Mapping the landscape of telemedicine and technology in behavioral addiction treatment: A bibliometric review

Abstract

Background

Behavioral addiction (BA) involves compulsive behaviors causing distress or interference with normal functions, akin to substance addiction. Presently, only gambling and gaming disorders are recognized, necessitating further exploration into behaviors like binge-eating, shopping, and internet addiction. Telemedicine, utilizing information and communication technologies, offers remote healthcare services. Reviews on internet-based interventions for BA show mixed efficacy, particularly for gambling disorder. However, research predominantly focuses on gambling, neglecting other BAs. This bibliometric review aims to map research trends and highlight gaps, emphasizing the need for broader telemedicine interventions beyond internet-based treatments.

Objectives

Examine the existing literature regarding telemedicine and technology-driven interventions for BA by analyzing the current research status and delineating publication patterns. Furthermore, highlight possible future research directions.

Results

Analysis revealed increasing research output, notably from Asian countries. Virtual reality (VR) interventions for gaming addiction and smartphone applications for managing addictive behaviors emerged prominently. Research gaps exist, particularly for other BA types.

Conclusions

Telemedicine and technology show promise for BA treatment, especially in gambling disorder. However, research gaps remain, necessitating further investigation across diverse BA types and populations. This review provides insights into the evolving landscape of telemedicine and technology in BA treatment, highlighting the need for continued research.

Keywords

Behavioral addiction telemedicine technology ICT virtual reality

Background

Behavioral addiction (BA) is characterized by diminished control of behavior which results in significant distress or interference with one’s normal functions without the influence of addictive substance.^1,2 Neurocognitive and brain imaging studies have also shown commonalities in the addictive nature between BA and substance disorder where similar neurocognitive activity was observed in brain areas associated with impulsive decision-making, decreased response to addiction cues and elicitation of cravings.³ Presently, gambling disorder and gaming disorder are the only two disorders classified in the International Statistical Classification of Diseases and Related Health Problems (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) as behavioral addiction. Gaming addiction, specified as internet gaming disorder (IGD) in the DSM, was listed under Section 3 as a disorder necessitating further research.

However, internet addiction is not the only BA requiring further research. Numerous behaviors with similar characteristics warrant comprehensive exploration to understand this multifaceted phenomenon better. A functional neuroimaging study by Balodis et al.⁴ posits that the action of binge-eating might be a compensatory behavior to stimulate activity in the reward neurocirculatory area when diminished activity was observed in the brain region associated with anticipatory processing in a monetary incentive delay task in obese participants with binge eating disorder. Research⁵ also found that behaviors, such as compulsive buying/shopping disorder,⁶ sexual addiction,⁷ computer and video game addiction,⁸ and internet addiction,⁹ displayed similar characteristics of BA, such as cravings and diminished control in decision making.

Telemedicine, facilitated by information and communication technologies (ICT), enables healthcare practitioners to deliver services remotely, fostering information exchange in diagnosis, treatment, research, and education.¹⁰ Several systematic reviews reviewed the effectiveness of internet-based intervention on BA with inconclusive findings. Chebli, Blaszczynski and Gainsbury¹¹ reviewed the effectiveness and treatment outcomes of internet-based intervention on addictive behaviors. For gambling disorder, four studies were identified, three of which were non-comparative studies evaluating cessation programs and one was a randomized controlled trial. They found that over 50% of the participants were able to maintain abstinence up to 3 years post-treatment and posit correlations between completion of the program and length of abstinence. A systematic review and meta-analysis by Sagoe et al.¹² examined the efficacy of internet-based treatment for gambling disorder. Results indicated a considerable effect size for general gambling symptoms, and a smaller but still significant effect for gambling frequency and amount of money lost in gambling, even at follow-up. The study also revealed that internet-based treatment has a small but significant effect on generic gambling symptoms at post-treatment as compared to face-to-face treatments. More recently, Boumparis et al.¹³ reviewed 29 relevant studies on the effectiveness of internet-based interventions on gambling, gaming, internet use, pornography, and hoarding, where most studies focused on gambling disorder. Coinciding with previous findings, internet-based intervention also indicated a reduction in gambling-related symptoms. However, due to the limited number of studies, evidence supporting the effectiveness of internet-based intervention on other BA was insufficient. Park et al.¹⁴ also reviewed 12 studies on the effectiveness of web-based treatments for various online BA, including online gaming, gambling, pornography, and internet/smartphone use. Results revealed effectiveness at improving symptoms post-treatment and at follow-up but highlighted high rates of attrition.

