Using Digital Media Advertising in Early Psychosis Intervention

A landing page was developed with the primary goal of encouraging help-seeking individuals in the New York City metro area to contact the ETP. [Further details about the layout of the landing page are available as an online supplement to this article.] In order to optimize visibility, the landing page focused on two core messages believed to be most relevant to help-seeking youths and their families: understanding early signs and symptoms of psychosis and finding local help.

The campaign landing page offered connection to the ETP through links to the ETP Web site, e-mail address, and phone number and the opportunity to “ask a question” by using an online form in which an ETP staff member could call, text, or e-mail an answer; examples of personal storytelling emphasizing the message that “you are not alone” via videos and blogs featuring participants sharing their stories of recovery through treatment; and the Prodromal Questionnaire–Brief (PQ-B), an evidence-based screening tool that visitors to the page could use to assess psychosis risk (24).

The campaign landing page was integrated into a parent Web site (www.strong365.org), offering visitors the opportunity to explore additional educational information about psychosis, treatment options, recovery stories, and resources. Content was informed by individuals with personal experiences of psychosis as well as mental health professionals with expertise treating early psychosis.

In order to provide the best opportunity to reach the intended audience, Google AdWords was utilized. Google AdWords allows advertisers to select keywords/phrases, create a linked advertisement, and allocate a budget and time frame. The ads appear in response to online searches that match selected keywords. Individuals who click on the ads are then directed to a dedicated landing page. Google AdWords are pay-per-click (the advertiser pays when a user interacts with ads), and ads can be demographically and geographically targeted. The campaign ran in New York City for 14 weeks between April 11 and July 18, 2016 with a total budget of $1,427.

More than 2,000 keywords/phrases were selected and organized across 15 thematic ad groups (Table 1). [Further details about the keywords are available in the online supplement.] In order to identify keywords, experts at the ETP were consulted, and feedback was obtained from the Strong365 National Youth Leadership Board. Within each thematic ad group, multiple ads were crafted that would appear as search results when a relevant keyword was typed into Google search. [Examples of ads are available in the online supplement.] General terms such as “psychosis,” as well as more specific terms such as “hearing voices” and “mind control,” were included in order to target both individuals searching for information for themselves and persons searching on behalf of a loved one. Keywords related to bipolar disorder were included in order to cast a wide net, given the occasional diagnostic uncertainty at the onset of illness (25).

A total of 154 unique ads were crafted, each comprising a headline, description line, and call to action. The headline thematically related to the user’s search and drove ad impressions (an impression was counted each time the ad was shown on a search result page). The description line offered supporting information, and the call to action encouraged searchers to perform a desired action (take a quiz, click on the ad, find support, etc.). Google AdWords’ algorithm selects ads based on a user’s search, the ad’s relevance to that search, and competition from other advertisers. The more a keyword was searched by users, the more frequently relevant campaign ads were shown.

Google analytics were used to record Web site engagement (time spent on the Web site, number of pages visited, and activity on the Web site, including watching the video and completing the psychosis screener). Google analytics was also used to collect demographic information and information about interests of users who interacted with the ads (26,27). Help-seeking actions were recorded by ETP staff based on e-mails and phone calls received. The Google AdWords platform recorded the number of impressions per ad group, keywords used within each theme, number of clicks linked to the Web site, and cost per click.

Table 2 presents the number of impressions, clicks, click-through rate, and cost per click by ad theme. The ads appeared 191,313 times and were clicked on 4,350 times, reaching a click-through rate (impressions/clicks) of 2.3%, at an average cost of $.33 per click, and $25 per person contacting the ETP (total cost of the campaign/number of individuals contacting the ETP). Compared with the Health and Medical Industry average (www.wordstream.com), the campaign had an above-average click-through rate (2.3% versus 1.8%) at a favorable cost per click ($.33 versus $3.17) and cost per desired outcome or action ($25 versus $126.29). The top five ad groups/themes in terms of number of clicks were bipolar disorder signs and symptoms, mental illness test/psychosis test, delusions/suspicion, schizophrenia signs and symptoms, and psychosis signs and symptoms.

