Introduction

With an average of 8.3 million viewers on Sundays at 8:15 p.m., the “Tatort” on the German television channel “Das Erste®” of the German joint organisation of regional public broadcasters as well as on the Austrian public broadcaster ORF® and on the Swiss public broadcaster SRF® is one of the most watched crime series on German television (https://de.statista.com/statistik/daten/studie/377327/umfrage/fernsehzuschauer-der-krimireihe-tatort/, last accessed on 03.11.2022). The first episode was broadcasted in 1970 (https://www.daserste.de/unterhaltung/krimi/tatort/kommissare/bildergalerie-ehemalige-kommissare-50-jahre-tatort100.html, last access on 25.01.2023) and is still running, making it the longest-running German TV drama. It is produced in German-speaking regions, with an average of 30 90-min episodes produced per year. Each episode typically features a closed plot, beginning with a violent crime, usually involving a corpse. Major cities in Germany as Munich, Berlin and Hamburg have their own teams of investigators with unique dialects, settings and detective personalities. In addition to Germany, “Tatort” is broadcasted in 50 other countries such as Poland, Iran and the USA, partly under the name “Scene of Crime”®. With this enormous reach, the series also casually informs about various pharmacological agents, some of which are mentioned as murder weapons, but also for curative therapies. Each TV station decides for itself (if necessary, in consultation with appropriate experts) in which way medical content is shown. In Germany, there is no higher authority for prior checking as Petra Putz, ARD®-Programme Directorate declared in an email dated May 19, 2022. In addition to the analysis of the individual active pharmacological substances and checking for plausibility in the presentation and use, there are possibilities of potential dangers through errors or imitation. Also, the question of what content is presented is important: from all this, errors in treatment by medical profession, positive and negative behaviour of normal viewers in dealing with drug therapies or also dangers in using active pharmacological substances and stigmatisation of them can emerge.

This situation prompted us to systematically analyse the pharmacological content of contemporary “Tatort” episodes from 2019 to 2021.

Materials and methods

Accessibility of the data

The episodes were retrospectively analysed over a 3-year period via the ARD media library or on the Amazon® channel “Das Erste Plus” in the original language in German. Included are all the episodes from 2019 to 2021 which were first broadcasted on ARD®. Due to lack of availability, the episodes “Murot and the marmot” (“Murot und das Murmeltier”), “The monster of Kassel” (“Das Monster von Kassel”), “Home sweet Home” (“Glück allein”) and “Meat loaf” (“Falscher Hase”) were excluded.

The “Tatort” is financed by the revenues of the GEZ (Gebühreneinzugszentrale der öffentlich-rechtlichen Rundfunkanstalten” (fee collection centre of the public service broadcasters in Germany)). GEZ collects a TV tax for public broadcasting in Germany, which amounts to 18.36€ per month for every household. In Germany, it is compulsory to pay this fee for news, sports, documentaries and entertainment. One can also find lots of content on the Internet. But with the provision of the 12th Amendment to the Interstate Broadcasting Treaty (“12. Rundfunkänderungsvertrag”), GEZ-financed content is only allowed temporarily on the Internet https://www.daserste.de/unterhaltung/krimi/tatort/videos/grenzfall-video-tgl-ab-20-uhr-100.html, last accessed on 03.11.2022). Three episodes, which were mentioned above, were no longer available for streaming.

Statistical analysis

The active pharmacological substances mentioned in the movie franchise were extracted and categorised according to the given name within the episode, the purpose used, the presentation within the scene and the statements made in terms of content. In addition, it was assessed whether the presentation was plausible, whether important information was given to the viewers, whether there was a stigmatisation or heroisation of the substance, whether the use was poorly handled or whether a danger in the sense of possible misuse or risky procedures must be assumed.

The episodes were numbered according to their release. The order is based on the list found on (Wikipedia Germany, 2022) the free encyclopaedia on the Internet (https://de.wikipedia.org/wiki/Liste_der_Tatort-Folgen, last accessed on 17.11.2022).