Nevertheless, most reviews predominately focused on gambling disorder and share common limitations on the quality of studies^11,13,14 reviewed. In addition, previous literature limited the use of telemedicine to Internet or web-based interventions and has never investigated the role of technological tools in the treatment of BA. However, it is critical to understand that the application of telemedicine should not be limited to internet-based treatments alone. Other modalities involving ICT that encompass the capture, storage, manipulation, analysis, retrieval or display of information, and are used when geographical distance is not a barrier, should also be considered and included in the broader scope of telemedicine interventions.¹⁵ Thus, it is timely for this bibliometric review to map out the research done within the field and highlight some of the featured publications. This review aims to better understand the current direction of the use of telemedicine and technology in treatment delivery for behavioral addictions disorders, identify key research gaps and highlight possible future research direction.

Method

Web of Science (WOS) database was used to identify articles relevant to this bibliometric review. The WOS database was selected for the ease of use for bibliographic analysis, comprehensiveness of academic disciplines and inclusion of citations since the 1900s.¹⁶ WOS not only indexes articles from all leading high-impact factor journals, but also offers advantages over Scopus and PubMed/MEDLINE in extracting essential bibliographic information, including journal titles, author names, total citations, and overall download rates.¹⁷ WOS has the most selective journal coverage, especially in the coverage in the subject areas of life science, physical science, and technology.¹⁸

Given the proclivity to incorporate broader terms when addressing BA,¹⁹ the main investigators developed the search strategy and consulted a library information specialist from Lee Kong Chian School of Medicine, Nanyang Technological University to further refine the search strategy to ensure comprehensive inclusion of relevant articles. The query was performed on WOS on 4th January 2023.

Building upon works by Boumparis et al.,¹³ Balodis et al.,⁴ and Lejoyeux and Weinstein,⁶ this study will extend the investigation by reviewing internet addiction, sex and pornography addiction, gaming addiction, gambling addiction, phone addiction, shopping addiction, and food addiction. Eight search strategies were formulated, one for telemedicine and one for each of the seven BAs. (see appendix) shows the specific search strategy for each keyword.

TS refers to a search based on the topic of interest. Each search strategy was first performed independently, then the entire query was combined using the Boolean operator “AND” to formulate a finalized search result for each type of behavioral addiction. The identified publications were then further filtered between the years 2012 and 2022 to observe recent changes.

Using this strategy, a total of 2387 publications were extracted from the WOS database. The identified publications were then exported into a plain text format file, where the reviewers (THS and SBA) screened the databases based on their titles and abstracts. The publication is excluded if: (i) it was a duplicated result of a previous publication, (ii) they were not relevant to the field or has no clear indication of the type of addiction, (iii) the treatment was not for any of the seven BA disorders, (iv) the treatment method or intervention adopted irrelevant to telemedicine or technological mean, and (v) there is an inclusion of subjects with other psychiatric comorbidities. Any disagreements regarding the inclusion or exclusion of specific publications were resolved by discussion in consultation with a third reviewer (MZWB).

Biblioshiny (R Studio, Version 4.3) was used to perform analysis the bibliometric data and helped with visualization of the following information: (a) the main information of the dataset, (b) annual number of published publications, (c) journals that published the most recent sources, (d) the most cited authors, (e) the most cited countries, (f) the most cited global documents, (g) the most utilized keywords, (h) co-occurrence of keywords, and (i) themes and trend topics across the years.

Results

Analysis of publications

A total of 23 publications were included in this study. These publications were published between 2016 and 2022. A total of 21 sources contributed to these 23 publications. Of the 23 publications, 16 were articles, one was editorial material, one was proceedings papers and five were reviews. These publications included a total of 78 author keywords. 119 authors contributed to the 23 publications, but none of the publications was single-authored. The number of co-authors per publication was 5.57. Figure 1 provides an overview of the annual number of publications published.

