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Antidepressant medications (AMs) are used as regimens of major depression disorders. Therefore, adherence to AMs is critical in ensuring improved quality of life, positive health outcomes, and costeffectiveness. All patients with major depression disorder must seek treatment from mental health providers to achieve optimal outcome. Because depression has a high public health impact, AMs are ranked as the most frequently prescribed medications in the US [1]. With an average rate of 55% adherence among patients with depression, nonadherence to AMs poses a huge challenge to the treatment of depression.

The prevalence of binge drinking behaviour in the overall general population in Malaysia is low (5.7%) when compared to the global prevalence [2]. Among the current drinkers, half of them engaged in binge drinking behaviour. The trends for binge drinking showed an increasing pattern and almost doubled by 2011 when compared to 2006 [3]. However, direct comparison could not be made as both studies.

Using different definition to measure binge drinking. This definition also maybe different to that noted in other countries, especially countries with a higher prevalence of alcohol use [4]. In this study, binge drinking was highest among the Bumiputera Sabah and Sarawak. The characteristics of binge drinking across race may differ due to differences in culture or attitude that may contribute to their binge drinking behaviour [5]. The high prevalence of such behaviour among Bumiputera Sabah and Sarawak may be related to culture where alcoholic beverages such as Tuak (home-brewed beverages) are considered traditional beverages. The tendency to binge also occurred during local festivals, such as Harvest festivals, where these alcoholic beverages are served and consumed in excess as a part of the celebration. As for Chinese, they may consume more alcohol due to social occasion but they were a low risk drinker that exhibits low prevalent for binge drinking habit. Surprisingly for the Indians, they were among the group that have been previously reported with high consumption of alcohol and bingeing habit [6], but their drinking pattern trend are slowly improving due to attempt cessation on alcohol drinking [7].

Other factors that may contribute to increased alcohol drinking frequency and bingeing may be related to the way in which various groups drink. For example, the Malays drink less frequently due to religious restrictions, and we speculate that they rarely drink but once they drink, they may drink excessively and engage in bingelike behaviour. Other studies have correlated binge drinking with depression and anxiety, and it may be that some patients drink and engage in binge behaviours as a way to cope with unpleasant emotions [8]. This pattern of drinking frequency has been noted in our Malaysian drinkers who tend to drink less but drink to intoxication as a mechanism by which to cope with their depression [9]. As expected, our finding of a higher prevalence of binge drinking among males has also been found in other studies. In the United States, binge drinking behaviour is more serious among males than females where binge drinking among males is approximately three times higher than that in females [10]. This pattern is noted in relation to the higher frequency of alcohol use among males when compared to females [11] (Figure 1).

Figure 1: Binge Drinking.

Discussion

Clearly, high consumption among males is simultaneous with bingeing habit compared with females. As in the present study, the proportion of drinking among males was higher than that in females, with males reporting alcohol use at least 2 to 4 times a month to a maximum of 4 or more times per week compared to females who primarily drank at least once a month and the majority of them were abstainers [12]. Binge drinking behaviour may correlate with the intensity of alcohol consumption on a typical day. In the current study, the proportion of alcohol intensity among binge drinkers was high, ranging from at least 3 or 4 drinks on a typical day to 10 or more drinks daily.

Males had relatively higher alcohol drinking intensity when compared to females. This finding is similar to a study conducted in the United States where they found that males who binged consumed a larger number of drinks per binge episode than females. Young adults are highly represented among binge drinkers, and most studies have reported that young adults contribute the most to the high prevalence of binge drinking noted in studies. However, in this study, although there was no significant difference across ages, the pattern of binge drinking was more common among those from aged 13 to 29 years old. A study from the European region on binge drinking among children and adolescents found that those who binged came from a low-income family, and their bingeing was significantly associated with family conflict. One study reported that underage binge drinking was associated with a coping mechanism for depression. However, other factors, e.g., peers, may also contribute to binge-drinking behaviours among adolescents [13]. In this study, despite significantly high prevalent of current alcohol use among high income and high education attainment, these socioeconomic status do not affect binge drinking habit. In contrast, other studies reported a significant correlation between socioeconomic statuses with bingeing behaviour.

They had concluded those with a lower level of education attainment and who reported higher income had a higher prevalence of binge drinking behaviour. Drinking frequency is positively correlated with bingeing as reported in most studies. The high frequency of drinking among people who binge is relatively high when compared to those who do not binge, as found in most studies elsewhere. However, in Malaysia, most binge drinkers drink less frequently (i.e., at least once a month or less). This finding differs from that noted in a United Kingdom study where most people drank more frequently (at least 2 times per week) [13]. Information on the types of alcoholic beverages that binge drinkers prefer is important for assessing policies, taxation practice, and marketing strategies related to drinking behaviour. The geographic differences between groups also play an important role in determining the preference for alcoholic beverages and may influence the drinker via cultural differences of prices of alcohol in a region. In United States, beer is still the most preferred drink of binge drinkers, and drinks with higher alcohol content, e.g., liquor, are the second most preferred alcoholic beverage. Our study also showed similar preferences for beer among binge drinkers and that such drinkers were least likely to prefer beverages of low alcohol content like Shandy. In low-income countries such as Bangladesh, most binge drinkers prefer to drink beverages with high alcohol content than alcoholic beverages with low alcohol content [14, 15]. Alcohol consumption and tobacco use have always been associated with an increased risk of cardiovascular disease. The concurrent use of alcohol and tobacco has been investigated in various studies. In the US, approximately 10 to 15 per cent of men and women reported consuming both alcohol and tobacco. Of the drinkers, those who smoked had a higher likelihood of engaging in binge drinking behaviour when compared to non-smokers.

The findings are similar to our study where the risk of bingeing was higher among smokers than non-smokers. In Hong Kong, for instance, females who smoked were at greater risk of bingeing if they were concurrent smokers. Perhaps, health campaign on Smoking should disseminate clear messages to the public on preventing concurrent excessive drinking because such behavioural may increase higher risk to their health outcomes. Cessation clinic should proactively consider screening for patients with alcohol use for early alcohol intervention when necessary. Research shows that low risk drinkers are not likely to experience an alcohol use disorder [16-18]. To date, there have not been many studies exploring the relationship between drinking risk level and binge drinking behaviour. In the United States, binge drinking behaviour was not a common practice among high-risk or alcoholdependent drinkers [19]. However, in contrast to these findings, our study revealed that binge drinking was higher among risky and highrisk drinkers. This pattern indicates that the harmful use of alcohol, which includes binge drinking behaviour, were more common among risk-taking and alcohol-dependent individuals in Malaysia [20].

Conclusion

Binge drinking behaviour among current drinkers is a significant problem in Malaysia. In particular, this pattern of drinking is quite problematic for males, Bumiputera Sabah and Sarawak as well as those who concurrently smoke. Focused interventions in the future should be targeted to this high-risk group to reduce the further harmful use of alcohol among drinkers and to reduce the burden of noncommunicable diseases related to alcohol use.

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