Results and discussion

Use of active pharmacological substances

In total, 92 active pharmacological substances were named in 51 different episodes out of 101 episodes (Fig. 1). Analgesics, sedatives and anaesthetics were mentioned the most often (49%); for example, fentanyl and lorazepam were named directly. The second largest group were drugs used in internal medicine (24%), followed by psychiatric (excluding sedatives) (10%) medications, followed by herbal preparations (8%) and antidotes (7%). Homoeopathic remedies (3%) were the least common category. Table 1 shows an overview of the names given in TV episodes to active pharmacological substances. They were ordered by pharmacological groups.

Fig. 1
figure 1

Designation of the active pharmacological substances. The designation of the active pharmacological substances within the Tatort episodes shown as a bar-chart, with values for the designation within the episodes

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Table 1 Pharmacologically active substances in “Tatort” from 2019 to 2021
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In 78 mentions (~ 73% of the total), active pharmacological substances were used for curative purposes. In only 20 mentions (~ 22%), they were used to kill or harm people. In ~ 40% of these cases, active substances were misused for stunning because of abductions, in ~ 60% for direct or indirect killing through, for example, withholding the correct medication. The remaining 10 mentions (~ 11%) used active pharmacological substances in the context of dependence syndromes. Multiple mentions occurred as well: active pharmacological substances were presented as curative within some episodes and were nevertheless misused.

Active pharmacological ingredients were particularly frequently titled with actual active ingredients (> 30%) (mostly in addition to other given names in the same episode); half of them were analgesics. Despite the official ban on product placement (according to Sven Döbler (MDR editor) in an email from May 31, 2022), Ritalin® (methylphenidate which is used for treatment of attention deficit hyperactivity disorder (ADHD)) was mentioned as a trade name in one episode. Fictitious product names were given in almost 10%; frequently for analgesics, although when the real active pharmacological ingredient mentioned. Drug classes were used primarily for psychiatric medications with mentions such as “antidepressants” (“Antidepressiva”) (episodes 1090, 1102, 1181) and “psychotropic drugs” (“Antipsychotika”) (episodes 1132, 1149), but also for medications used in internal medicine like “antibiotics” (“Antibiotika”) (in total 17%). In 14% of the cases, the active pharmacological substances were given in colloquial titles (such as “heart medication” (“Herzmedikation”), e.g., episode 1165), but also without designation in 25% of the cases.

Figure 2 shows the presentation of active pharmacological ingredients of all episodes. Multiple presentations occurred. The substance itself was shown most frequently as a tablet or as a liquid in a syringe (41%), followed by naming in dialogues (33%). In 26%, the depiction of the effect was shown cinematically. Packages of medication were shown in 22% of the cases (some of them were created especially for the series, so they were fictional). The production or procurement of preparations was shown less frequently (5%). In episode 1162, the plant red foxglove was briefly shown, cryptically referring to cardiac glycoside preparations. Historically, in some countries such as Germany, cardiac glycosides had been often used in the treatment of heart failure. But internationally, cardiac glycosides are rarely used nowadays because of their toxicity. One of the adverse drug reactions of cardiac glycosides is sedation. (Seifert 2019a). Consequently, poisoning with this drug could have been presented in this episode. At the same time, red foxglove is used in the teaching of German homoeopathy for problems falling asleep and sleeping through the night (without medical evidence) (Herfurth 2018).

Fig. 2
figure 2

Presentation and content of drugs. Content-related discussion regarding the active pharmacological substances depicted in “Tatort” from 2019 to 2021 in absolute figures shown as a bar chart. Multiple presentations occurred in some cases

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Looking to the content, the drug indication was identified most frequently (68%). In addition, the effect (39%) was shown, and adverse drug reactions were mentioned less frequently (21%). The application of active pharmacological substances was also shown (29%). Proportionally, oral administration was most frequently presented (44%); intravenous and intramuscular (11% each) as well as subcutaneous administration (7%) together were on par with inhalation of the active pharmacological substance: a cloth was hold in front of the patient, using an atomiser or using nasal cannula (19%). The tablet was crushed by the consumer and then dissolved in coffee or sniffed through the nose in two episodes (7%). There were also useful instructions for use, which mainly referred to fitness for duty and driving ability or limits for taking drugs (5%). The production or the possibility of procuring drugs was also discussed in “Tatort” (5%). One episode dealt with late complications (1%). The alleged indication was presented in the case of homoeopathic remedies, but always with the addition of ineffectiveness (2%).

