Family Dysfunction Differentially Affects Alcohol and Methamphetamine Dependence: A View from the Addiction Severity Index in Japan

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1 Int. J. Environ. Res. Public Health 2011, 8, ; doi: /ijerh OPEN ACCESS International Journal of Environmental Research and Public Health ISSN Article Family Dysfunction Differentially Affects Alcohol and Methamhetamine Deendence: A View from the Addiction Severity Index in Jaan Nagisa Sugaya 1, Ayako Haraguchi 1, Yasukazu Ogai 1,2, Eiichi Senoo 1,3, Susumu Higuchi 4, Mitsuru Umeno 5, Yuzo Aikawa 5 and Kazutaka Ikeda 1, * Tokyo Metroolitan Institute of Medical Science, Kamikitazawa, Setagaya-ku, Tokyo , Jaan; s: sugaya-ng@igakuken.or.j (N.S.); haraguchi-ay@igakuken.or.j (A.H.); ogai.ys@md.tsukuba.ac.j (Y.O.); senoo-ei@igakuken.or.j (E.S.) University of Tsukuba, Tennodai, Tsukuba, Ibaraki , Jaan Ibaraki Prefectural Medical Center of Psychiatry, 654 Asahi-cho, Kasama-shi, Ibaraki , Jaan National Hosital Organization Kurihama Alcoholism Center, 5-3-1, Nobi, Yokosuka, Kanagawa , Jaan; h-susumu@db3.so-net.ne.j Tokyo Metroolitan Matsuzawa Hosital, Kamikitazawa, Setagaya-ku, Tokyo, , Jaan; s: ve5m-umn@asahi-net.or.j (M.U.); yuzoaikawa@yahoo.co.j (Y.A.) * Author to whom corresondence should be addressed; ikeda-kz@igakuken.or.j; Tel.: ; Fax: Received: 15 July 2011; in revised form: 3 October 2011 / Acceted: 4 October 2011/ Published: 11 October 2011 Abstract: We investigated the differential influence of family dysfunction on alcohol and methamhetamine deendence in Jaan using the Addiction Severity Index (ASI), a useful instrument that multilaterally measures the severity of substance deendence. The articiants in this study were 321 male atients with alcohol deendence and 68 male atients with methamhetamine deendence. We conducted semi-structured interviews with each atient using the ASI, which is designed to assess roblem severity in seven functional domains: Medical, Emloyment/Suort, Alcohol use, Drug use, Legal, Family/Social relationshis, and Psychiatric. In atients with alcohol deendence, bad relationshis with arents, brothers and sisters, and friends in their lives were related to current severe sychiatric roblems. relationshis with brothers and sisters and artners in their lives were related to current severe emloyment/suort roblems, and

2 Int. J. Environ. Res. Public Health 2011, bad relationshis with artners in their lives were related to current severe family/social roblems. The current severity of sychiatric roblems was related to the current severity of drug use and family/social roblems in atients with alcohol deendence. Patients with methamhetamine deendence had difficulty develoing good relationshis with their father. Furthermore, the current severity of sychiatric roblems was related to the current severity of medical, emloyment/suort, and family/social roblems in atients with methamhetamine deendence. The results of this study suggest that family dysfunction differentially affects alcohol and methamhetamine deendence. Additionally, family relationshis may be articularly related to sychiatric roblems in these atients, although the ASI was develoed to indeendently evaluate each of seven roblem areas. Keywords: alcohol deendence; methamhetamine deendence; Addiction Severity Index; family relationshi 1. Introduction In 2003, aroximately 800,000 adults of the Jaanese general oulation of 120 million could be classified with alcohol deendence, making this grou one of the largest among the various mental disorders [1]. Additionally, stimulant deendence is a serious roblem not only for atients, but also for Jaanese society [2]. For examle, aroximately 25% of convicted risoners committed offenses under the Stimulant Control Law [3]. Previous studies have suggested that social suort is an imortant factor for imroving the symtoms of substance deendence. Coing and social suort are related to substance use behavior and treatment outcomes in adolescents [4,5]. Social suort also lays an imortant role in relase avoidance efforts for individuals who undergo substance use treatment. Social suort is a social fund from which individuals draw assistance when confronting stressors [6]. On the other hand, bad relationshis may be an aggravating factor. Previous studies have reorted an association between familial relationshis and substance deendence. Multidimensional Family Theray is uniquely suited to address adolescent substance abuse and related disorders, given its comrehensive interventions that systematically target the multile interacting risk factors that underlie many of the develomental disrutions of adolescence [7]. A revious study of alcohol deendence suggested that among the many biological, morhological, and social markers of increased maturation, visible signs of maturity are imortant triggers of alcohol use and alcohol use disorders, esecially when they occur early and in young eole with conduct roblems, deviant eers, roblem families, and inadequate arental suervision [8]. Another study of drug deendence reorted that drug use revention should not simly focus on reducing drug availability, but also hel young eole develo good family/eer relationshis and find healthy ways to enjoy themselves [9]. The Addiction Severity Index (ASI) is a semi-structured clinical research interview widely used in substance abuse treatment settings in the United States and many other countries. This instrument was designed to assess roblem severity in seven functional domains: Medical, Emloyment/Suort,