Figure 1.

Overview of the annual number of publications published per year.

On average, about 3.29 publications were published every year and the average citation per document was 9.26. The collaboration index²⁰ amongst the 23 publications was 5.57. The most productive countries were, in order of productivity, Germany (n = 15), Australia (n = 13), South Korea (n = 11), the United States (n = 6), Italy (n = 4), United Kingdom (n = 4), Japan (n = 4), China (n = 3), Indonesia (n = 3), Switzerland (n = 3), Denmark (n = 2), France (n = 2), Singapore (n = 2), Malaysia (n = 1), Poland (n = 1), Qatar (n = 1) and Saudi Arabia (n = 1). Figure 2 is a three-field plot that illustrates the association among the countries, authors and keywords used. This helps to visualize the most productive authors, their countries of origin and the keywords used by the authors.

Figure 2.

Association amongst country, author and Author’s keywords.

Journal analysis

Table 1 provides information on the sources where these publications were published. Most publications relevant to the topic were published in BMJ Open and Digital Health.

Table 1.

Sources in which publications were published.

Sources	Publications
BMJ open	2
Digital health	2
Behavioral sciences	1
Comprehensive psychiatry	1
Computer methods and programs in biomedicine	1
Current opinion in psychiatry	1
Current psychiatry reports	1
Frontiers in neuroscience	1
Future internet	1
Health promotion journal of Australia	1
International journal of environmental research and public health	1
JMIR serious games	1
Journal of behavioral addictions	1
Journal of gambling issues	1
Journal of gambling studies	1
Journal of medical internet research	1
Journal of pediatric nursing-nursing care of children & families	1
MHealth	1
Plos one	1
Proceedings of the 13th international conference on ubiquitous information management and communication (imcom) 2019	1
Technology and health care	1

Table 2 provides information on the leading authors in the field and the corresponding number of publications that they had published.

Table 2.

Leading authors in the field.

Authors	Publications
Kim H	3
Burrows T	2
Eom H	2
Jung YH	2
Kim E	2
Kim Jj	2
Leary M	2
Shin YB	2
Aborujilah A	1
Aboujaoude E	1
Al-Othman A	1
Ali Na	1
Ali R	1
Almotiri S	1
Baba T	1
Baker Al	1
Basenach L	1
Ben brahim F	1
Bewick bm	1
Bischof A	1

Table 3 provides an overview of the affiliations that produced the most publications in the field.

Table 3.

Affiliations with the most published publications.

Affiliation	Publications
YONSEI UNIV	5
UNIV LUBECK	3
UNIV NEWCASTLE	3
AARHUS UNIV	2
CATHOLIC UNIV KOREA	2
INST PSYCHOL	2
NATL UNIV SINGAPORE	2
RUHR UNIV BOCHUM	2
UNIV ATMA JAYA YOGYAKARTA	2
UNIV CHINESE ACAD SCI	2

Figure 3 provides an overview of the author’s collaboration dynamics by author’s countries. This information is pertinent for understanding the amount of good exchange of knowledge within the field.²¹

Figure 3.

Author’s collaboration dynamics.

Table 4 provides an overview of the analysis of the most globally cited publications. This information helps us to understand which articles have had the most impact in the field. Figure 4 shows the word cloud of the most frequently occurring author’s keywords.

Table 4.

Overview of most globally cited publications.

