JMIR FORMATIVE RESEARCH Fidel Kinori et al Original Paper A Web-Based App for Emotional Management During the COVID-19 Pandemic: Platform Development and Retrospective Analysis of its Use Throughout Two Waves of the Outbreak in Spain Sara Guila Fidel Kinori1,2, PhD; Gerard Carot-Sans3,4, PhD; Andrés Cuartero5, BSc; Damià Valero-Bover3,4, BSc, MSc; Rosa Roma Monfa3, BSc, MBA; Elisabet Garcia3, BSc, MBA; Pol Pérez Sust3,6, BSc, MSc; Jordi Blanch3, MD; Jordi Piera-Jiménez3,4,7, PhD; Josep Antoni Ramos-Quiroga1,2, MD, PhD 1 Department of Psychiatry, Hospital Universitari Vall d’Hebron, Barcelona, Spain 2 CIBERSAM, Universitat Autònoma de Barcelona, Barcelona, Spain 3 Information Systems Directorate, Servei Català de la Salut, Barcelona, Spain 4 Digitalization for the Sustainability of the Healthcare System DS3, IDIBELL, Barcelona, Spain 5 Sistema d'Emergències Mèdiques, Sistema de Salut de Catalunya, Barcelona, Spain 6 Information Systems Area, Departament de Salut, Barcelona, Spain 7 Faculty of Informatics, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain Corresponding Author: Jordi Piera-Jiménez, PhD Information Systems Directorate Servei Català de la Salut Barcelona Spain Phone: 34 651041515 Email: jpieraj@uoc.edu Abstract Background: Quarantines and nationwide lockdowns implemented for containing the spread of the COVID-19 pandemic may lead to distress and increase the frequency of anxiety and depression symptoms among the general population. During the nationwide lockdown of the first wave of the COVID-19 outbreak in Spain, we developed and launched a web-based app to promote emotional self-care in the general population and facilitate contact with health care professionals. Objective: This study aimed to describe a web-based app and analyze its utilization pattern throughout 2 successive waves of the COVID-19 outbreak in Spain. Methods: Our web-based app targeted all individuals aged 18 years or more and was designed by adapting the contents of a mobile app for adjuvant treatment of posttraumatic stress disorder (ie, the PTSD Coach app) to the general population and the pandemic or lockdown scenario. We retrospectively assessed the utilization pattern of the web-based app using data systematically retrieved from Google Analytics. Data were grouped into 3 time periods, defined using Joinpoint regression analysis of COVID-19 incidence in our area: first wave, between-wave period, and second wave. Results: The resulting web-based app, named gesioemocional.cat, maintains the navigation structure of the PTSD Coach app, with three main modules: tools for emotional self-care, a self-assessment test, and professional resources for on-demand contact. The self-assessment test combines the Patient Health Questionnaire-2 and the 7-item Generalized Anxiety Disorder scale and offers professional contact in the advent of a high level of depression and anxiety; contact is prioritized in accordance with a screening questionnaire administered at the time of obtaining individual consent to be contacted. The tools for emotional self-care can be accessed either on-demand or symptom-driven. The utilization analysis showed a high number of weekly accesses during the first wave. In this period, press releases regarding critical events of the pandemic progression and government decisions on containment measures were followed by a utilization peak, irrespective of the sense (ie, positive or negative) of the information. Positive information pieces (eg, relaxation of containment measures due to a reduction of COVID-19 cases) resulted in a sharp https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 1 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al increase in utilization immediately after information release, followed by a successive decline in utilization. The second wave was characterized by a lower and less responsive utilization of the web-based app. Conclusions: mHealth tools may help the general population cope with stressful conditions associated with the pandemic scenario. Future studies shall investigate the effectiveness of these tools among the general population—including individuals without diagnosed mental illnesses—and strategies to reach as many people as possible. (JMIR Form Res 2022;6(3):e27402) doi: 10.2196/27402 KEYWORDS web-based app; emotional management; lockdown; COVID-19; posttraumatic stress disorder; anxiety; quarantine; PTSD; app; emotion; development; platform; retrospective; usage; utilization lockdown context. Thus, considering the limited access of Introduction people to the health care system and the potential of ICT-based In the last months, most countries worldwide have experienced solutions to bridge these gaps, we aimed to develop a web-based uncontrolled outbreaks of the COVID-19 soon after reporting app platform for supporting emotional management among the the first case. The rapid spread of its causative agent, general population during the COVID-19 outbreak in our SARS-CoV-2, has led to an unprecedented overburdening of country. The existence of the PTSD Coach app provided us health care systems, prompting many governments to dictate with an opportunity to develop such a web-based app quickly strict lockdowns for containing the outbreak. and offer it to the local population timely. While such indiscriminate