3 Int. J. Environ. Res. Public Health 2011, Alcohol use, Drug use, Legal, Family/Social relationshis, and Psychiatric [10]. Therefore, family relationshis are an imortant factor in assessing the severity of substance deendence using the ASI. A comarison of the characteristics of family relationshis and the association between family relationshis and various roblems related to substance deendence in atients with alcohol and drug deendence using the ASI may be useful for establishing ersonalized rograms for individuals with substance deendence. However, no study of which we are aware has comared the differences in the association between family dysfunction and roblems related to substance deendence between alcohol and drug deendence. Moreover, the ratio of individuals who use methamhetamine is the highest in individuals with drug deendence in Jaanese hositals, suggesting that it may be meaningful to focus on the characteristics of individuals with methamhetamine deendence. Therefore, we investigated the differences in the influence of family dysfunction on alcohol deendence and methamhetamine deendence in Jaanese atients using the ASI as an exloratory survey. We hyothesized that family dysfunction in atients with alcohol and atients with methamhetamine deendence may be related to different asects of roblems related to substance deendence. The resent exloratory study may rovide future direction for more detailed investigations that lead to the develoment of more effective methods for finding aroriate sychological interventions for each atient. 2. Methods 2.1. Particiants We surveyed 370 atients with alcohol deendence and 83 atients with drug deendence. Valid data were obtained from 321 male atients with alcohol deendence (86.76%; mean age, 49.7 ± 11.0 years) and 80 male atients with drug deendence (96.39%; mean age, 32.9 ± 9.4 years). The articiants with alcohol deendence were recruited from nine nationwide hositals or recovery facilities for addiction treatment located in Jaan: National Hosital Organization Kurihama Alcoholism Center, Kanagawa (n = 91), Wakamiya Hosital, Yamagata (n = 55), Komakino Hosital, Tokyo (n = 50), Mie Prefectural Mental Medical Center, Mie (n = 42), Asahiyama Hosital, Hokkaido (n = 26), Ishikawa Prefectural Takamatsu Hosital, Ishikawa (n = 17), National Hosital Organization Hizen Psychiatric Center, Saga (n = 14), Akagi-Kohgen Hosital, Gunma (n = 13), and Tohokukai Mental Hosital, Miyagi (n = 12). The articiants with drug deendence were recruited from five nationwide hositals or recovery facilities for addiction treatment in Jaan: Tokyo Metroolitan Matsuzawa Hosital, Tokyo (n = 37), Self-Suort Services (i.e., a recovery facility run by a non-rofit organization for addiction recovery), Tokyo (n = 16), National Center of Neurology and Psychiatry Musashi Hosital, Tokyo (n = 17), GAIA (i.e., a recovery facility run by a non-rofit organization for addiction recovery), Okinawa (n = 8), and Fukko-kai Tarumi Hosital, Hyogo (n = 2) Methods The Jaanese version of the ASI [11,12] was used in the resent study. The ASI is a semi-structured clinical research interview designed to assess roblem severity in seven functional domains: Medical status, Emloyment/Suort status, Alcohol use, Drug use, Legal status, Family/Social relationshis,