Author, publication year and publication source	Publication	Total citations	TC per year
Park SY, 2016, Comput meth prog bio	The effects of a virtual reality treatment program for online gaming addiction	60	6.67
Van Velthoven MH, 2018, Digit health	Problematic smartphone use: Digital approaches to an emerging public health problem	55	7.86
Zhang MWB, 2017, Technol health care	Smartphone applications for immersive virtual reality therapy for internet addiction and internet gaming disorder	29	3.63
Shin YB, 2018, Plos one	Development of an effective virtual environment in eliciting craving in adolescents and young adults with internet gaming disorder	18	2.57
Lam LT, 2016, Curr psychiat rep	eHealth intervention for problematic internet use (PIU)	15	1.67
So R, 2020, J Gambl stud	Unguided chatbot-Delivered cognitive behavioural intervention for problem Gamblers through messaging app: A randomised controlled trial	11	2.20
Stramba-Badiale C, 2020, front neurosci-switz	Transcranial magnetic stimulation meets virtual reality: The potential of integrating brain stimulation with a simulative technology for food addiction	7	1.40
Kent S, 2021, Int J env res pub He	Digital intervention for problematic smartphone use	4	1.00
Gorowska M, 2022, Compr psychiat	Novel approaches for treating internet gaming disorder: A review of technology-based interventions	2	0.67
Brino Kas, 2022, J pediatr nurs	Problematic internet use in adolescents and implementation of a social media hygiene protocol	2	0.67
Yang YV, 2020, Behav sci-basel	Process evaluation of a personality targeted intervention for addictive eating in Australian adults	2	0.40
Ridley K, 2020, J Gambl issues	Win big fast! an evaluation of mobile applications available in Australia for problem gambling	2	0.40
Paterson M, 2021, Health promot J Aust	An overview of digital and online strategies to reduce gambling harm	2	0.50
Bottel L, 2021, J behav Addict	Efficacy of short-term telemedicine motivation-based intervention for individuals with internet use disorder - A pilot-study	1	0.25
Giansanti D, 2021, MHealth	Health in the palm of your hand-part 2: Design and application of an educational module for young people on the risks from smartphone abuse and the opportunities of telemedicine and e-Health	1	0.25
Shin YB, 2021, JMIR serious games	Managing game-related conflict with parents of young adults with internet gaming disorder: Development and feasibility study of a virtual reality app	1	0.25
Aboujaoude E, 2022, J med internet res	Assessment of the popularity and perceived effectiveness of smartphone tools that track and limit smartphone use: Survey study and machine learning analysis	1	0.20

Figure 4.

Word cloud of most frequently occurred author’s keywords.

Figure 5 illustrates the co-occurrence network of keywords used by authors. This is relevant to understanding the componential and structural knowledge within the field.²² Figure 6 illustrates the clustered themes of keywords used by authors within the field.

Figure 5.

Co-occurrence of author’s keywords.

Figure 6.

Clustered themes of author’s keywords.

Discussion

This bibliometric review seeks to identify the current research area of telemedicine and technological methods used for the treatment of BA disorders, identify possible research gaps, and highlight future research directions. The current trajectory of research in this study indicates an inclination towards specialized domains. The development of this area of research towards niche areas is evident from the highly cited articles on the use of VR in the treatment of gaming addiction^23–25 and the use of smartphone applications in the treatment or management of smartphone use²⁶ and gambling.²⁷ However, the use of telemedicine and technological tools is not limited to the treatment of gaming and gambling. A study by Leary et al.,²⁸ designed and reviewed the feasibility of an online workshop-based intervention to manage addictive eating.

The journals that published articles in this area of research were not limited to psychology and psychiatry but were also found in journals related to technology and computing. This demonstrates the multifaceted nature and interest of this area of research across multiple disciplines of studies. Findings from the analysis of the most productive authors, affiliations, and countries, we can observe that Asian countries, specifically Korea, appear to be most concerned about this area of study. Korea, as a country with one of the most advanced technologies, is highly prevalent in addictive behaviors, especially in gaming disorders,^29,30 due to stress and other factors. One of the biggest advantages of VR in the treatment of BA is the ability to simulate the real world through the construction of a virtual environment which allows additional or enhanced feedback³¹ to further aid individuals in learning to manage or regulate their addictive cravings or triggers.³² Currently, research trend shows interest in the use of VR as a means of treatment delivery for BA, though mostly targeted at gaming addiction. Research findings demonstrate VR helps understand the triggers of individuals suffering from gaming disorder²⁵ and has shown similar effectiveness with CBT in the reduction of online gaming urges.²³ However, prolonged use of VR might result in desensitization, familiarization, and learning.²⁵ Future studies could look at the use of VR in the management of other BA aside from gaming addiction, such as binge-eating disorder or smartphone use. Lastly, future direction for research could expand from the young adults and adolescents population.²⁹