strategies have succeeded in We present herein the development, main characteristics, and containing SARS-CoV-2 spread and reducing mortality [1], launch of the web-based app, named gestioemocional.cat evidence warns on many psychological harms potentially (“emotionalmanagement” in Catalan), and a retrospective associated with quarantines [2], particularly among older and analysis of its use throughout alternate periods of lockdown and dependent people and those with previous psychiatric ease of social distancing measures. pathologies [3-5]. Alongside the quarantine-specific stressors, the uncertainty associated with the pandemic scenario and Methods impossibility of accompanying loved ones during their hospital stay or end-of-life stage has contributed to psychological Design Objectives overwhelming in many cases [5]. The web-based app was developed in response to a request by the Catalan Health System and Catalan Ministry of Health to The use of mobile health (mHealth) and web-based technologies provide Catalonia citizens (Northeast Spain) with support for for health (eHealth) has been shown to improve access to health coping with the emotional struggle associated with the care services under confinement situations. In previous years, COVID-19 pandemic and the nationwide lockdown. The information and communication technologies (ICT) (including web-based app was designed to assess two main objectives: (1) mHealth and eHealth solutions) for people with mental health to provide users with tools and guidance for emotional needs have been gradually incorporated into routine care, as self-assessment and care, and (2) to establish a communication also for social groups not considered regular digital consumers channel to reach health care professionals in the advent of such as older people [6]. A successful example of ICT-based worsening of mental health symptoms. solutions for mental health is the mobile app for managing posttraumatic stress disorder (PTSD; ie, the PTSD Coach app), The web-based app targeted all individuals aged 18 years or developed by the Veterans Affairs National Centre for PTSD older with the capacity to use a mobile app or website. Spain and the Department of Defence’s National Centre for Telehealth has a high smartphone penetration rate [10], for which the & Technology [7]. The PTSD Coach app has been translated web-based app had the potential to reach a significant part of to many languages―including Spanish, a translation led by our the population. Nonetheless, technical requirements of the team [8]―and it is currently used in our psychiatry department web-based app were minimized to facilitate access. Furthermore, as an adjuvant to face-to-face therapy for PTSD. to achieve high acceptability and on-demand use of the web-based app [11], we decided to store the least information The Catalan Health Service, which provides universal health possible and not retain the user’s historical records. care to a population of 7.7 million inhabitants in Northeast Spain, has a long tradition of implementing ICT solutions for Development of the Web-Based App promoting integrated care and increasing the efficiency and The government request for developing the web-based app was quality of health care delivery. The overloading of the health made on March 26, 2020. A panel of experts consisting of 2 care system experienced during the COVID-19 outbreak boosted clinical psychologists with expertise in psychological trauma the implementation of various digital health strategies to and crisis intervention and 2 psychiatrists of the Catalan Health counteract the collapse of many health resources [9]. To our System coordinated and oversaw the web-based app knowledge, by the time of the nationwide lockdown in our development and content generation. Considering the limited country, no mHealth solutions had been developed for time for developing the web-based app and the effectiveness of supporting people with mental health needs in a quarantine or the previously developed PTSD Coach app, we used it as a https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 2 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al starting point to translate its contents and adapt them to a analysis was to describe the number of users throughout the lockdown or pandemic scenario when necessary. study period. We used a script to systematize queries for retrieving information on daily accesses to the web-based app. The panel of experts reviewed all items of the PTSD Coach app For longitudinal analysis of the use of the web-based app, the and grouped them into three categories: (1) items that could be number of events was transformed into a logarithmic scale and translated into local languages without changes in their content; plotted against a timeline covering the period from the (2) items that required adaptation owing to cultural differences, web-based app launch on April 15, 2020, to data set closure on need for broadening the clinical scope to cover anxiety and December 16, 2020. Key events regarding outbreak progression depression symptoms, or adequateness to the quarantine or (ie, relevant press releases on epidemiological information and pandemic scenario; and (3) items to be removed for definite government decisions) and the time window of each wave of inappropriateness