Korean J Fam Med. 2010;31:523-528 doi:10.4082/kjfm.2010.31.7.523 알코올의존환자의병식상태에따른선별검사의민감도 Original Article 조규철, 김종성 *, 정진규, 김성수, 이정길, 최동현 충남대학교의과대학의학연구소가정의학교실 Effects of Insight Level on the Sensitivity of Alcoholism Screening Tests in Alcohol Dependent Patients Kyu-Chol Cho, Jong-Sung Kim*, Jin-Gyu Jung, Sung Soo Kim, Jeong-Gil Lee, Dong-Hyun Choi Department of Family Medicine, Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon, Korea Background: Alcoholism screening tests are commonly used in primary medical care. This study examined how much the level of insight of alcohol-dependent patients would impact on the sensitivity of alcoholism screening tests. Methods: The sample consisted of 122 subjects who had been diagnosed with alcohol dependence and who completed Alcohol Use Disorders Identification Test (AUDIT), and CAGE questionnaire. AUDIT positive was defined as a score of 20 points or above and CAGE positive, 3 points or above. Insight level was classified as poor, fair, and good using the Hanil Alcohol Insight Scale (HAIS). Positive rates on the AUDIT and CAGE were analyzed according to the level of insight. Results: In good insight group, the sensitivity of AUDIT and CAGE identified 96.9% and 96.9% of the participants as alcohol dependence, respectively. In fair insight group, those were 92.7% and 96.4%, respectively. However, in poor insight group, these decreased substantially to 62.9% and 65.7%, respectively. After adjusting for general characteristics on the basis of good insight group, we found that the possibility of positive on the AUDIT was significantly lower in poor insight group (Odd ratios [OR], 0.025; 95% confidence interval [CI], 0.002 to 0.411). Also, the possibility of positive on the CAGE was significantly lower in poor insight group (OR, 0.016; 95% CI, 0.001 to 0.358). Conclusion: Alcohol-dependent patients with poor insight showed a high rate of false negatives in alcoholism screening tests. These suggest that primary care physicians should be careful in interpreting the results of alcoholism screening tests. Keywords: Sensitivity; Insight; AUDIT; CAGE; HAIS; False negative 서론 Received: August 27, 2009, Accepted: June 19, 2010 *Corresponding Author: Jong-Sung Kim Tel: 042-280-8172, Fax: 042-280-7879 E-mail: jskim@cnuh.co.kr This research was supported by Chungnam National University Hospital Research Fund, 2008. Korean Journal of Family Medicine Copyright 2010 by The Korean Academy of Family Medicine 알코올리즘선별에는여러가지선별검사들이개발되어사용되고있으며이러한검사에는미시간알코올리즘선별검사 (Michigan Alcoholism Screening Test, MAST), 1) 알코올사용검사 (Alcohol Use Inventory, AUI), 2) CAGE 검사, 3) Alcohol Use Disorders Identification Test (AUDIT) 4) 등이있다. Fiellin 등 5) 은 1966년부터 1998년까지 MEDLINE 문헌분석을통해알코올리즘선별검사들중 AUDIT는위험음주, 문제음주, 알코올 가정의학회지 Vol. 31, No. 7 July 2010 523