4 Int. J. Environ. Res. Public Health 2011, and Psychiatric status [10]. The Medical status domain gathers basic information about medical history. It addresses information about lifetime hositalizations, long-term medical roblems, and recent hysical ailments. The Emloyment/Suort status domain gathers basic information about work exerience and current sources of income. The Drug/Alcohol use domain gathers basic information about the atient's substance abuse history. It addresses information about current and lifetime substance abuse, the consequences of abuse, eriods of abstinence, treatment eisodes, and the financial burden of substance abuse. The Legal status domain gathers basic information about the atient's legal history. It addresses information about robation or arole, legal charges, convictions, incarcerations or detainments, and illegal activities. The Family/Social relationshi domain assesses relationshi roblems with family members or friends. The Psychiatric status domain is used not to diagnose sychiatric disorders but to assess the exerience of various sychiatric symtoms other than those associated with the effects of alcohol or drugs. Accetable reliability and validity of the ASI were confirmed in atients with drug [11] and alcohol deendence [12]. The ASI rovides a comosite score (CS). The CS in each roblem area is a mathematically calculated score mainly based on atient resonses to sets of items that ask the atient to reort behaviors during the 30 days rior to the interview. The CS is calculated using a weighted formula designed to rovide an equal contribution from each item and varies from 0 to 1, with a higher score indicating greater roblem severity. Additionally, we analyzed the items of the ASI related to education years, emloyment status, marital status, cohabitation, years of current cohabitation, exerience of abuse, family history of substance deendence or sychiatric disorders, and family relationshis in their life Procedure The recruitment criteria were the following: at least 18 years of age, a history of substance addiction roblems diagnosed as alcohol deendence or drug deendence based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and the ability to understand Jaanese. The inatients with alcohol deendence were rovided an average 80-day treatment rogram (e.g., grou meetings, alcohol education, family treatment rograms, sychotheray, and so on) after detoxification. After recovery from serious hysical and mental instability (nearly 1 month after hositalization), informed consent was obtained from the subjects, excluding the atients who had serious cognitive imairment and sychiatric roblems. The articiants with drug deendence were inatients or outatients at a Jaanese mental hosital or recovery facility or non-atients who were recovering from stimulant abuse in a recovery facility. Considering the time required for an interview and the reliability of the resonses, we excluded atients in a state of acute drug-induced sychosis. The ASI was administered by sychiatrists and clinical sychologists who were exerts in alcohol or drug deendence, carefully read the ASI manual [13], and learned the interview methods themselves. The average time required for administration of the questionnaire was 60 min. Inatient subjects were requested to answer the questions during the 30 days rior to the start of inatient treatment. The

5 Int. J. Environ. Res. Public Health 2011, Institutional Review Board of each institution aroved the study, and all of the articiants rovided written informed consent Statistical Analysis Comarisons between grous with regard to age, number of convictions, and ASI CS were conducted using the t-test. Comarisons between grous with regard to the characteristics of education, emloyment, marital status, cohabitation, exerience of abuse, and sychiatric symtoms were erformed using the x 2 test and Fisher exact test (multile comarisons were erformed using residual analysis). The relationshis between ASI CSs were analyzed using artial correlation analysis. The significance level was set at less than 0.05 or Statistical analyses were erformed with SPSS 18 (SPSS Inc., Chicago, IL). 3. Results 3.1. Particiant Characteristics Table 1 shows the substances that the articiants with drug deendence in this study mainly used. Most of the atients with drug deendence (85.00%) used methamhetamine, and others used cannabis (6.25%), inhalants (3.75%), analgesics/hynotics/tranquilizers (2.50%), antitussive drugs (1.25%), or hallucinogens (1.25%). We erformed the subsequent statistical analysis only in individuals who mainly used methamhetamine as atients with methamhetamine deendence (n = 68). Table 1. Substances that articiants with drug deendence in this study mainly used. Drug % Methamhetamine Cannabis 6.25 Inhalants 3.75 Analgesics/hynotics/tranquilizers 2.50 Antitussive drugs 1.25 Hallucinogens (e.g., lysergic acid diethylamide) 1.25 Table 2 shows the characteristics of the articiants. The mean age of the atients with alcohol deendence was significantly higher than that of atients with methamhetamine deendence (t = 12.31, < ). Significant differences were found in educational background (z = 17.72, = 0.003). Patients with alcohol deendence had a higher ratio of being a junior high school graduate ( < 0.05), and atients with drug deendence had a higher ratio of being a high school droout ( < 0.05). Significant differences were found in emloyment status (z = 36.26, < ). Patients with alcohol deendence had higher ratios of full-time emloyment ( < 0.05) and retirement ( < 0.05). Patients with methamhetamine deendence had higher ratios of art-time emloyment ( < 0.05) and unemloyment ( < 0.05). A significant difference was found in marital status (z = 64.08, < ). Patients with alcohol deendence had a higher ratio of being