As Ellerbeck and Seifert (2022) showed for poisons presented in the “Tatort” from 1974 to 2022, the mechanism of action of the active pharmacological substances was not shown very often: while it was reported for 12% for poisonings, it was only reported for 3% for drugs.

Regarding the individual active pharmacological substances in every episode, these were checked for various parameters: If the presentation or passages of the presentations are implausible, if the viewers are informed about the active pharmacological substances in a benefit-oriented way (more than just presented correctly), if there is a possibility of imitation or abuse by viewer and if there is a risk of stigmatisation. Figure 3 shows the individual groups of active pharmacological substances in relation to the various parameters.

Fig. 3
figure 3

Comparison of individual drug groups (2019–2021). The individual drug groups mentioned in the crime scene are shown as a bar chart in relation to the frequency of implausible, dangerous, stigmatising and positive representations. Muscle relaxants, local anaesthetics and antidotes are summarised in the group “others”

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Plausibility

Table 2 lists the active pharmacological substances that were implausibly presented. The majority of the depictions and uses of active ingredients in “Tatort” were plausible (82%); in most cases, there were only minor inaccuracies, which were presumably due to dramaturgy: 41% of the active ingredients were intended to render victims unconscious in a fast way. Chloroform (episodes 1113, 1129, 1149), which is no longer used in modern medicine, and other unknown agents (episodes 1051, 1141, 1171) worked quickly and reliably within a few seconds, and their depth of anaesthesia could be controlled well without monitoring; victims could be awakened immediately without an overhang. Chloroform does indeed have a sedative effect. However, this requires several deep breaths with a well-sealed mask enclosing the mouth and nose. Chloroform has a minimal alveolar concentration of 0.77 with a blood-gas coefficient of 8. Compared to sevoflurane, one breath is usually not enough to sedate with this agent. Furthermore, if unconsciousness were successful, the person would probably need to be ventilated, preferably secured by an endotracheal tube. In addition, circulation must be monitored, as the gas has a circulatory depressant effect (Solt et al. 2005). In the named episodes, effects on circulation and respiration were omitted, no airway management was needed.

Table 2 List of episodes with implausible depiction of pharmacologically active substances
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The brief insertion of red foxglove in episode 1162 may have alluded to cardiac glycosides: in this case, the perpetrator used it successfully and without complication for sedation, contrary to reality. The cardiac glycoside digitalis is obtained from the poison of the red foxglove. In this process, the Na+/K+-ATPase is inhibited. However, the drowsiness and sedation that is exploited in this episode is only an undesirable drug effect that can occasionally occur. Because of the primary cardiac effect, an overdose that would cause sedation would probably lead to heart failure beforehand (Seifert 2019a).

Psychiatric drugs were presented in a blurred way with regard to therapy and adverse drug reaction (episodes 1090, 1149, 1168). The end of episodes 1090 and 1168 has the potential to raise the question in viewers to what extent psychiatric illnesses should be treated and whether active pharmacological substances approved in Germany are suitable for this at all.

In episode 1092, the forensic doctor is not aware of the antidote flumazenil for benzodiazepine overdose; he mistakenly advises taking caffeine, which he says sufficiently counteracts sedation. Caffeine is the most commonly used psychoactive drug in the world. The endogenous substance adenosine causes mild sedation when it binds to the adenosine receptor. This process is antagonised by caffeine. Contrary to what the Tatort-episode suggests, caffeine does not interfere with the mechanism of action of benzodiazepines and thus does not antagonise their effect (Brunton et al. 2017m).

In episode 1140, closing the oxygen mask closed for a short time leads to a state of threatened asphyxiation (Brunton et al. 2017h).

Contrary to the current guidelines, episode 1155 gives the impression that “cortisone” is the first drug of choice for the treatment of anaphylactic shock (Seifert 2019b).

