Increasingly in UK and elsewhere, people are encouraged to self-refer for support and guidance in using online CBT. For example, Increasing Access to Psychological Therapies (IAPT)—a major Department of Health initiative with delivery across England—is promoting self-referral and finding positive benefits.32
This is also seen in the national telephone support line NHS Living Life. Approaches such as these are likely to access a range of people who might not otherwise seek help via their GP.33
Support and guidance are recommended for all forms of CBT resources—including online CBT.34
Although national treatment guidelines such as NICE (2009) and SIGN (2010)19
recommend the addition of support, many people accessing online CBT through free sites will do so without support.
This study showed that the 3868 people who clicked on our advert typically searched with the single word depression, although there were a great variety of terms entered, including misspellings. However, our study demonstrated that even a knowledgeable person may have to search quite hard to find online CBT, and it would be difficult, or extremely unlikely, for a naive user of depression websites (ie, someone not specifically searching for online CBT for depression and knowing how to find it) to find online CBT websites easily using a Google search. Although our estimates use a large number of assumptions, we consider that a nearly threefold increase in the probability of finding online CBT by the addition of a Google Advert is likely to lead to more people with depression registering and using online CBT. The real test of this will be if there is an increase in uptake demonstrated in our cluster randomised trial comparing intervention with control areas.
Based on our ‘click through rate’ (the number of times users clicked on our advert divided by the number of times it was presented) of 1.5% and that typically eight adverts are displayed on a page of search results, we estimated that users may click on an advert in 12% of cases when Google displayed search results and adverts. Although this is based on our empirical data, online adverts may not be viewed positively by internet users who are looking for credible information on the web. AdWords are sometimes used to promote bogus, misleading (eg, ‘miracle cures’) and malware-ridden sites, and many users will avoid them. Our own advert (), mentioning NHS and with a ‘.org.uk’ URL, may have had a better click through rate than other online adverts,36
so we may have overestimated the impact of online adverts.
The Department of Health was heavily criticised for spending £2.5 million on AdWords between February 2009 and January 2010.37
The Department of Health declined to give further details of how they had spent this money or its cost–effectiveness. By judicious design of the website, the NHS Choices and other NHS websites should bring high profile search results. In this study, for example, the NHS Choices depression section was the only website that regularly appeared in the top three search results. If people find a website via a normal web search, then online advertising such as AdWords may be a waste of money. However, this study shows that, if there is substantial ‘competition’ for a user's attention, advertising may be worthwhile. For example, the Royal College of Psychiatrists seems to be spending quite large sums on Google AdWords as their advert appears frequently alongside their website being found by ‘normal’ Google search. For people with depression, given that adverts will in any case appear, having an advert for RCPsych that gives the user a one in 140 chance of finding online CBT for depression improves their chances very slightly.
This exploration of how choices may be made given the websites and adverts currently being found by Google gives some indication that it would be worthwhile. The number of routes that could be taken, even on websites from which it is possible to reach online CBT, also shows the bewildering choice facing those with depression using the internet.
Another approach to assessing search experience is through observation in a laboratory3
setting or even ‘in the wild’, but recruiting, meeting and observing people with depression while they search the internet presents many ethical and practical difficulties. We were able to recruit 12 anonymous users who are likely to have searched for depression before, at various locations around the UK. They were able to supply us with information of their searches from their natural ‘habitat’, although we restricted their searching to just one search term. Ideally, we would ask the panel to search for more search terms but we thought this would jeopardise getting any response. The results suggested that although there was some modification of search results by users' previous search history and location, the variability was not that great. Although our sample of 12 users is small, given the lack of variation, it seems unlikely that a bigger sample would have identified other websites that would have increased the probability of finding online CBT.
Our study is also limited in that we only considered Google Search and not, for example, Google Search or Google AdWords embedded in partner sites, blogs or YouTube videos (the so-called Google Display Network). Also, not only do websites change but also Google search results change by location, user and over time. Website owners are also constantly modifying their websites and taking steps to raise their profiles for search engines such as Google. Google is also not the only way of advertising online and others have used, for example, paid location and demographic targeted adverts in Facebook on.38
The approach we have taken to assess the ease of finding CCBT could easily be replicated in future. The general idea of assessing the probabilities that expert and naive users may have in finding a particular website is applicable to anyone considering the addition of online adverts to promote online services or resources. Online adverts may compete both with other adverts as well as with the results of organic search, and health service providers considering the use of online adverts need a strategy that calculates the added (marginal) benefit and cost.