6 Int. J. Environ. Res. Public Health 2011, married ( < 0.05). Patients with methamhetamine deendence had a higher ratio of never being married ( < 0.05). Significant differences were found in cohabitation (z = 62.71, < ). More atients with alcohol deendence lived with their family ( < 0.05). More atients with methamhetamine deendence lived with their arents ( < 0.05). Significant differences were found in years at their current residence (z = 12.24, = 0.002). More atients with alcohol deendence had lived in their current residence for more than 10 years ( < 0.05). More atients with methamhetamine deendence had lived in their current residence for less than 10 years ( < 0.05). With regard to abuse, atients with methamhetamine deendence had a higher ratio of hysical abuse exerience (z = 8.48, = ). With regard to sychiatric symtoms in the ast month, atients with methamhetamine deendence had higher ratios of hallucinations (z = 17.11, = ) and trouble understanding, concentrating, or remembering (z = 16.57, = ). Patients with methamhetamine deendence had more convictions (t = 5.35, < ). Characteristic Table 2. Particiant characteristics. Alcohol deendence (n = 321) Methamhetamine deendence (n = 68) Mean age (years [SD]) (10.34) (8.51) < * Education Education (mean years [SD]) (2.69) (2.32) n.s. % Junior high school graduate < 0.05 * % Some high school < 0.05 * % High school graduate n.s. % Some college n.s. % College graduate n.s. % Unclear n.s. Emloyment (ast 3 years) % Full-time < 0.05 * % Part-time < 0.05 * % Retired < 0.05 * % Unemloyed < 0.05 * % Other < 0.05 * % Public assistance reciient (ast 30 days) n.s. Marital status % Married < 0.05 * % Never married < 0.05 * % Searated/Widowed/Divorced n.s. Cohabitation % With family < 0.05 * % With souse n.s. % With arents < 0.05 * % Alone n.s. % Other < 0.05 *

7 Int. J. Environ. Res. Public Health 2011, Characteristic Years of current cohabitation Table 2. Cont. Alcohol deendence (n = 321) Methamhetamine deendence(n = 68) % < 10 years < 0.05 * % years < 0.05 * % > 20 years < 0.05 * Abuse % Emotional abuse % Physical abuse * % Sexual abuse Psychiatric symtoms % Serious deression % Serious anxiety or tension % Hallucinations * % Trouble understanding, concentrating, or remembering * % Trouble controlling violent behavior % Serious thoughts of suicide % Attemted suicide Number of convictions (mean years [SD]) 0.14 (0.74) 1.32 (1.79) < * 3.2. Relationshi between ASI Comosite Scores SD, standard deviation; * significant difference. Table 3 shows the correlations between ASI CSs after controlling for age. For atients with alcohol deendence, the CS of sychiatric roblems was significantly correlated with the CSs of drug use (r = 0.27, < ) and family/social roblems (r = 0.28, < ). For atients with methamhetamine deendence, the CS of sychiatric roblems was significantly correlated with the CSs of medical roblems (r = 0.33, = 0.008), emloyment/suort roblems (r = 0.40, = 0.001), drug use (r = 0.40, = ), and family/social roblems (r = 0.43, = ). The CS of family/social roblems was significantly correlated with the CS of medical roblems (r = 0.33, = 0.007) and legal roblems (r = 0.35, = 0.004). Table 3. Correlations between ASI comosite scores after controlling for age. Alcohol deendence Emloyment Alcohol use Drug use Legal Family/Social Psychiatric Medical Emloyment Alcohol use Drug use Legal Family/Social r r r r < * r r 0.28 < *

8 Int. J. Environ. Res. Public Health 2011, Methamhetamine deendence Medical Emloyment Alcohol use Drug use Legal Family/Social Table 3. Cont. Emloyment Alcohol use Drug use Legal Family/Social Psychiatric r * * r * r r * r * 0.48 r * * Significant correlation ( < 0.01). Table 4 shows the comarison of ratios of each sychiatric symtom in the ast month between grous of high and low CSs of Family/Social relationshi roblems. These grous were divided on the basis of median CSs of Family/Social relationshis. In atients with alcohol deendence, high CSs of Family/Social relationshi roblems was associated with higher ratios of serious deression (z = 10.98, = 0.001), serious anxiety or tension (z = 6.17, = 0.02), and serious thoughts of suicide (z = 6.81, = 0.01) than the low CS grou. In atients with methamhetamine deendence, no significant difference was found between grous of high and low CSs of Family/Social relationshi roblems in ratio of each sychiatric symtom. Table 4. Comarison of ratios of each sychiatric symtom between grous of high and low CSs of Family/Social relationshi roblems. Alcohol deendence Family/Social High Low Serious deression (%) * Serious anxiety or tension (%) * Hallucinations (%) Trouble understanding, concentrating, or remembering (%) Trouble controlling violent behavior (%) Serious thoughts of suicide (%) * Attemted suicide (%)