Often, a sedative was injected in psychologically decompensated patients; a possible oral administration (episodes 1132, 1164, 1167) and crisis intervention through conversation was not considered beforehand (episodes 1122, 1188) (Table 3). In general, the use of benzodiazepines in acute traumatic situations is controversial, as these drugs influence episodic memory. It is currently being discussed whether this procedure promotes the tendency to develop post-traumatic stress disorder at a later stage (Klein 2008).

Table 3 Summary of the use of tranquillisers and other psychological interventions in mental crises
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The mode of action of the drugs in the Tatort episodes studied from 2019 to 2021 is even less frequently explained than for poisons from 1974 to 2022 (Ellerbeck, Seifert 2022), perhaps because the poisons were more often in focus of the action than drugs. In addition, according to Ellerbeck and Seifert 2022, symptoms were shown in 87% of the poisoning cases, whereas this was only the case in 39% of the drugs studied here. It should be noted that the work of Ellerbeck and Seifert deals exclusively with poisonings in episodes of “Tatort” from the years 1974–2021 in the sense of a longitudinal study.

Educating the viewers

Table 4 lists the active pharmacological ingredients for which the viewers were profitably educated beyond the correct presentation which occurred in 29% of the cases. Illnesses can affect anyone, even an altruistic doctor was suffering from depression (episode 1181) or a trained commissioner from arterial hypertension (episode 1167) who were treated by using medication. It was pointed out that therapies can also be done without drugs, e.g., through better sleep hygiene for problems falling asleep and staying asleep (episode 1161) (DGSM S3-Guideline 2017) or a lifestyle change in arterial hypertension (episode 1167) (Badermann et al. 2020).

Table 4 Pharmacologically active substances for which the viewers were profitably educated beyond the correct presentation
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The correct intake was pointed out for antibacterial drugs (episodes 1082, 1141): regarding the duration of taking antibacterial therapy, it should always be taken according to the doctor’s recommendation. Otherwise, taking the medication for too short or too long can promote resistance (U.S. Department of Health & Human Services 2021).

The same applied to the presentation of “heart medication” (episode 1165), and there was also reference to unfitness for duty as a policeman when taking lorazepam (episode 1180), whereas in episode 1092, contrary to current case law in Germany, no strict driving ban was imposed by a forensic doctor prescribing lorazepam. Driving ability is impaired by taking benzodiazepines. According to German law, for example, it is no longer permissible to drive a vehicle on German roads under this effect. A doctor must point out the inability to drive (Halbe 2018).

Normal common cold infections were never treated with antibacterial therapy, but at most with vitamin-mineral preparations (Pecora et al. 2020). A doctor was not consulted for this if there were no problems like fever (episodes 1104, 1106, 1141).

The existence and use of antidotes like naloxone and flumazenil was discussed (episodes 1092, 1119, 1143, 1160). Naloxone is used as an antidote for opioid overdose like heroin. A street worker explains these circumstances in episode 1160. In episode 1190, the intramuscular application of an antidote is shown. Flumazenil is administered as an antidote in benzodiazepine overdose (like diazepam), binding to the benzodiazepine receptor at the allosteric binding site of the ionotropic GABAA receptor that activates a chloride channel (Brunton et al. 2017f). The scenes educate viewers on the use of emergency pens and antidotes in case of poisoning.

The non-existent pharmacological efficacy of homoeopathy was also shown (Michalsen et al. 2017) as well as the dangers of using homoeopathic medication instead of antibacterial drugs (episodes 1141, 1095). Meningitis can also develop from a harmless bacterial infection which is shown in episode 1141. Antibiotics (antibacterial drugs) inhibit bacterial metabolism, preventing the spread of disease. (Martindale et al. 1989). Late or omitted administration of antibacterial drugs can lead to deadly complications, as shown in this episode.

Derivable dangers

Table 5 lists the active pharmacological substances where dangers to viewers can be inferred. In Tatort, ways are presented to kill or harm other persons. In 20% of the “Tatort” episodes, dangers for the public could be identified.