Kyu-Chol Cho, et al: Effects of Insight Level on the Sensitivity of Alcoholism Screening Tests in Alcohol Dependent Patients 사용장애모두의선별에대해가장효과적이며 ( 민감도, 51-97%; 특이도, 78-96%) CAGE는알코올사용장애선별에우위를보인다고발표하였다 ( 민감도, 43-94%; 특이도, 70-79%). Kaplan과 Sadock 6) 은 상황의원인과의미를이해하는환자의능력 (the ability of the patient to understand the cause and meaning of a situation)" 으로병식을정의하였다. Kim 등 7) 은자신의음주문제에대한자각이알코올리즘환자의병식평가요소에포함되어야한다고주장하였다. 그러나알코올의존환자들은많은방어기제, 특히부정 (denial) 을사용하는것으로알려져있다. 8,9) 이러한점에서저자들은알코올의존환자에서환자의병식상태가알코올리즘선별검사의결과에영향을미칠가능성이있다고생각하였다. Otto와 Hall 10) 은병식과관련하여 MAST와같은자가보고형알코올의존선별검사의경우에환자의병에대한인식수준이검사결과에중요한영향을미치게된다고보고하였다. 그러나알코올의존환자의병식부족이자가보고형알코올의존선별검사의결과에어떤영향을주는지에대한연구가부족한실정이다. 알코올리즘선별검사의민감도는위음성과직접적으로관련이있다. 위음성인경우는실제로환자이면서도환자가아닌것으로평가되는것을말하며민감도가낮을수록위음성은증가한다고해석할수있다. 알코올리즘선별검사는일차진료영역에서흔히사용되는검사이다. 선별검사의위음성은일차진료영역에서중요한문제라고할수있다. 이에본연구에서는일차진료영역에서흔히사용하고있는알코올리즘선별검사의민감도에알코올의존환자의병식상태가어떤영향을주는지에대해알아보고자하였다. 방법 1. 연구대상 2008년 8월 1일부터 10월 31일까지대전지역의일개알코올치료센터에입원한환자 122명을대상으로하였다. 대상자들은 DSM-IV-TR (Diagnostic and statistical manual of mental disorder. 4th ed.) 11) 진단기준에의해알코올의존으로확진된환자들로서정신과전문의와가정의에게연구목적과사용범위를설명받은후본연구에동의하였다. 2. 자료의수집사회인구학적특성으로서환자의연령, 성별, 교육, 배우자, 종교, 직업, 흡연에대해조사하였다. 임상적특성및음주력으로서음주와관련된신체적질환병력유무, 4촌이내문 제음주자유무, 절주경험유무, 알코올리즘에대한치료교육을받았던경험유무, 첫음주연령, 첫문제음주연령, 음주로인한첫입원연령등을조사하였다. 알코올의존선별검사인 AUDIT, CAGE 및병식평가척도인 Hanil Alcohol Insight Scale (HAIS) 7) 설문을동시에실시하였다. 3. 연구도구 1) AUDIT 세계보건기구 (WHO) 에서개발한 10문항의설문지로서지역의일차의료인들에게적합한도구이다. WHO 12) 에서제시한기준에의하면 8점이상은위험음주로서간단한조언을할단계로, 16점이상은간단한상담과지속적관찰을할단계로, 20점이상은알코올의존에대한진단적평가가이루어져야할단계로분류하였다. 이에본연구에서는알코올의존환자에대한 AUDIT의민감도를조사하기위해 20점이상인경우를양성으로정의하였다. 또한 AUDIT 의각설문문항은 2005년에 National Institute on Alcohol Abuse and Alcoholism (NIAAA) 13) 에서제시한기준을적용하였다. 2) CAGE Ewing 14) 에의해 1970년에개발된 4문항으로이루어진알코올리즘선별검사도구이다. CAGE 질문에소요되는시간은약 1분정도로일차의료영역의외래에적합한도구라고할수있다. Mayfield 등 3) 에의하면 CAGE 도구의알코올리즘에대한예견치는, 한문항에해당될경우에 62% 이며, 두문항에해당되는경우는 82%, 세문항에해당될경우 99%, 네문항모두에해당되면 100% 로서, 전체적인예견능력은 87% 에이르러문제음주를선별하는데있어서매우유용하게사용될수있다고하였다. 이에본연구에서는알코올의존환자에대한 CAGE의민감도를조사하기위해 Mayfield 등, 3) Ewing 14) 이제시한기준에따라 3점이상인경우를양성으로정의하였다. 3) HAIS 알코올중독환자의병식을측정하기위해 Kim 등 7) 이개발하고신뢰도와타당도를검증한 20문항의자가보고형설문지를사용하였다. 이척도는자신의음주문제에대한자각, 음주에대한조절력상실및의존상태에대한자각, 단주의필요성에대한자각, 자신의음주가현재상황의원인이되었다는것과주위사람들에게고통을주었다는것에대한자각, 치료의필요성에대한자각을측정함으로서알코올의존환자의병식을평가한다. 병식상태에따른집단구분은 Kim 등 7) 524 Vol. 31, No. 7 July 2010 Korean J Fam Med