in accordance with the intended use of the the outbreak were added to the plot. The 2 waves of the App. Owing to the urgency of the development of the web-based COVID-19 outbreak were defined using Joinpoint regression app, item review was based on the clinical criteria and the analysis of publicly available data on COVID-19 incidence in expertise of panel members. Of note, 2 of them had contributed our area. A permutation test with 0.05 confidence and 4499 to developing and translating the PTSD Coach App and had, permutations was used as described elsewhere [12]. Differences therefore, in-depth knowledge of the rationale behind each item. in the distribution of test scores on each of the priority levels The resulting contents were used to develop the web-based app in the 3 study periods (ie, first wave, second wave, and between using the corporate colors and design of the Catalan Health waves) were assessed using a Pearson chi-square test and setting System. The authors of the PSTD Coach app kindly provided the significance threshold at a 2-sided α value of .05. The rest permission to adapt and translate their App. of the analyses were descriptive, and no other hypothesis tests Time Frame and Launching Strategy of the Web-Based were conducted. All analyses and plots were performed using App R package [13]. The first case of COVID-19 in Spain was officially reported in late January 2020. The Spanish government halted public Results gatherings on March 9, 2020, and led to a state of alarm and a Platform Components nationwide lockdown on March 13, 2020. The lockdown started a progressive easing on May 10, 2020, and was definitely lifted The gestioemocional.cat web-based app has the same navigation on June 20, 2020. structure as the PTSD Coach app. Table 1 summarizes the changes introduced to the PTSD Coach items to adapt them to The web-based app gestioemocional.cat was launched by the the intended use of the gestioemocional.cat web-based app; the Catalan Health Department on April 15, 2020. Information resulting list of items was translated to the local languages (ie, regarding the web-based app was disseminated using television Spanish and Catalan). Figure 1 outlines the navigation structure and radio advertisements, which were released through the of the web-based app. The main menu provides the user with channels of the public corporation. access to three sections: (1) resources for emotional Utilization Analysis and Statistics management, (2) tools for self-assessment, and (3) professional resources. Data for utilization analysis of the web-based app were gathered from Google Analytics. The main objective of the utilization https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 3 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al Table 1. Summary of content changes for adaptation of the PTSD Coach app into gestioemociona.cat web-based appa. PTSD Coach app contents Gestioemocional.cat contents Rationale for change Main menu Manage symptoms Resources for emotional management Wording change (no specific syndrome) Take assessment Self-assessment tools —b Health care resources Health care resources — Learn — Intended for an on-demand use; no personal histo- ry recorded Symptoms Remind of trauma Painful memories Wording adapted to a broader scope Disconnected from people Self-isolation Wording adapted to a quarantine context Disconnected from reality Disconnected from reality — Sad or hopeless Sadness or hopelessness — Worried or anxious Worries Wording adapted to a broader scope Angry Negative emotions Wording adapted to a broader scope Unable to sleep Unable to sleep — Tools Ambient sounds Ambient sounds — Body scan Body scan — Change your perspective Change your perspective — Contact with others Contact with others — Deep breathing Deep breathing — Grounding Grounding — Inspiring quotes Inspiring quotes — Leisure activities Leisure: time alone Wording adapted to a quarantine context Mindfulness Mindfulness — Muscle relaxation Muscle relaxation — Observe thoughts Observe thoughts — Relationship tools Relationship tools — Sleep tools Help falling asleep — Soothe the senses Soothe the senses — Soothing images Soothing images — Thought shifting Thought shifting — Time out Time out — RID: coping with triggers (Removed) In a non–posttraumatic stress disorder setting, no specific trigger is expected Calming thoughts (user uploaded) (Removed) No personal section or user history was included Schedule worry time (Removed) Intended for an on-demand use Positive imagery (Removed) No personal section or user history was included My feelings (Removed) No personal section or user history was included Self-assessment 3 items (evaluate your state, assessment history, Evaluate your state No personal section or user history were included and schedule self-assessment) PTSD Checklist for DSM-5c Patient Health Questionnaire-2 Broadening of assessment scope (anxiety and de- pressive symptoms expected) https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 4 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al PTSD Coach app contents Gestioemocional.cat contents Rationale for change Generalized Anxiety Disorder-7 Broadening of assessment scope (anxiety and de- pressive symptoms expected) Professional resources User can choose or be redirected toward