MORE ALCOHOL DEPENDENCE THAN ABUSE IN RURAL CHINA

Recent research has suggested a significant increase ofalcohol consumption and use disorders in China, andattributed this to a culturally lax attitude to binge-drinking, business-related drinking and the adoption ofwestern life-styles following globalization [1,2]. Accord-ingly, the pattern of DSM-IV alcohol use disorders inurban regions is now quite similar to those of westernpopulations [3,4]; that is, these disorders are mainlyprevalent among young to middle-aged males [2] andabuse is significantly more common than dependence[2,5]. However, about 70% of the Chinese populationconsists of rural and ethnic minority people, amongwhom recent DSM-IV-based community surveys repeat-edly found the prevalence of dependence to be signifi-cantly higher than that of abuse [6,7]. Moreover, bothdisordersaremoreprevalentamongoldermales[6,7].Insome surveys, including both urban and rural regions,the prevalence of dependence was also estimated to behigherthanthatof abuse[8].Thesefindingssuggestthatspecial aetiological pathways may shape the pattern ofalcohol use and its disorders in non-urban people inChina.Using both anthropological and epidemiologicalresearch methods [9], we found that drinking is a well-accepted means of relieving physical and psychologicalsymptomsamongolderChinesemeninruralandminor-ity areas. Many of them believe that alcohol can reducefatigue, relieve pain, enhance sleep and ‘expel wetnessand restore bodily imbalance’. Drinking after heavylabour,includingsolitarydrinkingamongolderpeople,isespecially popular [9]. Because of the perceived healthbenefits, regular drinking without binge drinking anddrunkennessisalocallyendorsedkindof self-medicationfor a variety of symptoms. None the less, consumptionlevels are often much larger than the professionally rec-ommended limit of ‘proper drinking’, and can result inalcohol dependence without apparently causing psycho-social problems associated with the diagnosis of alcoholabuse [9]. If they do occur, these problems are not dealtwithlegallybecausetherearefewpoliceofficersavailableto handle them. Drink-driving rarely occurs, as very fewpeople own a vehicle [7]. The physical complications ofalcohol dependence are rarely detected, because nearlyall rural or minority people no longer have access to freehealth care following privatization and the breakdown ofthepreviouslycollectivistichealthcaresystem[10].Con-sequently, there is ample time for dependence to developamong older male people in rural regions. As alcohol ismuch cheaper than health visits, future research shouldexamine in more detail how ‘self-medication withalcohol’ may explain the special pattern of alcohol usedisorders and its policy implications in China.This atypi-cal pattern has been discussed rarely in the literature,indicating that the diagnosis of alcohol abuse is morelikely to be shaped by socio-cultural factors than that ofdependence, which is more physiological in origin. Noso-logically, a dimensional and more quantitative approachto alcohol use disorders that integrates the features ofboth abuse and dependence is worth considering in theDSM-V [11].