Internet Search for 988 in the Lead Up to and Rollout of the New National Mental Health Emergency Hotline

Introduction

On July 16, 2022, 988 became a national, three-digit number for those experiencing a mental health emergency, equivalent to 911 for physical health emergencies [1]. Although the FCC adopted rules to establish 988 in 2020, public health systems have been strained by the COVID-19 pandemic [1], leading administrators to vocalize a lack of preparedness—including time to educate the public [2]. To assess public awareness and engagement, we evaluated the extent to which internet search for 988 increased in the lead up to and following rollout of 988.

Methods

Using Google search trends (http://google.com/trends) and Keywords Everywhere (https://keywordseverywhere.com/), we quantified internet searches within the USA mentioning 988 from August 16, 2021, to August 16, 2022. Google Trends yields relative search volume (RSV) indices from 0 to 100, where 100 represents the highest search volume per capita within a defined geography and timeframe; geographies and time intervals with lower search volumes per capita are assigned proportionally smaller RSVs [3]. Keywords Everywhere uses an application programming interface (API) to ascertain global search volume (GSV) for search engine results pages.

We also examined daily GSV in the three-month period from May 16 to August 16, comparing observed and expected volume based on a forecast from an autoregressive integrated moving average (ARIMA). We compared trends to 911 search volume over the same period, which—by contrast with 988—did not launch any new services during the analytic period.

Lastly, we examined the association between state access to mental healthcare and RSV over the three-month interval, using Mental Health America’s Access to Care state rankings—a composite of nine metrics [4]. We hypothesized states with the weakest access to care would also have the lowest RSV, after adjusting for state differences in age and racial/ethnic distribution, education levels, and median income. Rankings were organized into quintiles, with RSV set as the dependent variable. Analyses were conducted in STATA [5].

Results

The week of 988 rollout (July 17–July 23) observed the highest GSV for 988 over the 12-month period: roughly 162,100 searches. This compared to 31,600 searches each week of June. The ARIMA model indicated a spike in GSV for 988 during the week of rollout, as well as the subsequent month (Fig. 1). Searches were cumulatively 313% of expected volume (95% CI: 186%, 996%), with daily rates exceeding the expected prediction interval from July 12 to July 30. By comparison, differences between observed and expected GSV for 911 were not significant.

Figure 1.

Observed versus expected daily Google search volume for 988 in the USA

Washington DC observed the highest RSV for 988 (RSV: 100), followed by Hawaii (RSV: 54) and Oregon (RSV: 52). RSV was highest in states in the top quartile of mental healthcare access compared to the bottom (13.6 points higher, 95% CI: 0.6, 26.5; p = 0.04) (Table 1). Average, unadjusted RSV in the top quintile was 40.2, compared to 25.8 in the bottom quintile.

Table 1.

Google Search Volume and Mental Health Access, by US State/Region

State/region	Google search volume	Mental health access quartile
DC	100	1
HI	54	3
OR	52	2
KS	46	4
RI	43	1
ME	42	1
NM	40	3
ID	38	4
MO	36	4
WI	36	1
CO	35	3
MD	35	2
NH	35	1
UT	35	3
IL	34	2
MA	34	1
NJ	34	3
VA	34	4
WA	34	4
CT	33	1
PA	33	1
CA	32	4
NV	32	5
OK	32	3
MS	31	5
AK	30	4
AZ	30	5
IA	30	2
OH	30	2
MT	29	2
GA	28	5
MI	28	2
NE	28	4
NY	28	2
WV	28	3
FL	27	5
MN	27	1
NC	27	4
DE	25	1
IN	25	3
TX	24	5
VT	24	1
KY	23	2
WY	23	4
SC	22	5
TN	22	5
AR	21	4
SD	19	3
LA	17	4
ND	17	3
AL	16	5

Google search volume defined as “interest over time” relative search volume. Mental health access as measured by Mental Health America’s Access to Care Rankings

Discussion

Internet searches for 988 reached a 12-month high during the week of 988 rollout: more than a fivefold increase from weeks prior, indicating significant public engagement. While GSV has since declined, it has remained at almost double the volume prior to rollout and markedly exceeds that of the national suicide prevention lifeline—the antecedent to 988. GSV remained below searches for 911 over the same period. Likewise, and by comparison, GSV for monkeypox peaked at 20.6 million searches during the first week of August, indicating much more engagement than 988.

We also observed more than a fivefold difference in search volume by state, suggesting marked variation in public awareness, engagement, and interest throughout the country. Our findings suggest outreach may be particularly warranted in states with the lowest RSV and weaker access to mental healthcare. Lack of awareness and engagement in 988 in these settings may reflect heightened mental health stigma or less public health education efforts to date [2].

This study was limited by the temporal and geographic resolution of search information available in Google Search’s public domain. Additionally, searches were not linked to attempts to contact 988, and they may reflect non-human activity such as bots, or humans executing the same search multiple times. Search volume is only one, albeit important, proxy indicator to gauge public awareness and engagement. It should continue to be examined to determine whether education campaigns and outreach efforts are succeeding.

Data Availability

Upon request from the lead author, data are available.

Declarations

Conflict of Interest

The authors declare no conflicts of interest.