9 Int. J. Environ. Res. Public Health 2011, Table 4. Cont. Methamhetamine deendence Family/Social High Low Serious deression (%) Serious anxiety or tension (%) Hallucinations (%) Trouble understanding, concentrating, or remembering (%) Trouble controlling violent behavior (%) Serious thoughts of suicide (%) Attemted suicide (%) * Significant difference Family History of Alcohol Deendence, Methamhetamine Deendence, and Psychiatric Disorders Table 5 shows the family histories of alcohol deendence, methamhetamine deendence, and sychiatric disorders in the articiants of the resent study. Of the atients with alcohol deendence, 36.33% had fathers with alcohol-related roblems, 20.87% had uncles (aternal) with alcohol-related roblems, and 25.94% had brothers with alcohol-related roblems, and these ratios were significantly higher comared with atients with methamhetamine deendence (father, z = 7.97, = 0.005; uncle, z = 6.31, = 0.009; brother, z = 8.81, = 0.002). Of the atients with methamhetamine deendence, 9.52% had brothers with drug-related roblems, and the ratio was significantly higher than that of atients with alcohol deendence (z = 22.90, = 0.005). Table 5. Family history of alcohol deendence, methamhetamine deendence, and sychiatric disorders. Relation Alcohol deendence Methamhetamine deendence Grandmother (maternal) (%) Alcohol Drug Psychiatric disorder Grandfather (maternal) (%) Alcohol Drug Psychiatric disorder Mother (%) Alcohol Drug Psychiatric disorder

10 Int. J. Environ. Res. Public Health 2011, Relation Table 5. Cont. Alcohol deendence Methamhetamine deendence Aunt (maternal) (%) Alcohol Drug Psychiatric disorder Uncle (maternal) (%) Alcohol Drug Psychiatric disorder Sisters (%) Alcohol Drug Psychiatric disorder Grandmother (aternal) (%) Alcohol Drug Psychiatric disorder Grandfather (aternal) (%) Alcohol Drug Psychiatric disorder Father (%) Alcohol * Drug Psychiatric disorder Aunt (aternal) (%) Alcohol Drug Psychiatric disorder Uncle (aternal) (%) Alcohol * Drug Psychiatric disorder Brothers (%) Alcohol * Drug * Psychiatric disorder * Significant difference Comarisons of Family Relationshis between Patients with Alcohol Deendence and Patients with Methamhetamine Deendence In the Family/Social relationshi domain, atients answered Yes, No, or Neither about whether they had a close, long-lasting, ersonal relationshi with family members, artners, or friends in their life. Particiants who answered Yes were assigned to the good relationshis grou, and articiants who answered No were assigned to the bad relationshis grou. In the comarison of

11 Int. J. Environ. Res. Public Health 2011, exerience of good relationshis with family members (Table 6), atients with alcohol deendence had a significantly higher ratio of exerience of good relationshis with their father (z = 17.77, < ). Table 6. Comarisons of the ratios of good family relationshis between atients with alcohol deendence and atients with methamhetamine deendence. Alcohol deendence Methamhetamine deendence Mother (%) Father (%) < * Brothers/sisters (%) Partner (%) Children (%) Friends (%) * Significant difference Comarison of Severity of Addiction between and Family Relationshis Tables 7 and 8 show the comarisons of ASI CSs between good and bad family relationshis. Patients with alcohol deendence who exerienced bad relationshis with their brothers and sisters (t = 2.99, = 0.003) and artners (t = 3.47, = ) had a higher CS of emloyment/suort roblems. Patients who exerienced bad relationshis with their artners had a higher CS of family/social roblems (t = 4.90, < ). Patients who exerienced bad relationshis with their mothers (t = 2.73, = 0.02), fathers (t = 2.84, = 0.01), brothers and sisters (t = 2.82, = 0.005), and friends (t = 2.99, = 0.02) had a higher CS of sychiatric roblems. In atients with methamhetamine deendence, no significant difference was found between good and bad family relationshis in ASI CSs. Table 7. Comarison of severity of addiction between good and bad family relationshis in atients with alcohol deendence. relationshi Mother relationshi relationshi Father relationshi Medical 0.22 (0.29) 0.29 (0.33) (0.28) 0.29 (0.34) 0.14 Emloyment 0.53 (0.28) 0.55 (0.29) (0.29) 0.55 (0.27) 0.60 Alcohol use 0.55 (0.22) 0.54 (0.22) (0.23) 0.55 (0.23) 0.78 Drug use 0.01 (0.04) 0.01 (0.03) (0.04) 0.01 (0.03) 0.66 Legal (0.03) 0.01 (0.05) (0.03) (0.04) 0.99 Family/Social 0.23 (0.22) 0.25 (0.21) (0.22) 0.23 (0.20) 0.88 Psychiatric 0.13 (0.18) 0.20 (0.24) 0.01 * 0.12 (0.18) 0.20 (0.23) 0.01 *