crisis Exhaustive list of telephone numbers for Adapted to local resources resources, professional care, or choose persons in general health and mental health support his/her social network a Unchanged contents (ie, rationale for change dashed) were directly translated to the local languages (ie, Catalan and Spanish) without content changes. b —: not available. c DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Figure 1. Navigation structure of the gestioemocional.cat web-based app. CAP: primary care center (for the Catalan acronym "Centre d'Atenció Primària"), GAD-7: 7-item Generalized Anxiety Disorder scale, PHQ-2: Patient Health Questionnaire-2. https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 5 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al Resources for Emotional Management screen positive should be further evaluated with the PHQ-9 to The section “resources for the emotional management” can be determine whether they meet the criteria for a depressive accessed through two pathways: symptom-guided and resource disorder [18]. The Spanish version of the PHQ-2 has shown type–guided (Figure 1). Symptoms include painful memories, good reliability and validity in identifying depressive symptoms self-isolation, disconnection from reality, sadness or in the primary care setting [19]. The GAD-7 was developed for hopelessness, worries, negative emotion, and sleeping its use in primary care, and it has high sensitivity in identifying disturbances. All these symptoms have been identified as very symptoms of the anxiety spectrum. The Spanish validation of common during quarantines and lockdowns in the context of the questionnaire has shown good reliability and validity [20]. the COVID-19 pandemic [14,15]. Resource types include body To facilitate self-assessment, the 2 questionnaires were merged scan (ie, audio-guided), change one’s perspective (ie, random into a single questionnaire. The combination of the PHQ-2 and text messages to rationalize distress thoughts), connect with GAD-7 for a joint assessment of anxiety and depression has others (ie, list of ideas or tips for establishing interpersonal shown high internal reliability and strong convergent and relationships under a quarantine context), deep breathing (ie, construct validity when assessing its association with other audio-guided technique for emotional regulation trough mental health, quality of life, and disability measures [21]. All breathing), grounding (ie, list of tips for helping to be fully items of the combined questionnaire refer to the frequency of present for whatever is occurring right here and now), symptoms within the past 2 weeks and are rated on a 4-point inspirational phrases, use of personal leisure time (ie, list of scale where 0=“never,” 1=“less than seven days,” 2=“more than proposed activities to be performed during the lockdown), seven days,” and 3=“almost every day.” mindfulness exercises, progressive relaxation, observe thoughts The results of the 2 questionnaires are combined to provide 4 (ie, audio-guided techniques to help coping with distress priority levels of care needs (Figure 2). Users with low scores thoughts), relationships improvements (ie, list of tips to improve in the PHQ-2 and GAD-7 (ie, suggestive of mild symptoms of peer communication), help falling asleep (ie, list of proposals anxiety and depression) are encouraged to the routine use of for sleeping better), calm the senses, relaxing images, thought self-management and self-assessment tools to either maintain shifting (ie, list of phrases to be repeated over 5 minutes using (level 4) or improve (level 3) their emotional health status. a countdown tool), and time-out (ie, list of proposals to change Conversely, users with high scores on the PHQ-2 and GAD-7 the environment when remaining quarantined). (ie, suggestive of severe anxiety and depressive symptoms) are Irrespective of the pathway chosen to access the section offered telephone contact with professionals of the emergency “resources for the emotional management,” the web-based app medical service. Users who agree to be contacted by a health suggests a particular resource based on the user’s distress level, care professional are redirected to a consent form, which collects assessed using a single-item questionnaire (ie, what is your minimum personal data. Contacts are prioritized on the basis distress level? [use the arrows to indicate how you feel]) and of the combined result of the self-assessment questionnaire (ie, rated on a 10-point scale with scores ranging 0-10. Users can 1 or 2) and a screening form asking about 6 extreme mental select the distress level either stepwise―using up and down health conditions: suicidal ideation, loss of a loved one due to arrows―or using a distress thermometer with an intensity color COVID-19, family member admitted to hospital owing to code (Figure 1). COVID-19, living with someone at high risk of severe illness or with COVID-19 symptoms, current psychiatric treatment, Self-assessment and previous psychiatric treatment. Affirmative responses to The self-assessment section is based on two questionnaires for these questions were assigned the highest priority, irrespective a mental health assessment with a Spanish version adapted and of the self-assessment questionnaire results (Figure 