Child Psychiatrists: We Desperately Need More Shows Like & Juliet

When the American Academy of Child and Adolescent Psychiatry (AACAP) annual meeting is in New York City, child psychiatrists will dash to Broadway. But there was something special about this musical that drew their attention. As a part of the AACAP program entitled, “Mozart Across the Millenia, A New Papageno Production: & Juliet,” nearly 100 AACAP members saw the show in an effort to explore the potential Papageno (or suicide protective) effect of the musical as Juliet’s alternate ending involves her overcoming a suicidal crisis and finding non-suicide alternatives. The term “Papageno Effect” was named after a character in Mozart’s opera The Magic Flute who overcomes his own suicidal crisis with the help of 3 spirits. In a country where suicide is the second or third leading cause of death for 10-14 and 15-24 year olds respectively, media with potential suicide protective effects are greatly needed.¹ Recent entertainment media intended for youth audiences such as 13 Reasons Why, which was associated with higher suicide rates following the show’s release, have drawn concern.² Similarly, in their 2022 report,³ the Trevor Project found that two thirds of the 13-24-year-olds who identify as LGBTQ+ who were polled noted that news media coverage related to laws which restrict transgender individuals’ rights impacted their mental health negatively. Additionally, the majority of those polled reported that racism was the most important issue impacting the world. & Juliet is an example of how shows can be used to improve public mental health through modeling of help seeking/problem solving in “Papageno” stories, inclusive and authentic positive representation, and inspiring hope. We call for the entertainment industry to follow its lead.

This adaptation of Romeo & Juliet sends the hopeful message that we do not know what good things may be around the corner, to the upbeat backdrop of Max Martin’s pop hits. At the same time, it highlights one’s sense of personal agency in the ability to problem solve, turn that corner together with trusted supports, and forge a new path.

Research has shown that media can confer suicide contagion or suicide protective effects which are likely mediated through social learning of modeled behavior depicted on screen.^2,4,5 For example, if a character is shown to reach out for help, a viewer who identifies with that character may be more likely to do the same. Because of this research, guidelines have been made publicly available for news and entertainment media.^6,7 & Juliet did a great job of following the guidelines of showing that help is available, portraying characters with suicidal thoughts who do not go on to die by suicide, and portraying everyday characters who can be a lifeline. In the show, multiple characters face relatable struggles, leaning on each other to work through their problems. Juliet knows her worth in a society that has decided she has none. May is a nonbinary character finding love with the support of their friend group. Angelique steps out of the sidelines to become a main character, showing us that love can be found at any stage of life. William Shakespeare and his wife, Anne Hathaway, walk us through the trials of marriage and growing as a couple. Shakespeare learns to compromise his professional ideals in the name of personal progress. The show creators exemplify personal agency in their reimagination of this play, which in its original form, actually has the potential to confer suicide contagion in vulnerable communities. This is mirrored in Shakespeare and Anne’s ability to tap into endless possibilities and alternate endings as they write the musical as it unfolds, further solidifying the message of personal agency.

Research also focuses on the importance of authentic and positive representation in media. In their 2022 report,⁸ the Center for Scholars and Storytellers noted that LGBTQ+ teens ranked LGBTQ+ and mental health as their top 2 topics of content that they want to watch. Additionally, the majority of the 662 teens (aged 13-18) polled wanted a Black male cast as the hero, which they noted has the potential to reduce implicit bias in viewers.⁹ We know that for youth who identify as LGBTQ+, having 1 supporting adult in their life can significantly reduce their risk for suicide,¹⁰ but unfortunately not all youth have this. However, authentic and positive media representation of characters without tragic endings can help and has helped in this respect.

A shared commentary from the AACAP attendees was that unfortunately this production is not accessible to all youth who may benefit from it. However, our hope is that by spreading the word of its potentially positive effects, & Juliet may reach more individuals and encourage the creation of similarly preventative productions. If it is adapted for screen (as has been done for productions like Hamilton), its reach would be wider still, especially since youth are actually spending the largest fraction of their screen time streaming shows/movies.¹¹ As a tool for advocacy and public health, media has great potential to reach a large audience. Its effect for change could even be measured in human lives saved.

Dr Sust is clinical assistant professor of Psychiatry and Behavioral Sciences at Stanford University, and a child & adolescent psychiatry specialist. Dr Harness is a clinical assistant professor in the Department of Psychiatry at the University of Michigan. Dr Berson is an assistant professor in the Department of Psychiatry at the University of South Carolina School of Medicine in Greenville, SC.

References

1. 10 Leading Causes of Death, United States, 2020. National Vital Statistics System; National Center for Health Statistics; CDC. Accessed January 15, 2024. https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2020-508.pdf

2. 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(2):236-243.

3. Issues impacting LGBTQ youth. The Trevor Project. 2022. Accessed January 15, 2024. https://www.thetrevorproject.org/wp-content/uploads/2022/01/TrevorProject_Public1.pdf

4. Domaradzki J. The Werther effect, the Papageno effect or no effect? A literature review. Int J Environ Res Public Health. 2021;18(5):2396.

5. Niederkrotenthaler T, Till B, Kirchner S, et al. Effects of media stories of hope and recovery on suicidal ideation and help-seeking attitudes and intentions: systematic review and meta-analysis. Lancet Public Health. 2022;7(2):e156-e168.

6. Reporting on suicide prevention. American Foundation for Suicide Prevention. 2021. Accessed January 15, 2024. https://afsp.org/reporting-on-suicide-prevention/

7. Entertainment messaging. National Action Alliance for Suicide Prevention. Accessed January 15, 2024. https://theactionalliance.org/messaging/entertainment-messaging

8. Rivas-Lara S, Pham B, Baten J, et al. CSS teens & screens 2022. Center for Scholars & Storytellers; UCLA. 2022. Accessed January 15, 2024. https://static1.squarespace.com/static/633f0603fdaa7311ba384d21/t/641a88d4c053171de1819a84/1679460573224/Teens+%26+Screens+2022.pdf

9. Lai CK, Marini M, Lehr SA, et al. Reducing implicit racial preferences: I. A comparative investigation of 17 interventions. J Exp Psychol Gen. 2014;143(4):1765-1785.

10. The Trevor Project Research Brief: Accepting Adults Reduce Suicide Attempts Among LGBTQ Youth. The Trevor Project. 2019. Accessed January 15, 2024. https://www.thetrevorproject.org/wp-content/uploads/2019/06/Trevor-Project-Accepting-Adult-Research-Brief_June-2019.pdf

11. Nagata JM, Abdel Magid HS, Pettee Gabriel K. Screen time for children and adolescents during the Coronavirus disease 2019 pandemic. Obesity (Silver Spring). 2020;28(9):1582-1583.