This review looks at the existing trend of telemedicine and technology in the treatment of behavioral addiction. One of the strengths of this study is that the use of telemedicine is not limited to Internet or web-based intervention but also includes the use of technological tools in the treatment of BA. Results from this study show a rising trend in the use of VR and smartphone applications in the treatment of BA. This study also highlighted other possibilities of using VR for the treatment of different forms of BA. There are several limitations to this analysis. First, the search strategy was limited to recent years. This potentially might exclude older relevant studies and limit the trends observed in this study. Secondly, despite the authors’ effort to ensure the search strategy was able to include all relevant literature, due to the nature of the academia, there might be new terminologies or keywords that are not included in the search strategies. This might cause the search results to leave some relevant articles out. Lastly, as the search was performed in early Jan 2023, the publication might not be the most updated by the time of journal publication.

Footnotes

Acknowledgments

The authors would like to thank Ms. Yasmin Lynda Munro from Lee Kong Chian School of Medicine's Library for her invaluable inputs on the development of the search strategies and acknowledge the contributions by Ms Charis Ng in this study.

Authors’ contributions

All authors contributed to the conceptualization of the study. Data Curation and Analysis, T.H.S.; Data Investigation and Writing – Original Draft Preparation, T.H.S., S.BA; Writing – Review and Editing, T.H.S., S.BA and M.Z.W.B. All authors have read and agreed to the published version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Hui Shan Tan

Syidda

Data Availability Statement

The datasets generated and/or analyzed during the current study are available from the corresponding author.*

Appendix

Table 1.

Search strategies.

1	Telemedicine	TS=(telemedicine or “tele medicine” or “tele-medicine” or “telehealth” or “tele health” or “tele-health” or “teleconsultation” or “tele consultation” or “tele-consultation” or “health app” or “intervention app” or “electronic health” or “e-health” or ehealth or “mobile health” or mhealth or “m-health” or “digital health” or “digital technology” or “communication technology” or “interactive program” or “online support” or “virtual consultation” or “virtual visit” or “virtual reality” or “virtual treatment” or “virtual therap” or “virtual intervention” or “digital treatment” or “digital intervention” or “telehealth service” or “remote patient monitoring”)
2	Internet addiction	TS=(internet addiction OR internet addiction disorder OR addictive behavio?r OR social media addiction OR internet dependenc* OR technology addiction OR digital addiction OR compulsive internet use OR pathological internet use OR problematic internet use OR internet overuse OR pathological computer use)
3	Sex and pornography addiction	TS=(porn* OR porn addiction OR pornography addiction OR sex addiction OR sexual addiction OR compulsive sexual behavio?r OR CSBD OR hypersexuality OR nymphomania OR physical addiction OR sexual fetish OR erotic fixation OR erotica OR addictive behavio?r)
4	Gaming addiction	(((TS=(“online”)) OR TS=(“internet”))) AND (((TS=(“gaming”)) AND ((((TS=(“pathologic”)) OR TS=(“problem*”)) OR TS=(“disorder”)) OR TS=(“excessive”)) OR TS=(“addiction”))) OR TS=(Video game addiction OR addictive behavio?r OR technology addiction)
5	Gambling addiction	TS=((online OR internet) AND (problem OR disorder OR excessive OR gambling) AND (pathologic* OR addiction)) OR TS=(addictive behavio?r)
6	Phone addiction	TS=((online OR internet) AND (problem OR disorder OR excessive OR technology OR mobile phone OR cell phone OR smartphone) AND (pathologic* OR addiction)) OR TS=(addictive behavio?r)
7	Shopping addiction	TS=(Online shopping addiction OR internet shopping addiction OR online compulsive shopping OR internet compulsive shopping OR shopaholic OR oniomania OR addictive behavio?r)
8	Food addiction	TS=(food addiction OR food obsession OR food compulsion) OR TS=(Overeat* )

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