2). validated: the Patient Health Questionnaire-2 (PHQ-2) [16] and Scheduled telephone calls are performed by the same the 7-item Generalized Anxiety Disorder scale (GAD-7) [17]. professionals attending calls from people who reach the The PHQ-2 is intended as a first-step approach to identify emergency medical service seeking mental health support. Once depressive symptoms on the basis of the frequency of depressed the phone contact has been established, health care professionals mood and anhedonia. While not recommended for depression perform an independent assessment, irrespective of the contact diagnosis or monitoring, it is considered useful for screening source (ie, direct call to emergency medical services or for depression, which is the most common psychological scheduled call through the web-based app). conditions in clinical practice and research; individuals who https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 6 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al Figure 2. Prioritization algorithm for proactive contact with health care professionals on the basis of the assessment of mental health status. GAD-7: 7-item Generalized Anxiety Disorder scale, PHQ-2: Patient Health Questionnaire-2. care professionals, the Official College of Psychologists, which Healthcare Resources can respond to population demands and transfer cases to public The section “healthcare resources” allows the user to proactively health care professionals, and the Vall d’Hebron Coronavirus contact community resources, including general health Section, a web-based platform available 24 hours a day, 7 days information, emergency medical services, general government a week for attending concerns related to emotional and social information office, the user’s primary care center, and the office impact of the COVID-19 pandemic. for women under gender violence. Additional resources include the Galatea Foundation, aimed at providing support to health https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 7 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al Utilization by the press. Most of the press releases announcing changes on Between April 15, 2020 (ie, the launch date), and December containment measures were immediately followed by a 16, 2020, the web-based app reported 582,826 accesses. Figure utilization peak, irrespective of the sense of these changes (ie, 3 shows the longitudinal analysis of the number of users and increasing or easing restrictions). Immediately after announcing critical events of pandemic progress. During the final period of the easing of restrictions (eg, the start of the de-escalation plan), the nationwide lockdown, the daily number of users peaked the daily number of users remarkably decreased. The decrease concomitantly with key news or government actions released was particularly abrupt when Barcelona, the most populated area, entered the first phase of the de-escalation plan. Figure 3. Longitudinal analysis of the number of accesses to the web-based app (logarithmic scale). Each time point shows the cumulative number of users in the 5 previous days. Red dotted lines show press releases of key events and government decisions regarding the COVID-19 outbreak. A: April 17, 2020—the Catalan Ministry of Health reports and posts the highest RT-PCR–positive and hospitalization rates. B: April 28, 2020—the Spanish government announces a de-escalation plan, to be deployed in 4 phases. Catalonia exceeds 10,000 deaths due to COVID-19. C: May 5, 2020—the government announces an upcoming partial lockdown. D: May 25, 2020, Barcelona—the greatest area in Catalonia, enters de-escalation phase 1. E: June 21, 2020—the whole country officially starts the “new normal” state. F: October 16, 2020—the government dictates a temporal lockdown of bars and restaurants. G: October 25, 2020—the government dictates nationwide curfew from 10 PM to 6 AM. H: October 30, 2020—the government dictates a permanent closure of area boundaries and weekend closure of city boundaries. The time window of each period (ie, first wave, between waves, and second wave) was defined using a Joinpoint regression analysis. RT-PCR: reverse transcription–polymerase chain reaction. The number of users during the second wave of the outbreak differences in the distribution of percentages across the priority was persistently lower than that in the first wave. During this levels (obtained from the self-assessment module) between the period, use of the web-based app was less sensitive to the analysis periods (Figure 4). The percentage of tests scoring for announcement of government measures. priority levels 1 or 2 (associated with more severe symptoms of anxiety and depression) was higher in the second wave and Progression of Self-assessment between-wave periods. Overall, the offer of professional help During the study period, the web-based app recorded 142,337 was accepted in 8588 cases (11.4% of all cases with priority self-assessment tests: 124,087 (87.2%) during the first wave, levels 1 or 2 and, therefore, triggering the message for an offer 8510 (6.0%) during the period between waves, and 9740 (6.8%) of professional help). during the second wave. The chi-square test revealed significant https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 8 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al