12 Int. J. Environ. Res. Public Health 2011, relationshi Brothers and Sisters relationshi Table 7. Cont. relationshi Partner relationshi Medical 0.22 (0.29) 0.26 (0.32) (0.31) 0.27 (0.31) 0.77 Emloyment 0.51 (0.27) 0.61 (0.30) 0.00 * 0.48 (0.29) 0.60 (0.27) 0.00 * Alcohol use 0.53 (0.22) 0.57 (0.23) (0.22) 0.53 (0.22) 0.46 Drug use 0.01 (0.04) 0.01 (0.04) (0.04) 0.01 (0.04) 0.26 Legal (0.03) 0.01 (0.05) (0.04) 0.01 (0.04) 0.67 Family/Social 0.22 (0.22) 0.26 (0.19) (0.19) 0.33 (0.23) 0.00 * Psychiatric 0.13 (0.17) 0.20 (0.25) 0.02 * 0.13 (0.18) 0.17 (0.22) 0.09 Children Friends relationshi relationshi relationshi relationshi Medical 0.25 (0.31) 0.32 (0.32) (0.30) 0.31 (0.34) 0.15 Emloyment 0.50 (0.30) 0.56 (0.27) (0.29) 0.59 (0.29) 0.07 Alcohol use 0.54 (0.23) 0.55 (0.21) (0.22) 0.55 (0.22) 1.00 Drug use 0.01 (0.04) (0.02) (0.04) 0.01 (0.02) 0.43 Legal (0.02) 0.01 (0.04) (0.03) 0.01 (0.05) 0.36 Family/Social 0.22 (0.22) 0.27 (0.19) (0.21) 0.23 (0.22) 0.82 Psychiatric 0.13 (0.19) 0.15 (0.21) (0.18) 0.22 (0.26) 0.02 * * Significant difference. Table 8. Comarison of severity of addiction between good and bad family relationshis in atients with methamhetamine deendence. relationshi Mother relationshi relationshi Father relationshi Medical 0.05 (0.17) 0.13 (0.24) (0.13) 0.12 (0.25) 0.08 Emloyment 0.67 (0.22) 0.74 (0.25) (0.21) 0.70 (0.25) 0.99 Alcohol use 0.12 (0.19) 0.19 (0.27) (0.20) 0.16 (0.23) 0.27 Drug use 0.09 (0.09) 0.12 (0.12) (0.09) 0.12 (0.11) 0.19 Legal 0.02 (0.07) 0.04 (0.13) (0.06) 0.03 (0.11) 0.32 Family/Social 0.14 (0.13) 0.23 (0.20) (0.13) 0.21 (0.18) 0.06 Psychiatric 0.23 (0.24) 0.32 (0.27) (0.23) 0.30 (0.27) 0.34 relationshi Brothers/Sisters relationshi relationshi Partner relationshi Medical 0.05 (0.14) 0.12 (0.24) (0.20) 0.05 (0.14) 0.54 Emloyment 0.66 (0.21) 0.77 (0.25) (0.26) 0.73 (0.21) 0.10 Alcohol use 0.10 (0.19) 0.21 (0.26) (0.24) 0.13 (0.24) 0.43 Drug use 0.09 (0.09) 0.12 (0.12) (0.12) 0.09 (0.09) 0.93 Legal 0.02 (0.08) 0.04 (0.11) (0.11) (0.01) 0.09 Family/Social 0.15 (0.16) 0.23 (0.17) (0.14) 0.17 (0.14) 0.80 Psychiatric 0.23 (0.26) 0.30 (0.24) (0.26) 0.24 (0.23) 0.94

