Patient Education: Vying for Attention
Half a million online quiz completes, 42 million video views and 93 million total impressions. Marc Iskowitz on how Shire's disease-awareness campaign engaged untreated Gen Y-ers, and why the time is ripe for more community-wide patient-education efforts like it
Over the years, drugmakers have sought to raise awareness that attention-deficit hyperactivity disorder, a condition typically diagnosed in childhood, affects young and old alike. Their efforts have only been partially successful.
In 2010 Americans spent $7.2 billion on treatment for ADHD, according to IMS Health. Use of ADHD drugs such as Johnson & Johnson's Concerta and Shire's Vyvanse tripled among those aged 20 to 44 between 2001 and 2010, and it doubled over that time among women in the 45-to-65 group, according to a report from Medco.
Increased recognition of ADHD as a lifelong disorder has been a main factor behind the growth, along with marketing and awareness pushes aimed at either caregivers (parents) or adults. But market research has shown there is one age group which has never really been addressed and which has eluded the heightened knowledge from marketing efforts: 18-24 year-olds.
“If you look at the data, usually from the age of 13-18 is when you start to see a fairly large drop-off of these patients,” observes Sheri Stump, Vyvanse consumer brand director, Shire. “Some of them no longer do have ADHD, but the majority of those patients actually do continue into adulthood with [the condition].”
It's easy to understand why. Eighteen-year-olds are transitioning away from the pediatrician they may have seen for the past 15-18 years. Some are leaving home, whether going off to college or entering the workforce, and with that lifestyle change comes a different way of viewing their health. In Stump's words, Shire saw a “blaring gap” in the need to bring this group back into the treatment fold.
Marketing to millennials
Industry has done a fair amount of education targeting the older end of the age spectrum. In 2008 J&J launched—only to take down in 2011—the “ADHD Moms” Facebook page, where mothers of children with ADHD could go to hear from other moms, including Debbie Phelps, whose son, Olympic gold medalist swimmer Michael Phelps, was diagnosed with the condition. Shire has also enlisted older celebrities such as Howie Mandel to speak about their experiences and how medication has eased his struggle with the disorder, which is marked by difficulty focusing.
Among adults, the Harvard/NIMH National Comorbidity Survey Replication found that 4.4% of adults, ages 18-44 in the US, experience symptoms and some disability from ADHD. Yet millennials lacked a credible, nationally known personality with whom they could connect. “It was an educational need that we felt we could address,” says Stump.
Shire's response was last June's “Own It” campaign, an unbranded effort featuring as its celebrity spokesman Adam Levine, lead singer of the pop-rock band Maroon 5. In a series of videos created by Digitas Health that saw early play on YouTube before they migrated to mobile, Levine, 32, says that it's important for young adults and adults to realize that there's a chance they may still have ADHD if they had it as a child.
“I wondered why I couldn't organize my thoughts…It was my ADHD, and like many kids with ADHD, I didn't outgrow it,” Levine says confidently in scenes where he's shown playing the guitar and writing.
“Strategically, Digitas Health wanted to design creative that would be appealing to this target audience,” says Lara Viau, VP, group director, marketing, for the agency. She explains why that dictated an unbranded approach: “In all the work we've done with consumers and across various conditions, we've found that the most effective way to connect and engage is to build a relationship with them.”
Own It was no different, seeking to connect from a health-seeking perspective. “Especially with this audience that's so savvy and cynical toward marketing,” Viau says, “the hard sell does not work.”
Adds Stump, “We went with the unbranded educational campaign, because there was that educational gap and we really needed to inform these young adults that they could do something simple.”
The primary goal of Own It was plugging the knowledge gap in this demographic. Second was to motivate Gen Y-ers and adults who were previously diagnosed with ADHD to take an online quiz at OwnYourADHD.com, then talk with a doctor. That URL takes users to consumer health portal EveryDayHealth.com, where they can take the quiz developed by Psych Central, an online mental health network.
The results, as of last December, have been favorable: six months after launch, the effort has drawn about 500,000 quiz completes; more than 31,000 opt-ins to receive an ADHD Action Guide; more than 42 million views of the campaign video; and 93 million total impressions, including search, mobile and display.
Along with its social media strategy (mainly consisting of placement on YouTube), Shire also put a large emphasis on mobile, building HTML5 creative that was distributed through Jumptap and Pandora. “Nearly a quarter of the users who engaged with the campaign have done so through mobile,” adds Mary Boyle, Vyvanse consumer brand manager.
“Digital was utilized as the lead media channel in the campaign, because Shire wanted to place its message where it knew its target audience would be, and data suggests that this audience uses the Internet to do virtually everything,” Boyle notes, adding that YouTube reaches 90% of adults diagnosed with ADHD each month.
That was also a wise move considering data from Manhattan Research's ePharma Consumer study show that, when looking for disease or condition information and services online, more than half of online ADD/ADHD adult patients and parents of pediatric ADD/ADHD patients trust disease or condition websites from pharma companies (selecting 4 or 5 on a 5-point trust scale). This is higher than the average online consumer.