조규철외 : 알코올의존환자의병식상태에따른선별검사의민감도 의연구에서제시하는기준을따라 -20점에서 3점을부정병식 (poor insight) 군, 4점에서 15점을부분병식형성 (fair insight) 군, 16점에서 20점을병식형성 (good insight) 군으로정했다. 이기준을적용했을때 HAIS의병식평가에대한민감도는 76.9-100% 이며, 특이도는 83.3-94.9% 이다. 4. 자료의처리대상자들의병식상태분류에따른세군의연령, 교육, 첫음주연령, 첫문제음주연령, 음주로인한첫입원연령, AUDIT, CAGE, HAIS 점수를비교하기위해 ANOVAs with Scheffe's post hoc test를사용하였다. 성별, 배우자유무, 종교유무, 직업유무, 흡연유무, 음주와관련된신체적질환병력유무, 4촌이내문제음주자유무, 알코올리즘에대한치료교육을받았던경험유무등을비교하기위해 Fisher's exact test를실시하였다. 또한병식상태에따른세군의 AUDIT와 CAGE 의민감도를비교하기위해 Fisher's exact test 를사용하였다. 병식형성군을기준으로부분병식형성군과부정병식군의알코올리즘선별검사의양성가능성을비교해보기위하여대상자들의병식상태와함께일반적특성과음주관련특성들을보정하여 logistic regression analysis 를실시하였다. 모든통계 Table 1. Sociodemographic and drinking characteristics by the insight level. Variables Poor (N = 35) Fair (N = 55) Good (N = 32) Age (y) 50.5 ± 8.2 47.5 ± 9.4 46.9 ± 6.1 Sex Male 32 (91.4) 45 (81.8) 29 (90.6) Female 3 (8.6) 10 (18.2) 3 (9.4) Education (y) 10.3 ± 4.2 10.0 ± 3.6 10.4 ± 4.3 Living with a spouse Yes 12 (34.3) 22 (40.0) 20 (62.5) No 23 (65.7) 33 (60.0) 12 (37.5) Religion Yes 14 (40.0) 24 (43.6) 16 (50.0) No 21 (60.0) 31 (56.4) 16 (50.0) Occupation Yes 8 (22.9) 15 (27.3) 11 (34.4) No 27 (77.1) 40 (72.7) 21 (65.6) Smoking Non-smoking 8 (22.9) 25 (45.5) 17 (53.1) Ex-smoking 3 (8.6) 11 (20.0) 2 (6.3) Smoking 24 (68.6) 19 (34.5) 13 (40.6) History of alcohol-related physical disease Yes 24 (68.6) 39 (70.9) 25 (78.1) No 11 (31.4) 16 (29.1) 7 (21.9) Family history of alcohol-related problems Yes 10 (28.6) 31 (56.4) 19 (59.4) No 25 (71.4) 24 (43.6) 13 (40.6) Age at first drinking 23.1 ± 11.1 22.8 ± 7.3 20.1 ± 8.5 Age at first drinking problems* 42.9 ± 11.5 37.6 ± 10.4 34.5 ± 9.5 Age at first admission due to alcoholism 43.8 ± 10.9 42.5 ± 9.6 42.5 ± 8.6 Experience with alcoholism-education Yes 20 (57.1) 39 (70.9) 21 (65.6) No 15 (42.9) 16 (29.1) 11 (34.4) Alcohol Use Disorders Identification Test score* 20.8 ± 6.7 27.2 ± 5.4 31.0 ± 6.3 CAGE score* 2.9 ± 1.0 3.5 ± 0.6 3.7 ± 0.5 Hanil Alcohol Insight Scale score* -1.6 ± 4.7 9.1 ± 3.3 17.1 ± 7.8 Values are presented as mean ± SD or number (%). *P < 0.05 by ANOVA with Scheffe's post hoc test. P < 0.05 by Fisher's exact test. 가정의학회지 Vol. 31, No. 7 July 2010 525
Kyu-Chol Cho, et al: Effects of Insight Level on the Sensitivity of Alcoholism Screening Tests in Alcohol Dependent Patients 의유의수준은 0.05 미만으로하였으며, 분석은 SPSS ver. 13.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 결과 1. 대상자들의사회인구학적및임상적특성전체대상자 122명중부정병식군은 35명 (28.7%), 병식부분형성군은 55명 (45.1%) 이었으며병식형성군은 32명 (26.2%) 이었다. 병식상태가높을수록배우자와함께사는경우가유의하게많았고역시병식상태가높을수록 4촌이내의문제음주자가있는경우가유의하게많았다. 첫문제음주연령은병식상태가낮을수록유의하게증가하였다. AUDIT, CAGE 점수는병식상태가높을수록모두유의하게증가하였다 (Table 1). 