13 Int. J. Environ. Res. Public Health 2011, Table 8. Cont. Children Friends relationshi relationshi relationshi relationshi Medical 0.11 (0.20) 0.07 (0.19) (0.21) 0.09 (0.20) 0.77 Emloyment 0.54 (0.34) 0.66 (0.27) (0.24) 0.69 (0.23) 0.94 Alcohol use 0.16 (0.18) 0.34 (0.34) (0.21) 0.17 (0.25) 0.55 Drug use 0.04 (0.06) 0.07 (0.11) (0.10) 0.12 (0.12) 0.46 Legal 0.03 (0.09) 0.00 (0.00) (0.09) 0.04 (0.11) 0.62 Family/Social 0.15 (0.13) 0.15 (0.12) (0.15) 0.16 (0.16) 0.69 Psychiatric 0.14 (0.19) 0.14 (0.19) (0.24) Discussion * Significant difference. With regard to the comarisons of family relationshis between atients with alcohol deendence and atients with methamhetamine deendence, atients with methamhetamine deendence had difficulty develoing good relationshis with their father. With regard to the association between good relationshis and the severity of substance deendence, in atients with alcohol deendence, bad relationshis with arents, brothers and sisters, and friends were related to severe sychiatric roblems. relationshis with brothers and sisters and artners were related to severe emloyment/suort roblems. relationshis with artners were related to severe family/social roblems. In atients with methamhetamine deendence, no association was found between relationshis and severity of substance deendence. With regard to the associations between ASI CSs, sychiatric roblems were related to drug use and family/social relationshis in atients with alcohol deendence, and sychiatric roblems were related to medical, emloyment/suort, and family/social relationshi roblems in atients with methamhetamine deendence. In atients with alcohol deendence, relationshis with various family members and friends were related to their mental condition, and bad relationshis with their artners may be heavily involved in their difficult interersonal relationshis. Because roblems with family/social relationshis were related to sychiatric roblems, bad relationshis with their artners may be involved in sychiatric roblems through their difficulties with interersonal relationshis. Additionally, the association between sychiatric roblems and drug use in atients with alcohol deendence may be affected by the drugs rescribed for their sychiatric roblems. Notably, some atients with alcohol deendence reorted deendence on barbiturates or other analgesics/ hynotics/tranquilizers. Moreover, a deterioration of sychiatric roblems may be involved in increased medical roblems, emloyment/suort roblems, and drug use roblems. These results suggest that although the ASI was develoed to indeendently evaluate each of these seven roblem areas [12], family relationshis may be articularly related to sychiatric roblems. Moreover, with regard to the associations between family/social relationshis and secific symtoms, bad family/social relationshis in alcohol deendence were related to the resence of serious deression, serious anxiety or tension, and serious thoughts of suicide, and bad family/social relationshis in methamhetamine deendence were not related to the resence of secific sychiatric symtoms.

14 Int. J. Environ. Res. Public Health 2011, family/social relationshis in atients with alcohol deendence and atients with methamhetamine deendence may be differentially related to sychiatric roblems. Investigating the association between family relationshis and sychiatric disorders may be useful, based on the relationshi between family/social relationshis and sychiatric status found in the resent study. The average age of the atients with alcohol deendence was higher than the average age of the atients with methamhetamine deendence, suggesting that having a long-term residence may be attributable to the higher average age of the atients with alcohol deendence. With regard to educational background, the higher ratio of junior high school graduation in atients with alcohol deendence may be attributable to the age grou of atients with alcohol deendence, which contained many older atients. The higher ratio of being a high school droout in atients with methamhetamine deendence may reflect their difficulty maintaining their relationshis or comleting their schoolwork on school days. With regard to emloyment status, the higher ratio of retirement in atients with alcohol deendence may be attributable to their higher average age, and the higher ratios of art-time emloyment and unemloyment in atients with methamhetamine deendence may reflect their difficulty retaining a job. With regard to abuse exerience, the higher ratio of being a victim of hysical abuse in atients with methamhetamine deendence may make develoing a trusting relationshi with someone difficult. Consistent with this ossibility, a revious study suggested that male victims of hysical and sexual abuse have difficulties seeking and retaining gainful emloyment, trusting others, develoing intimate relationshis, and regulating their anger and behavior [14]. The higher number of convictions in atients with methamhetamine deendence suggests that methamhetamine deendence is comlicated by antisocial ersonality disorder. With regard to family histories of alcohol deendence, drug deendence, and sychiatric disorders, atients with alcohol deendence had higher ratios of having a father, aternal uncle, and brother with alcohol-related roblems. Patients with methamhetamine deendence had higher ratios of having a brother with drug-related roblems. These significant results were found only with male relatives, and substance (alcohol or drug) use that became a roblem for atients was common when substances were used by their male relatives. However, because these results may have been affected by the high revalence of individuals with alcohol or drug deendence in the male oulation [15], these results should be interreted with caution. Additionally, information about antisocial characteristics among not only the atients but also their families may be worth collecting in future studies to ascertain differences in the interactions between arents and children with substance deendence. Based on the above results from atients with alcohol deendence, unestablished family relationshis over time influenced a wide range of roblems, esecially the severity of sychiatric roblems. This result suggests the usefulness of sychological theray for treating family dysfunction and self-hel grou theray. In atients with methamhetamine deendence, unestablished relationshis with their father over the years may not have been linked to their resent severity of substance deendence in ASI CSs. Moreover, not simly relationshis with secific family members but overall family/social relationshis may be related to severity in ASI CSs (e.g., Psychiatric, Medical, and Legal roblems). Given the result that atients with methamhetamine deendence often lived with their arents, investigating the effect of bad relationshis with their father on relationshis with their brother with drug-related roblems may be imortant. Furthermore, verifying the ossibility that