Lead media agency Good Apple also spread rich media and banner placements across MTV.com, Hulu.com and NBC.com. The agency was so accurate with placements, in fact, that some older ADHD patient advocates—who make it their business to track marketing activities—had not seen the campaign (see sidebar below, Patient POV).
Traditional media played a role, too. Print ads in WebMD Campus, distributed in book stores and elsewhere, allowed the marketers to be even more targeted in reaching Gen Y-ers. And Shire worked with PR agency Porter Novelli to get PSA status for the video, so it is running on traditional TV at no cost. Having the endorsement of two non-profits, ADDA (the Attention Deficit Disorder Association) and CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder), helped in that regard.
With its heavy reliance on new media last year, Shire dialed back its branded ADHD advertising spend. The firm spent $12.4 million on DTC advertising for Vyvanse and pediatric-only product Intuniv in the 12 months to September 2011, a nearly 80% decrease from the prior 12-month period, figures from Kantar Media show. Like Vyvanse, Adderall XR, the other ADHD drug Shire sells in the US, contains the stimulant amphetamine (Intuniv is non-stimulating). Methylphenidate-based Equasym is sold outside the US.
Hurdles to helping
While Shire has a track record of investing strongly in the digital channel and has been doing it for a longer period of time than some other companies, some efforts have drawn scrutiny. In 2008, a YouTube testimonial featuring celebrity Ty Pennington speaking about his experience with Shire's Adderall XR drew a warning letter from the division now called the Office of Prescription Drug Promotion, formerly DDMAC.
Known as the first public statement by FDA related to the video-sharing site, the letter scolded the drugmaker for suggesting unapproved uses. The notice also served as a legal watershed, with lawyers construing from it OPDP's tendency to view an implied outcome claim whenever an ad piece mentions both the consequences of a disease and use of a product.
Shire is not alone in attracting untoward attention from regulators. FDA has, in the past, slapped ads like those for Eli Lilly's 2005 “Videogame” spot for Strattera, in which the agency said distracting visuals competed with the presentation of risk information.
There are also aspects of the ADHD audience that make the unbranded approach ideal for this group. “People with ADHD may be skeptical about materials coming from a pharma company and tend to rely heavily on their healthcare provider,” says Chris Kelly, a VP at healthcare marketing agency HealthEd, “so the benefit of disease-state education, if it comes from a credible source, is that it's something where people will be engaged.”
According to Kelly, who worked for a number of years in an in-patient psychiatric hospital and outpatient mental health clinic that included kids and adults with ADHD, when designing education for the ADHD audience, it's critical to give people quick access to engaging information (i.e., video, interactive tools) that won't require a lot of reading. “Many patents with ADHD also have some type of reading or learning disorder,” he says, “so when they click on a website page and see a long stream of copy, in most cases they're just going to click away.”
Tone is also crucial. ADHD is a very serious condition. Its symptoms, like impulsivity, can have a devastating impact on work life and relationships, and contribute to conduct disorder and substance abuse. “The way you reach people with ADHD is to sort of validate the struggle,” Kelly says, “rather than using humor to engage.”
He adds that there's still a stigma associated with the disorder. “This condition is minimized by society, in many cases by family members who often don't understand it,” he says. And the fact that ADHD is still perceived as primarily a pediatric disorder works at cross purposes to pulling young adults suffering from the condition back into the treatment fold.
That's why, even though society as a whole has become more aware of ADHD, Kelly says that young adults have been slow to recognize they have it, adding that “any messaging or content or findings around the impact of ADHD are critical to working against the past myths that it's primarily a childhood disorder.”
Ditto for some middle-aged adults, who may just be finding out they have it. “They've wondered their whole life if they have ADHD. Now they are getting a diagnosis. They respond well to have an educator or source say, ‘We realize there is a lot of humor around this condition, but it's a real medical condition that causes a real, devastating impact on peoples' lives.'”
The case for education
Community wide wellness calls to action, like Own It, are taking on more importance across the healthcare continuum. A report released by several non-profit health groups in December shows improvements have stalled nationally in rates of obesity, diabetes, smoking cessation and cardiovascular deaths. Several factors have contributed. For one, the economic downturn has caused people to smoke, eat more and exercise less, the groups say.
The economy is having another negative effect. A November 2011 report shows demand for healthcare waned between 2007 and 2010, with physician visits falling by 4%, a trend largely attributed to the downturn. That, says the Center for Studying Health System Change (HSC), has made it easier for people who can still afford to see a doctor to book timely appointments and, in turn, reduced some consumers' need or drive to obtain health information on their own.
“At the same time, one would expect to see other consumers—those cutting back on healthcare—increasing their health information seeking, as a substitute for obtaining information from clinicians,” the report states. Perhaps the decline may reflect consumer frustration with the quality of health information available…or the very abundance of it—“information overload,” as HSC terms it.
Whatever the reason, according to HSC, the proportion of consumers seeking health information dropped from 56% in 2007 to 50% in 2010. So did people's use of traditional media as sources of such information. Book, magazine and newspaper use fell sharpest, from 33% to 18%; followed by TV or radio, sliding from 15.6% to 10.0%. Surprisingly, Internet use increased just slightly, 31.1% to 32.6%.