Whereas the headlines drove impressions, supporting text affected the number of clicks. [Further details about the number of impressions, clicks, and click-through rate by description line are available in the online supplement.] The most clicked ads had a description line that read, “You’re Not Alone. We Can Help” (93% of clicks). The next two most popular description lines were “Hard to Tell What Is Real?” (3% of clicks) and “Getting Help Early Matters” (1% of clicks). The campaign’s top clicked call-to-action lines included: “Take an Online Quiz/ Find Support” (55% of clicks) and “Learn the Signs/Find Support” (38% of clicks). Thematically, ads related to bipolar disorder had the most ad clicks over the campaign period, with 3,234 clicks (74% of total campaign clicks).

According to Google analytics, among recorded sessions of those who clicked on ads (N=3,257), 74% (N=2,410) were female and 26% (N=847) were male. Age distribution was as follows: 18–24 (N=393), 25–34 (N=499), 35–44 (N=596), 45–54 (N=746), 55–64 (N=654), and ≥65 (N=369). Eighty percent (N=2,606) clicked ads through mobile devices, 10% (N=326) through tablets, and 9% (N=293) through desktop computers. The top three interests of those who clicked ads were movies, news (entertainment and celebrity), and television. The peak time of day for ad clicks was between 5:00 and 6:00 p.m.

The median time visitors spent on the landing page (session duration) was 51 seconds (interquartile range=74 seconds; mean=115 seconds). The median number of pages viewed on the Web site (not including links to other relevant Web sites) per session was 1.29. Fifty-six percent (N=2,436) of users ended their sessions on the landing page, and 44% (N=1,918) clicked further into the Strong365 site. Landing page visitors engaged in a range of help-seeking actions (Table 3).

Fifteen percent (N=671) of landing page visitors completed an online psychosis screener, and 453 individuals (10%) scored positive. All were encouraged to reach out to the ETP in order to learn more. Only 1% (N=57) directly contacted the ETP. In the 14 weeks prior to campaign initiation, the ETP received on average of 2.5 community referrals weekly. During the campaign, the ETP received on average of 5.5 community referrals weekly. Among those who did contact the ETP, none were enrolled. They were either lost to follow-up or were ineligible based on symptoms (not experiencing a primary psychotic disorder) or symptom duration (more than 2 years) and were referred elsewhere.

There are several noteworthy limitations to this study. Although Google analytics is capable of providing insight into the demographic characteristics of searchers, it is impossible to know precisely who they are and why they are searching. It is unclear if ads were interacting with a prospective patient, family member, concerned friend, or someone else entirely. However, based on the searches conducted and interaction with Web site content, one can assume that these are individuals using the Internet to search for information related to psychosis. Another limitation is the competition for specific keywords, notably on behalf of pharmaceutical companies. Certain keywords, such as schizophrenia and bipolar disorder, are already linked to drug company ads, which directly affected the number of times the campaign ads were served and where they were displayed on the search results page. Finally, Google does not allow advertisers to directly target teenagers. Given the goal of early identification and engagement, we have begun to explore targeting youths through social media platforms such as Facebook, Instagram, and Twitter, which allow for advertisement to this demographic group. In addition, we plan to link to secondary school, university, and community college Web sites.

Campaign results reinforce the need to better understand the population of users who are searching for psychosis-specific information online. In order to do so, researchers will need to employ a variety of methods, including running campaigns with limited keywords targeted to a very specific population (parents, for example), deeper analysis of the characteristics of users who enter the Web site, and deeper analysis of engagement by users once they are on the Web site. Future campaigns should also consider exploring various types of advertisements (video, for example), as well as different messaging content and images, to determine which ads most effectively engage specific populations. In addition, the dominance of ad impressions and clicks related to bipolar disorder suggests that future campaigns should consider how best to educate and engage individuals with psychotic symptoms more broadly.

Campaign results also reinforce the need to understand the many steps from online search inquiry to clinical treatment. Given the campaign’s high levels of engagement among users once they are on the site, there is an opportunity to explore different forms of online engagement tools, rather than focusing specifically on immediate referral to specialty care. It is possible that the leap between searching for information online and making contact with a clinical team is too big for many individuals as an initial step. Intermediate steps toward treatment in the form of digital engagement tools would also allow researchers to learn more about what users are seeking and why, as well as the barriers they face in considering treatment for psychosis.