그밖에병식상태분류에따른세군의사회인구학적및임상적특성들은통계적으로유의하지않았다. Table 2. The sensitivity of alcoholism screening tests according to the insight level. Insight level Screening tests Poor (N = 35) Fair (N = 55) Good (N = 32) AUDIT 20* 22 (62.9) 51 (92.7) 31 (96.9) CAGE 3* 23 (65.7) 53 (96.4) 31 (96.9) Values are presented as number (%). AUDIT: Alcohol Use Disorders Identification Test. *P-value < 0.001 by Fisher's exact test. Table 3. The odds ratios for positive result in alcoholism screening tests according to the insight level among alcohol dependent patients. Odds ratio (95% Confidence interval) Insight level AUDIT 20 CAGE 3 Good (N = 32) 1 1 Fair (N = 55) 0.188 (0.013-2.774) 0.422 (0.021-8.477) Poor (N = 35) 0.025 (0.002-0.411)* 0.016 (0.001-0.358)* AUDIT: Alcohol Use Disorders Identification Test. *P < 0.05 by logistic regression analysis with adjustment for the age, sex, education, living with a spouse, religion, occupational state, family history of alcohol-related problems, history of alcoholrelated physical disease, age at first drinking, and age at first drinking problems. 2. 병식상태에따른선별검사의민감도대상자들의병식상태에따른 AUDIT 설문지의알코올의존에대한민감도는부정병식군에서는 62.9% (22명/35 명 ) 이었다. 병식부분형성군에서의민감도는 92.7% (51명/55 명 ) 이었으며, 병식형성군에서는 96.9% (31명/32명) 로부정병식군이병식부분형성군과병식형성군에비해민감도가유의하게낮았다 (P<0.001). 병식상태에따른 CAGE의알코올의존에대한민감도는부정병식군에서는 65.7% (23명/35 명 ) 이었다. 병식부분형성군에서의민감도는 96.4% (53명/55 명 ) 이었으며, 병식형성군에서는 96.9% (31명/32 명 ) 로 AUDIT 에서와같이부정병식군이병식부분형성군과병식형성군에비해민감도가유의하게낮았다 (P<0.001) (Table 2). 병식형성군을기준으로부분병식형성군과부정병식군의알코올리즘선별검사의양성가능성을알아보기위하여일반적특성과음주관련특성들을보정하였다. 병식형성군대비부정병식군의 AUDIT 설문지의양성비율이유의하게낮았다 (OR, 0.025; 95% confidence interval [CI], 0.002-0.411), 병식형성군에비해부정병식군의 CAGE 설문지의양성비율도역시유의하게낮았다 (OR, 0.016; 95% CI, 0.001-0.358) (Table 3). 고찰 본연구는일차진료영역에서알코올리즘을선별함에있어우수하다고알려진 AUDIT 4) 와알코올리즘선별에있어가장간편하고우수한변별력을보이는 CAGE 3) 를이용하였다. 연구대상자중부정병식군에서알코올리즘선별검사의민감도가 AUDIT 의경우 62.9%, CAGE의경우 65.7% 로병식부분형성군과병식형성군에비해유의하게낮음을확인하였다. 알코올의존환자들은병식이형성되기전까지부정, 투사, 합리화등의많은방어기제들을사용하며, 8,9) 이는환자내부에서다양한치료의장애물로작용하게된다. 특히 Rinn 등 15) 의보고에따르면부정은알코올의존환자들이흔히보이는특징적인사고의왜곡으로, 이방어기제를통해환자는자신의생활, 알코올소비량, 음주문제가있었던기간을축소하거나무시하게된다고하였다. 본연구에서부정병식군이알코올리즘선별검사의민감도가낮은이유도이러한알코올의존환자에서보이는다양한방어기제, 특히부정이라는방어기제사용의결과로보인다. 따라서병식수준이낮은환자의경우알코올리즘선별검사의해석에있어서임상의가주의를기울여야함을암시한다. 526 Vol. 31, No. 7 July 2010 Korean J Fam Med
조규철외 : 알코올의존환자의병식상태에따른선별검사의민감도 Otto와 Hall 10) 은알코올리즘선별검사인 MAST가알코올의존환자를선별함에있어서취약성이있을것으로가정하였고이를조사하기위하여알코올리즘환자 20명, 일반정신과환자 20명, 내과환자 20명등총 60명의환자를대상으로연구를시행하였다. 그결과, 알코올의존환자의경우자신의결과를위장하고자하는상황에서위음성률은 50% 를보였고, 일반정신과환자나내과환자와는달리낮은 MAST 점수를보고한다는결과를얻었다. 본연구에서는부정병식군의 AUDIT 에대한위음성률이 37.1%, CAGE에대한위음성률이 34.3% 를보였다. 이는병식상태에따른위음성률이 AUDIT 와 CAGE에서도, 특히부정병식상태의알코올의존환자에서알코올리즘선별검사의위음성이매우높음을시사한다. De Silver 등 16) 은총 252명 ( 위험음주 62명, 문제음주 88명, 알코올사용장애 88명 ) 에대해 AUDIT 타당도를조사하였고알코올사용장애에대해 AUDIT 점수가 20점이상일경우민감도가 92.0% 라고보고하였다. 