Table 5 Derivable dangers through the representation of pharmacologically active substances in the individual crime scene episodes
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Insulin was introduced as a difficult-to-detect murder agent in episode 1143, leading to death either directly because of hypoglycaemia or through accidents in the context of neurological deficits, including the depiction of easy subcutaneous application. Hypoglycaemia often causes falls, which are one of the most common injuries among elderly. Insulin, a key factor in diabetes mellitus, stimulates glucose uptake into human cells and glycogen synthesis and inhibits lipolysis, lowering the blood glucose concentration. (Seifert 2019e) Since diabetes is a widespread disease in Germany, accessibility to this medication is easy, the active substance is well known, and its effect is very potent (Seifert 2019e). There is also an application error within episode 1143: Insulin is injected via pull-up cannula into a three-way valve.

The extraction of narcotics such as fentanyl by boiling or sucking fentanyl patches was also discussed in detail in several episodes (Episode 1160, 1096, 1111). Fentanyl, a powerful synthetic opioid analgesic, as a patch is used for pain patients (Brunton et al. 2017g). Disposal in household waste is possible; patches may only be used for a maximum of 3 days, after which up to 50% of the active ingredient is still present, but the patch delivers no longer a constant dose (Editors of DAZ 2018). In episode 1160, a geriatric nurse uses fentanyl nasal spray as an easy way to fall asleep. This is particularly alarming because fentanyl in this form of application has a high potential for dependence (Editors of medline-plus 2020).

Episode 1167 used ephedrine for killing: ephedrine is used for urinary incontinence in dogs and is easy to obtain from the veterinarian who actually holds the dispensing right in Germany (§ 43 Abs. 4 und 5 Arzneimittelgesetz (Medicines Act) of Bundesrepublik Deutschland, current version from 1976).

Episode 1177 showed a schoolgirl under psychological pressure who, according to her own statement, was receiving methylphenidate through an employee of a special school. The employee had stolen the tablets from her schoolchildren in the morning to sell them abusively. Methylphenidate is an indirect dopamimetic, structurally related to amphetamine. Its effect is more strongly geared to mental than to motor activity, which is why it is often abused in relation to other drugs. The substance has its indications in ADHD and narcolepsy. (Brunton et al. 2017b). The effect of tachyphylaxis leads to a complete depletion of the vesicles when taken continuously, which causes a performance kink (Seifert 2019c).

Furthermore, the omission or substitution of permanent medication showed alternative possibilities of murder (episode 1095, 1165). Risky behaviour when taking active substances was also presented: taking analgesics in combination with alcohol against headaches or while having a hangover (Editors of drugs.com 2017) as well as swallowing several tablets at once without reading the package leaflet (episodes 1093, 1104, 1109, 1129, 1130, 1179). At the same time, the active ingredient of analgesics was often not explained in detail (episodes 1081, 1093, 1109, 1171). Episode 1155 at least suggested that “cortisone” (which may mean prednisolone) is the emergency drug of choice for an anaphylactic shock. Adrenalin, however, is considered a first-line medication due to its immediate onset of action. Only adrenalin is lifesaving in this case, whereas prednisolone has a membrane-stabilising effect only after a long delay. This effect supports in a later phase; likewise, H1R antagonists only help effectively against itching and urticaria, but not sufficiently against oedematous swellings in the facial region. This is a misrepresentation with consequences, especially remembering that anaphylactic reactions can affect any doctor at any discipline. Also, adrenaline with its large adverse drug reaction profile can generally have a deterrent effect to doctors (Seifert 2019b).