Figure 4. Distribution of the results of the self-assessment test across priority levels (ie, risk group) in each of the analysis periods: first wave (n=124,087), between waves (n=8510), and second wave (n=9740). The 3 periods were defined using a Joinpoint regression analysis. The Pearson chi-square test for percentage distribution was significant at P<.001 (χ26=1349.1). mental health care during the second wave and between-wave Discussion periods. Principal Findings Limitations In this study, we describe a web-based app aimed at providing Development and launching of the web-based app were strongly the general population with self-care and self-assessment tools influenced by the urgency and overloading of the health care for emotional health during the lockdown associated with the system, which challenged the design of an adequate assessment COVID-19 pandemic and establishing a new communication strategy of the platform. We chose the PTSD Coach app because channel between the population and health care professionals. of the symptom overlapping between PTSD and those reported In addition, to reporting the characteristics of the web-based elsewhere for lockdown situations, particularly regarding anxiety app, we analyzed the utilization pattern of the web-based app and depression. One of the advantages of the PTSD Coach app during the first 10 months of the COVID-19 outbreak in Spain. was the body of evidence on its effectiveness for The frequency of use of the web-based app was particularly self-management of mental health needs. However, owing to high during the first wave of the outbreak in Spain and the shift in the target population (ie, from people diagnosed progressively declined until reaching a baseline activity below with PTSD to the general population), effectiveness of our 1000 weekly accesses after halting the national lockdown. web-based app cannot be assumed and should be confirmed in During the first wave, the number of accesses peaked after press future studies. Of note, the complicated scenario in which the releases associated with the pandemic progression or changes web-based app should be assessed will strongly challenge the in the containment measures dictated by the government. trial conduct. Interestingly, positive news (eg, relaxation of social distancing measures) were immediately followed by a sharp increase in Another important limitation of our retrospective analysis was utilization and a successive decline. The between-wave and the limited data stored, which precluded more exhaustive second wave periods were characterized by a less responsive assessments of behavior patterns among users (eg, to pattern of web-based app users. discriminate between entries of new users and regular access of the same user). However, because of the negative correlation The self-assessment module of the web-based app, designed to that often exists between App use or demand and permissions work as a sentinel for detecting severe mental health symptoms for accessing private data [11], we were concerned that and proactively offer direct contact with health care collecting too much data from users might be a barrier to professionals, was mostly used during the first wave. However, web-based app utilization. Of note, the government the scores of the self-assessment questionnaire were higher after announcement of launching a COVID-19 tracer app raised many the first wave, suggesting a higher proportion of people with privacy concerns among the population and was strongly https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 9 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al criticized. In light of this general perception, we prioritized the increased anxiety symptoms, grief processes, and difficulties acceptability of the web-based app over the capacity of associated with intensive cohabitation [26,27]. Similarly, other collecting personal information. As a result, our database for countries have reported increased demand for attention from the retrospective analysis lacked important information that people with mental health needs during nationwide lockdowns might have helped to understand behavior patterns among users. associated with the COVID-19 pandemic [28,29]. One of the most remarkable consequences of this limitation is The design of our retrospective analysis precludes drawing the lack of data at a user level, which precludes discriminating strong conclusions regarding the reasons underlying the between entries of new users and regular access of the same observed trend toward a less responsive usage of the web-based user. More importantly, the lack of historical records of users app during the second wave of the outbreak. However, this prevents us from analyzing improvement or worsening of mental finding is consistent with the “pandemic fatigue” phenomenon health state. Finally, we could not analyze the usage of the highlighted by the World Health Organization and defined as web-based app in accordance with socioeconomic status, which an expected and natural response to a prolonged public health has been highlighted as a source of inequality in other aspects crisis [30]. This type of reaction might correspond to M associated with access to COVID-19 resources [22,23]. Seligman’s Paradigm on learned