary Atherton, Senior House Officer Timothy Williams, Senior House Officer Jethro Purkis, Senior House Officer Gillian Combe, Senior House Officer Andrew J Brindley, Senior House Officer Geraldine McCarthy, Specialist Registrar Roger Denny, Specialist Registrar Department of Mental Health, Gloucester House, Southmead Hospital, Westbury-on-Trym, Bristol 1 Hawton K, Simkin S, Deeks JJ, O'Connor S, Keen A, Altman DG, Phil G, Bulstrode C. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study. BMJ 1999; 318:972-7.(10 April.) 2 Gould MS, Shaffer, D. The impact of suicide in television movies. N Engl J Med 1986; 315:690-4. 3 Shapiro CM, Blake F, Fossey E, Adams B. Daylight saving time in psychiatric illness. J Affect Disord 1990; 19:177-81. |
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Anthony O'Brien
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Dear BMJ Shortly after publication of a study in the BMJ claiming TV portrayal of self poisioning may increase hospital admission for overdose (1), a patient presented to us with a paracetamol overdose. Without prompting he said he had been influenced by media reporting of the results of the study. Since this information was obtained without use of a questionnaire or leading questions, we suggest that this study of one has more face validity than the published paper which appears to have significant potential for bias in data collection. Further interpretation of data collected by Hawton et al could infer that being a 'Casualty' viewer is a protective factor against taking an overdose! (22% general population watch Casualty vs 17% overdose population). Noting the BMJ's recent enthusiasm to publish papers involving TV drama (1,2,3), we are currently conducting our own audit entitled "effect of technical linguistics in a TV drama on conversations in Emergency Departments". We have just recruited our first subject; a handsome, tanned specialist registrar who managed to cram "Cross-table-C-spine, BP 60 palp, Chem 7, CBC", and "Urgent Psych consult", into a single sentence whilst drinking a Diet Coke and perspiring heavily beneath surgical blues. Yours etc. Anthony O'Brien, SHO in Psychiatry Sian Hughes, SPR in Psychiatry Hillview Lodge, Royal United Hospital, Bath 1 Hawton et al. Effects of portrayal in a TV drama on presentation to hospital for self poisoning. BMJ 1998;318: 972-7. 2 Gordon PN, Williamson S, Lawler PG. As seen on TV; observational study of CPR in British mediacl dramas. BMJ 1998;317:780-3. 3 Tim Cranford, Richard Hooper, Sarah Evans. Death rates of characters in soap operas on British television. BMJ 1998;315: 1649-52. |
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