Possibility of stigmatisation

Table 6 lists the active pharmacological substances for which there could be a risk of stigmatisation by viewers. Stigmatisation occurred with 16% of the active pharmacological substances shown in “Tatort”. Analgesics were denied their effect (episode 1081) or were declared as “pure chemistry” (episode 1096). Elsewhere, pharmacological therapies were demanded, and occupational therapy was considered useless (episode 1109). In modern pain therapy, occupational therapy is an important component of therapy for reducing pain. Its effectiveness has been proven in studies, especially for chronic pain (Nielsen 2021). Benzodiazepines were said to have an extremely addictive potential; moreover, the positive effects were not highlighted nor saying why it may be important to take these drugs (episode 1177). A similar presentation happened for “antidepressants” (no differentiation for the specific active substance was made), which were mainly portrayed negatively: a clinic director suggests that you can identify people taking antidepressants just by viewing the patients face (episode 1090) or the medication turned patients “into zombies” (episode 1104). Also, about “psychiatric drugs”, a doctor explained that pharmacological therapy had the power to make people mentally ill instead of alleviating the symptoms of the disease (episode 1132). This is particularly alarming because psychiatric diseases are also stigmatised in society, and the patient group is particularly vulnerable about adherence to medication. Adverse drug effects often initially overshadow the benefits at the beginning of therapy, which leads to an increased dropout rate (Cesková 2009). In episode 1177, Methylphenidate (Ritalin®) was presented on the one hand as a “miracle drug” for mental peak performance—for example, a schoolgirl succeeds in joining an orchestra, which is filmed with impressive camera settings and backed with virtuoso music—and on the other hand, the rejection of the drug by an employee at a special school, here appearing as an eminence for the viewer, who collects the methylphenidate in the school and then sells it for profit. “Tatort” has also investigated the topic homoeopathy in episode 1141, which is reflected very critically. The danger in case of using homoeopathic medication as a monotherapy is shown: an infant dies because of not treating streptococcal meningitis with antibacterial drugs. It should be noted, however, that in this episode, there was no clear separation from herbal preparations—a circumstance that the homoeopathy industry in Germany also uses for profit (editors of aponet.de 2022).

Table 6 Stigmatisation of pharmacologically active substances in Tatort episodes from 2019 to 2021
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Although the active ingredient of analgesics is named precisely in many episodes, in other episodes, the drug is simply referred to as “painkillers”. In these episodes, the active ingredients and their specific areas of use are not discussed in detail, nor is the profile examined more closely (episodes 1081, 1093, 1109, 1129, 1171, 1179).

Limitations and conclusions

The crime series “Tatort” is fictional. Nevertheless, it takes on socially significant topics such as widespread diseases and generates an opinion among viewers about active pharmacological substances in medicine. At the same time, ARD® broadcasts not only entertainment but also “educational television”. Thus, it could be expected that other movie franchises in television and Internet without educational agenda make even more mistakes in relation to active pharmacological substances than ARD®. Moreover, it was often difficult to draw conclusions about the active ingredients because they were not explicitly named or shown.

The television-show “Tatort” teaches Germany and many other countries about active pharmacological substances. Doctors must be aware of this, especially when prescribing drugs: education about active ingredients is important because every patient is passively informed by watching movies and series. This information can be incorrect or questionable, which can massively limit their adherence—active reading of the package insert is not necessary to become unsettled. In depictions of drug abuse, there is a natural dilemma in films between providing information to protect the public and at the same time instructing people to commit a crime. However, Tatort, which also addresses common diseases such as back pain, hypertension or depression, shows corresponding medication therapy options and deals with topics such as antibacterial resistance and homoeopathy—but not always in the necessary depth and range which would be required. Especially active pharmacological substances that are used as analgesics or in psychiatry are particularly affected—in a peer group that already shows lower adherence (Cesková 2009).

Most of the mistakes were made in the stage of writing the script, which could have been easily avoided through proper medical advice or discussion. But the final movie still involves actors, directors, producers and film editors, as well as the “Freiwillige Selbstkontrolle der Filmwirtschaft” (FSK, an institute to control violence, sex and drugs in movies), which can rearrange or remove scenes.

To minimise imitation of dangerous behaviour like committing a murder, the series sometimes resorts to fictitious product names (10% of all names in the period shown) or makes cryptic references to ingredients, for example by using images of red foxglove, which is supposed to stand for cardiac glycosides.

In the future, it would be desirable to involve personnel with pharmacological expertise in the production of “Tatort”-episodes at the script writing stage to avoid stigmatisation and misinformation and at the same time provide education for the audience without encouraging abusive behaviour. “Tatort” script writers should take the opportunity and educate the audience on the mechanism of action of commonly used drugs. Understanding how drugs work can make a great contribution towards increasing drug therapy adherence and reducing stigmatisation of valuable drugs.