**1. Introduction**

The World Health Organization (WHO) reports that as of 2017, there has been a 13% increase in mental health issues worldwide [1]. Mental health has been further affected since restrictions on social gatherings were placed to counter COVID-19 outbreaks [2]. The ramifications of COVID-19 include social isolation, economic crises, and unemployment, which are among the known risk factors for mental health illnesses [3]. Statista, a major provider of market and consumer data, surveyed around 23,000 participants worldwide, within the age range of 16–74 years, on mental health during the pandemic. The organization found that as of early 2021, 40% of the participants had reported a negative impact on their mental well-being during the last six months [4].

With the pandemic spreading, the interest in digital health for mental illnesses has accelerated [5,6]. Several studies, based on the populations of China [7], Spain [8], Canada [9], and Australia [10], discussed the adoption of mental health apps as a way to provide mental healthcare to their population. Along with this, there has been an increase in the number of apps claiming to provide mental health care in the market, as well as a boost in the number of downloads of these mental health apps [10,11]. The growing number of mental health

**Citation:** Aziz, M.; Erbad, A.; Almourad, M.B.; Altuwairiqi, M.; McAlaney, J.; Ali, R. Did Usage of Mental Health Apps Change during COVID-19? A Comparative Study Based on an Objective Recording of Usage Data and Demographics. *Life* **2022**, *12*, 1266. https://doi.org/ 10.3390/life12081266

Academic Editor: Daniele Giansanti

Received: 11 July 2022 Accepted: 27 July 2022 Published: 19 August 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

app downloads could mean that more people are seeking mental health support or are receptive to it. Several demographic factors may need to be considered to identify these people, such as whether a certain age group or gender is predominantly downloading these apps. Additionally, downloading apps alone does not mean that a user is committing to use them; it would, however, show their receptiveness to help.

Jaworski et al. [12] investigated the daily usage of COVID Coach, a publicly available mental health app, with respect to the number of days the app was used. The study found that almost 50,000 people used the COVID Coach app from March 2020 to October 2020, and the app had a consistent daily active usage. Kozlov et al. [13] studied the usage of Mindfulness Coach based on the number of downloads and number of days. Their study found that the app is used infrequently and for short sessions. Almost 40% of returning users would open the app but not use it. Research conducted during COVID-19 from March to April 2020 focused on estimating the usage of popular mental health apps [14]. The study used monthly active users as a base metric to estimate usage and focused on the during-COVID-19 times. Wang et al. [15] found the number of downloads of mental health apps to increase during the COVID-19 period as compared to pre-COVID-19. Their research focused on the popular mental health apps based on the number of downloads and classified apps as per the developer's choice.

With respect to demographics, Mackenzie et al. [16] studied the differences in helpseeking outlooks amongst the different age and gender groups using a sample size of 206 participants. Their study used questionnaires to measure the help-seeking attitudes and the mental health conditions of the participants. They found older adults above 60 and females to be more receptive to seeking help regarding their mental health. Additionally, Segal et al. [17] performed a cross-sectional study on the beliefs and help-seeking attitudes of people based on their ages. They used questionnaires to gather information about the beliefs and help-seeking attitudes of people. Their results showed that older adults aged 60–95 years reported willingness to seek help on the same level as the adults aged 17–26 years. Furthermore, Kern et al. [18] conducted a study at the university level to investigate the help-seeking attitudes of young adults aged around 18–22 years old. Their survey responses showed that most students have a positive attitude towards receiving mental health support through mental health apps. Forbes et al. [19], on the other hand, found that their survey responses showed older adults above 60 as less likely to recognize their need for mental health care.

A major limitation in the research literature relates to the utilization of self-reported data to quantify the usage of mental health apps. This may lead to reporting bias which means that participants may underestimate or overestimate their mental health behaviors. Additionally, with regard to the use of smartphone apps, such as average screen time and average launches, users tend to underestimate their smartphone usage behavior [20,21]. Furthermore, previous research studies have mostly utilized usage metrics that do not take into consideration the actual time spent on mental health apps and focus only on the number of downloads or number of days of use of mental health apps. Torous et al. [22] state that almost 70% of users leave a health app after 10 uses. The number of downloads and the number of days alone are, therefore, not representative of the usage of mental health app users. Additionally, past research investigated the popular mental health apps downloaded by users to study their usage, whereas the change in usage may only be to certain categories of these apps. For example, some apps require spending time on them, whether to meditate or do mindfulness exercises, while others are based on reminders or recording daily moods and habits.

In this paper, we compare mental health app usage before and during the COVID-19 pandemic, using objective data collected from a smartphone app that monitors smartphone usage. We analyze the users who are using these mental health apps based on age and gender. We also classify the mental health apps into two categories to study the change in usage that may exist due to the type of app. Hence, taking into consideration the pre-COVID-19 and during-COVID-19 use of mental health apps, our research questions (RQ) are:

RQ1. Is there a change in the number of users?

RQ2. Is there a change in the usage with respect to daily average time spent, the daily average number of launches, average session time, and the number of days of use?

RQ3. Is there a change in the usage across the two categories of mental health apps: the guidance-based and the tracking-based apps?