helplessness, which describes Nevertheless, while all these limitations compromise analytical a passive behavior exhibited by a subject after enduring repeated approaches of the web-based app, the absence of personal aversive stimuli beyond their control. It is worth noticing, questions and no need for signing in are likely to promote the however, our finding that self-assessment tests more often scored platform use, in line with the overarching goal of the project, priority levels 1 or 2 during the between-wave and second wave which was to help the population during the stressful periods suggests that people with higher mental health needs circumstances of the lockdown. were more likely to retain the usage of the web-based app after Comparison With Prior Work the first wave. To our knowledge, by the time of developing the web-based Finally, the fact that 8588 self-assessment tests ended up with app, no other mHealth solutions for promoting emotional a scheduled telephone call with health care professionals for self-care in the general population during a lockdown or mental health support indicates that the web-based app has quarantine situation had been launched or published. The closest emerged as an additional communication channel for seeking example of an mHealth tool that matched our aim was the PTSD professional help. The number of telephone contacts represents Coach app, which was innovative in the sense that users can a low percentage (11.4%) of the total situations in which access tools through two alternative pathways: on-demand and professional support was offered. However, this finding is symptom-driven [7]. Although the PTSD Coach app was consistent with current evidence, which suggests that most designed as adjuvant to face-to-face therapy for PTSD, its people with common mental health problems do not seek authors suggested that it could also help people not receiving professional help [31,32]. psychological treatment [24,25]. Further experiences also showed good usability and ease of cultural adaptation of the Conclusions App [8], encouraging us to adapt its contents to a lockdown and In the first year of the COVID-19 pandemic, various authors pandemic scenario in our country. have emphasized the need to promote original and creative ways to help people cope with the new and stressful conditions during Although we cannot directly compare the utilization patterns the pandemic [33,34]. We did not want to miss the opportunity of our web-based app with other mHealth or eHealth solutions to adapt mHealth tools with proven efficacy in self-management for lockdown contexts, the trends observed in our analysis are of stressful situations to the pandemic scenario. Future studies consistent with information reported elsewhere. For instance, shall investigate the extent to which this tool helps people cope the increased consumption of alcohol and drug abuse reported with the pandemic scenario and address strategies for making during this period in our area [15] could likely be attributed to as many people as possible aware of this resource. Acknowledgments The authors would like to thank all the teams involved in the development of the technological solution and the delivery of the intervention from Servei Català de la Salut, Centre de Telecomunicacions i Tecnologies de la Informació, Sistema d’Emergències Mèdiques and Departament de Salut. We also thank the developers of the PTSD Coach app (particularly Drs Jason E Owen and Erik Kuhn) for kindly permitting us to adapt the contents of their app. Conflicts of Interest JB was on the speakers’ bureau and/or acted as consultant for Janssen-Cilag, GILEAD, MSD, ViiV, Menarini in the last 3 years. 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JMIR Ment Health 2020 Mar 26;7(3):e18848 [FREE Full text] [doi: 10.2196/18848] [Medline: 32213476] Abbreviations GAD-7: 7-item Generalized Anxiety Disorder scale ICT: information and communication technologies mHealth: mobile health PHQ-2: Patient Health Questionnaire-2 PTSD: posttraumatic stress disorder Edited by A Mavragani; submitted 23.01.21; peer-reviewed by G Iaccarino, SK Mukhiya; comments to author 18.02.21; revised version received 10.03.21; accepted 31.01.22; published 31.03.22 Please cite as: Fidel Kinori SG, Carot-Sans G, Cuartero A, Valero-Bover D, Roma Monfa R, Garcia E, Pérez Sust P, Blanch J, Piera-Jiménez J, Ramos-Quiroga JA A Web-Based App for Emotional Management During the COVID-19 Pandemic: Platform Development and Retrospective Analysis of its Use Throughout Two Waves of the Outbreak in Spain JMIR Form Res 2022;6(3):e27402 URL: https://formative.jmir.org/2022/3/e27402 doi: 10.2196/27402 PMID: 35142638 ©Sara Guila Fidel Kinori, Gerard Carot-Sans, Andrés Cuartero, Damià Valero-Bover, Rosa Roma Monfa, Elisabet Garcia, Pol Pérez Sust, Jordi Blanch, Jordi Piera-Jiménez, Josep Antoni Ramos-Quiroga. Originally published in JMIR Formative Research (https://formative.jmir.org), 31.03.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 12 (page number not for citation purposes) XSL• FO RenderX JMIR FORMATIVE RESEARCH Fidel Kinori et al bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included. https://formative.jmir.org/2022/3/e27402 JMIR Form Res 2022 | vol. 6 | iss. 3 | e27402 | p. 13 (page number not for citation purposes) XSL• FO RenderX