15 Int. J. Environ. Res. Public Health 2011, atients with methamhetamine deendence may not often establish good relationshis with their father because of their exeriences of abuse by their arents may be meaningful in future studies. A revious study suggested the imortance of distinguishing between alcohol and drug deendence disorders and examining their differential etiological athways [16]. The resent study may also suggest the necessity of searately investigating the association between family relationshis and various roblems related to substance deendence in alcohol deendence and methamhetamine deendence. The results of the resent study may rovide suort for the ossibility that the results of the ASI as an intake instrument may be an indicator of early intervention for family and social roblems, and ersonalized rograms that augment usual interventions may be useful. Although this study rovided useful new insights, it has a few limitations. First, the samle did not contain female atients. Role differences in a family may exist between males and females. Future studies should assess female atients. Second, the uniformity of the articiants in this study may be roblematic, including differences in age and resent status (i.e., inatient, outatient, or recovering individual) between the alcohol deendence grou and methamhetamine deendence grou. Third, this study utilized a cross-sectional design, so we could not establish a causal relationshi between family relationshis and roblems related to alcohol or drug deendence. However, the results of this study may be beneficial for future longitudinal studies. Acknowledgements We acknowledge Michael Arends for his assistance with editing the manuscrit. This work was suorted by grants from the MHLW of Jaan (H19-iyaku-023, H22-iyaku-015), MEXT of Jaan ( , ), Smoking Research Foundation, and Mitsubishi Foundation for Social Welfare Activities. References 1. Osaki, Y.; Matsushita, S.; Shirasaka, T.; Hiro, H.; Higuchi, S. Nationwide survey of alcohol drinking and alcoholism among Jaanese adults. Nihon Arukoru Yakubutsu Igakkai Zasshi 2005, 40, Ikeda, K.; Yamamoto, H.; Takamatsu, Y.; Haraguchi, A.; Umeno, M.; Senoo, E. New aroaches toward treatment of methamhetamine deendence. Seishin Igaku 2004, 46, Ministry of Justice Research and Training Institute. White Paer on Crime in Jaan 2003; Ministry of Finance Printing Bureau: Tokyo, Jaan, 2004; Hamdan-Mansour, A.M.; Puskar, K.; Sereika, S.M. Perceived social suort, coing strategies and alcohol use among rural adolescents/usa samle. Int. J. Ment. Health Addict. 2007, 5, Wills, T.A.; Sandy, J.M.; Yaeger, A.M.; Cleary, S.D.; Shinar, O. Coing dimensions, life stress, and adolescent substance use: a latent growth analysis. J. Abnorm. Psychol. 2001, 110, Thoits, P.A. Stress, coing, and social suort rocesses: Where are we? What next? J. Health. Soc. Behav. 1995, 35, Rowe, C.L.; Multidimensional family theray: addressing co-occurring substance abuse and other roblems among adolescents with comrehensive family-based treatment. Child Adolesc. Psychiatr. Clin. N. Am. 2010, 19,

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