본연구에서는 20점을기준으로알코올의존을선별함에있어 AUDIT의민감도가전체대상자에서 85.2% 를보여이전의연구에비해낮게측정되었다. 이러한차이는연구대상의차이를고려해서해석해야할것으로생각된다. 본연구대상은 122명모두알코올의존환자만을대상으로하였고그중부정병식군으로분류된환자가 35명 (28.7%) 이었다. 반면 De Silver 등 16) 이조사한연구대상은알코올사용장애환자가전체대상자중 88명 (17.7%) 으로알코올의존환자가비교적적게포함되었고병식에대한평가역시이루어지지않았다. 이런이유로두연구의민감도에대한직접적인비교는어려우나알코올의존환자중에서병식이부족한경우가 84.3-94.7% 를차지하는것으로보고 17-19) 되는현실에서알코올의존환자가많이포함되면될수록위음성이높아지고그만큼민감도는떨어질가능성이있다고생각된다. 본연구대상자들의 CAGE 점수의분포는 1점에서 4점이었으며 AUDIT 점수의분포는 6점에서 40점이었다. AUDIT 의경우 122명중 120명 (98.4%) 이 NIAAA 13) 에서제시한문제음주선별기준인 8점이상이었고 CAGE의경우 122명 (100%) 모두 Ewing 14) 이제시한음주문제선별기준인 1점이상이었다. 알코올의존으로진단받았음에도불구하고 AUDIT 점수가 8 점이상 20점미만이 16명 (13.1%), CAGE 점수가 1점이상 3점미만이 15명 (12.3%) 이었다. 이는임상진료에서 WHO 12) 에서제시한알코올의존의선별기준점수인 AUDIT 20점에해당되지않더라도 AUDIT 8점이상인환자에대해항상알코올의존에대한위음성의가능성을염두에두어야함을나타내는것으로생각된다. CAGE 역시 Mayfield 등, 3) Ewing 14) 이제시한 알코올의존의선별기준점수 CAGE 3점에해당되지않더라도 CAGE 1점이상인환자에대해 AUDIT 와마찬가지로알코올의존에대해위음성의가능성을항상염두에두어야할것으로생각된다. 즉이러한환자들에게는알코올의존에해당되는지여부에대해진단적면담을시행하는것이필요하다고생각된다. 다른나라의경우병식에관한연구가없어서직접적으로비교할수없지만병식이부족한알코올의존환자가많은한국과같은국가들에서는이러한진단적면담이더욱필요하다고사료된다. 이러한점에서, AUDIT 8점이상의대상자들에게알코올사용장애여부에대한평가를시행하라는 NIAAA 20) 의권고내용은매우적절한것으로생각된다. 즉, 20점미만의환자에대해임상의는병식수준이낮은알코올의존환자일가능성을늘염두에두어야한다. 그러나본연구가제한점은한병원의환자들을대상으로연구하였고, 대상인원이 122명으로적어연구의결과를일반화하기가어렵다는점이다. 또한설문지작성과정에서정신과전문의또는가정의가설명을담당하였기때문에설명담당자간의차이에의한영향의가능성을배제할수없었다. 알코올의존환자의선별검사와병식평가에대한연구가부족한관계로선행연구들과직접적인비교가이루어지지못한것도본연구의제한점이다. 추후일반인구집단을대상으로진단적면담을병행하는대규모연구를통해알코올리즘환자의선별검사와병식에대한보다일반화된결론이필요할것으로사료된다. 요약 연구배경 : 일차진료에서알코올리즘을선별하는도구는흔히사용된다. 본연구는알코올리즘선별검사들의민감도가환자의병식상태에따라어떻게영향을받는지에대해알아보고자하였다. 방법 : 알코올의존으로진단된 122명의환자들을대상으로하였다. 알코올리즘선별검사와함께병식상태를평가하였다. 알코올리즘선별검사는 Alcohol Use Disorders Identification Test (AUDIT) 와 CAGE 설문지를이용하였다. AUDIT는 20점이상, CAGE는 3점이상을알코올의존양성으로하였다. 병식상태는 Hanil Alcohol Insight Scale 을이용하여부정병식군, 병식부분형성군그리고병식형성군으로분류하였다. 결과 : 부정병식군 (35명) 의 AUDIT에대한민감도는 62.9% 였으며 CAGE에대한민감도는 65.7% 이었다. 병식부분형성군 (55명) 의 AUDIT에대한민감도는 92.7%, CAGE의민감도 가정의학회지 Vol. 31, No. 7 July 2010 527
Kyu-Chol Cho, et al: Effects of Insight Level on the Sensitivity of Alcoholism Screening Tests in Alcohol Dependent Patients 는 96.4% 이었다. 병식형성군 (32명) 의 AUDIT 에대한민감도는 96.9% 이었으며, CAGE의민감도역시 96.9% 였다. 병식형성군대비부정병식군의 AUDIT 설문지의양성비율이유의하게낮았다 (Odd ratios [OR], 0.025, 95% confidence interval [CI], 0.002-0.411). CAGE 설문지의양성비율도부정병식군에서유의하게낮았다 (OR, 0.016; 95% CI, 0.001-0.358). 결론 : 알코올의존환자의병식상태가낮은경우알코올리즘선별검사의위음성이높았다. 이러한결과는일차진료의사가알코올리즘선별검사결과를해석함에있어서주의를기울여야함을암시한다. 중심단어 : 민감도 ; 병식 ; AUDIT; CAGE; HAIS; 위음성 REFERENCES 1. Selzer ML. The Michigan alcoholism screening test: the quest for a new diagnostic instrument. Am J Psychiatry 1971;127: 1653-8. 2. Horn JL, Wanberg KW, Foster FM. The alcohol use inventory. Denver (CO): Center for Alcohol Abuse Research and Evaluation; 1974. 3. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry 1974;131:1121-3. 4. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption II. Addiction 1993;88:791-804. 5. Fiellin DA, Reid MC, O'Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med 2000;160:1977-89. 6. Kaplan HI, Sadock BJ. Psychiatric report, and typical signs and symptoms of psychiatric illness. In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook of psychiatry. 5th ed. Baltimore: Williams & Wilkins; 1989. p. 468-75. 7. Kim JS, Kim GJ, Lee JM, Lee CS, Oh JK. HAIS (Hanil Alcohol Insight Scale): validation of an insight-evaluation instrument for practical use in alcoholism. J Stud Alcohol 1998;59:52-5. 8. Graham K. Identifying and measuring alcohol abuse among the elderly: serious problems with existing instrumentation. J Stud Alcohol 1986;47:322-6. 9. Graham AV, Berolzheimer N, Burge S. Alcohol abuse: a family disease. Prim Care 1993;20:121-30. 10. Otto RK, Hall JE. The utility of the Michigan Alcoholism Screening Test in the detection of alcoholics and problem drinkers. J Pers Assess 1988;52:499-505. 11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 2000. 12. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. AUDIT: the alcohol use disorders identification test: guidelines for use in primary health care. Geneva: World Health Organization; 2001. 13. National Institute on Alcohol Abuse and Alcoholism. The physician's guide to helping patients with alcohol problem. Bethesda: National Institutes of Health; 2005. 14. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252:1905-7. 15. Rinn W, Desai N, Rosenblatt H, Gastfriend DR. Addiction denial and cognitive dysfunction: a preliminary investigation. J Neuropsychiatry Clin Neurosci 2002;14:52-7. 16. De Silver P, Jayawardana P, Pathmeswaran A. Concurrent validity of the alcohol use disorders identification test (AUDIT). Alcohol Alcohol 2008;43:49-50. 17. Kim JS, Park BK, Yu IS, Oh MK. Improvement of insight in patients with alcohol dependence by treatmen programs. J Korean Acad Fam Med 2000;21:1180-7. 18. Kim KC, Lee KS, Jung G, Shin SE. The relationship between insight level and defense mechanisms in alcoholic patients. J Korean Acad Addict Psychiat 2004;8:115-23. 19. Sung SK, Lee JJ, Kim HO, Lee KH. Effectiveness of inpatient treatment program on the insight and satisfaction of alcoholics. J Korean Acad Addict Psychiat 2002;6:20-9. 20. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician s guide. Bethesda: National Institute on Alcohol Abuse and Alcoholism; 2005. 528 Vol. 31, No. 7 July 2010 Korean J Fam Med