Will such findings trigger more digital unbranded disease awareness? For its part, Shire says the relationship with Levine and use of the Own It creative will continue through 2012, with more ADHD education in store. It will also announce new spokespeople for the campaign.
Perhaps we may see more non-branded campaigns seeking to raise our collective consciousness about conditions. If so, efforts like Own It may become part of a new wave of such messaging, as pharma companies address the new public-health challenges by blanketing the web and other media outlets with patient education.
The great Adderall shortage of 2011 (and beyond)
While Shire's “Own It” campaign was beckoning Gen Y-ers back into the treatment fold, a shortage of Adderall was wreaking havoc with generic drug supply. The shortage first surfaced in March 2011. By the fall, the FDA's website had noted that Shire was able to produce and fill “adequate” levels of Adderall XR prescriptions. But the two companies that sell authorized generic versions of XR—Teva and Impax Labs unit Global Pharmaceuticals—were said to be having “supply issues,” along with “increased demand” and “inadequate finished product” which were hampering their distribution.
Suspecting that Shire was blocking supply lines, Impax had filed a lawsuit in 2010 for breach of contract. In an SEC filing, Shire blamed the Adderall shortfall on Drug Enforcement Agency limits on the amount of product that it can manufacture.
As the disagreement played out, sales of Shire's branded alternative, Vyvanse, increased 37% to $1.2 billion for the 12 months to September 30, 2011, vs. the prior 12 months. Its Adderall XR revenues climbed 18% to $943 million, according to IMS Health.
“There had been some spotty distribution of the ‘XR' [last] year, and that issue was resolved more than six months ago,” says Shire senior director, corporate communications Matt Cabrey. Now, he says, there's plenty of XR—branded and authorized generic—to go around.
Still, the ADHD drug shortage threatens to enter its second year. As of mid January, the FDA's website noted, the three companies that make immediate-release Adderall—Sandoz, CorePharma and Teva—were said to be experiencing “increased demand” and “supply issues” that were interfering with availability. Methylphenidate, the active ingredient in J&J's Concerta and Novartis' Ritalin, was also running scarce.
Three health activists were assembled by Wego Health to represent the patient perspective, and asked for their opinions of “Own It” and other ADHD educational activities. Click here to see a discussion on educating ADHD patients and here to see a talk about what's missing from marketing campaigns.
Before being shown the “Own It” campaign creative, panelists were asked if they had seen any ADHD marketing efforts targeting the 18-24 age group. None had. “It's a gap, from what I can see,” says Terry Matlen, a psychotherapist, consultant, writer and coach specializing in adult ADHD.
“In that age range, the kids have a big tendency to decide that they're not going to take medication anymore,” adds Kay Marner, co-editor of Easy to Love but Hard to Parent, a book about parenting kids with ADHD and other mental-health conditions. Nor are there a lot of resources for parents of 20-somethings with the condition, observes Tara McGillicuddy, a senior certified ADHD coach specializing in adult ADHD.
Matlen is encouraged by what she sees as pharma marketers making more of an effort to educate. “Going in with the concept as if I didn't know as much about ADHD, I like the idea of not seeing so much branded stuff out there.”
Which brings us to Shire's “Own It” campaign. When shown the campaign assets, panelists expressed surprise.
McGillicuddy says she may have seen Tweets connected to the effort, “But as someone who's really active in the online community…it would have been very beneficial if people leading this campaign reached out to someone like me who has that reach.”
Then again, interjects Marner, “If these kids have stopped taking medication and are not identifying themselves as people who are suffering from ADHD and needing help, they're not going to be going to ADHD sites. They will be going to general sites that other young adults go to. So that really does make sense. Maybe we didn't need to know about it!”
Nevertheless, “even a powerhouse campaign like Own It can be multiplied by engaging Health Activists,” says Jack Barrette, CEO, Wego Health. “When the program is genuinely helpful, online community leaders will spread it organically.”
As far as the campaign creative, “I think it does a good job of targeting that age group,” says Matlen, “which is probably why I never saw it.”
“It looks just fabulous,” adds Marner, highlighting the “simple ways to get people involved,” like a quiz. Matlen calls out the tagline, “I didn't outgrow ADHD. Did you?” spoken by Adam Levine, as a “plus,” considering “We're always trying to educate people that most children do not outgrow ADHD. There's that misconception that continues to this day.”
McGillicuddy objects to the celebrity tie-in: “From what I hear from a lot of people, they're sick of seeing these really successful people…It grabs the attention, but then we need the average successful person—the teacher, the person who's held a job for three years at Wal-Mart.”
Matlen and McGillicuddy also lamented the lack of female spokespeople. Shire's effort “doesn't really target girls and young women, and the majority of young women are being missed because their symptoms are so different,” says Matlen. Marner disagrees. “In this generation, more girls are being diagnosed vs. women who are adults today who were diagnosed as adults,” she says.