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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 36  |  Issue : 1  |  Page : 60-65

Psychological insulin resistance in patients with type 2 diabetes mellitus


1 Department of Internal Medicine, Mansoura University, Cairo, Egypt
2 Department of Psychiatry, Beni Suef University, Beni Suef, Egypt
3 Department of Psychiatry, Alazhar University, Cairo, Egypt

Date of Web Publication23-Mar-2015

Correspondence Address:
Rania Hussein
Department of Psychiatry, Alazhar University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.153794

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  Abstract 

Aim
Our study was conducted to review factors responsible for psychological insulin resistance among patients with type 2 diabetes mellitus.
Patients and methods
In our study on 100 patients with type 2 diabetes mellitus enrolled from an outpatient clinic of diabetes, all patients were noncompliant to diet and exercise, with high HbA1c, and all planned to be converted to insulin therapy.
Results
The results showed that a large number of factors account for psychological insulin resistance in patients; the main categories were emotional, cognitive, social, cultural, and interaction with health providers.
Conclusion
We concluded that there is a significant need of evidence-based interventions that help remove psychological barriers about insulin use in patients.

Keywords: exploration of insulin refusal, insulin rejection, psychological insulin resistance, unwillingness of shift to insulin


How to cite this article:
El Shafei MM, Sayyah HS, Hussein R. Psychological insulin resistance in patients with type 2 diabetes mellitus. Egypt J Psychiatr 2015;36:60-5

How to cite this URL:
El Shafei MM, Sayyah HS, Hussein R. Psychological insulin resistance in patients with type 2 diabetes mellitus. Egypt J Psychiatr [serial online] 2015 [cited 2019 Aug 17];36:60-5. Available from: http://new.ejpsy.eg.net/text.asp?2015/36/1/60/153794


  Introduction Top


Psychological insulin resistance (PIR) refers to psychological barriers to initiation and resistance to insulin therapy.

Some studies define PIR mostly as reluctance to initiate insulin treatment or insulin injection omissions.

The concept is defined in studies mostly as a diabetes management obstacle influenced by psychological factors, such as cognitive, emotional, relational, and cultural, and not as a psychological disorder (Polonsky et al., 2005).

By preventing patients from taking the insulin they need, PIR can cause patients' glycemic levels to increase beyond the recommended targets and put patients at risk of developing complications that affect the quality of life (Larkin et al., 2008).


  Aims Top


The aims of this paper were to determine how to study and measure PIR, what factors predict PIR, and what interventions can be proposed to reduce PIR.


  Patients and methods Top


Hundred patients with type 2 diabetes mellitus were enrolled conveniently from an outpatient clinic of diabetes. They were all noncompliant to the diet regimen or physical exercise. They had a high level of HbA1c. All planned to be converted to insulin therapy. Before starting the shift to insulin, they were subjected to the Insulin Treatment Appraisal Scale (ITAS) to assess their PIR (Snoek et al., 2007) (Appendix I).



For simplification of statistics, items 1, 2, 4, 5, 11, 12, 16, and 20 were categorized as psychosocial concerns about insulin therapy (maximum score = 16).

Items 3, 6, 17, 18, and 19 were categorized as perceived advantages of insulin therapy (maximum score = −10).

Items 6, 10, 13, 14, and 15 were categorized as items describing patients' fear of injection (maximum score = 10).

Items 7 and 9 were categorized as items representing patients' fear of insulin side effects (maximum score = 4).

Total score of ITAS (maximum score = 30).

Patients with a total ITAS score less than or equal to 10 were considered to have no PIR (n = 60) (group 1).

Patients with a total ITAS score more than 10 were considered to have PIR (n = 40) (group 2).

After comparing the two groups, another scale was applied on the group of patients with PIR to determine the most important factors that lead to PIR (attitudes about insulin therapy) (Appendix II)

(Polonsky et al., 2005). This will help in designing targeted educational programs for these patients to decrease PIR.

Statistical analyses

IBM SPSS statistics (V. 22.0, 2013; IBM Corp., Armork, New York, USA) was used for data analysis. Data were expressed as mean ± SD for quantitative parametric measures in addition to median percentiles for quantitative nonparametric measures and both number and percentage for categorized data.

The following tests were conducted:

  1. Comparison between two independent mean groups for parametric data using the Student t-test.
  2. Comparison between two independent groups for nonparametric data using the Wilcoxon rank-sum test.
  3. The χ2 -test to study the association between each of the two variables or comparison between two independent groups with regard to the categorized data.
The P of error at 0.05 was considered significant, whereas values of 0.01 and 0.001 were considered to be highly significant.


  Results Top


There was no significant statistical difference between groups 1 and 2 regarding the level of HbA1c ([Table 1]).
Table 1 Comparison between group 1 and group 2

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There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the age of the patient, which was lower in group 1 (45.9, SD = 11.7) compared with group 2 (53.25, SD = 8.25) (P = 0.006). This implies that more PIR was observed in older patients than in younger patients.

There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the duration of illness, with a much shorter duration of illness in group 1 (7.5, SD = 7.3) compared with group 2 (10.8, SD = 5.39) (P = 0.001). This implies that a longer duration of illness is associated with more PIR.

There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the total score of the ITAS and psychosocial concerns regarding insulin therapy. They were much higher in group 2 than in group 1.

There was no significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the perceived advantages of insulin therapy (P = 0.548).

There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the subscale of fear of insulin injection as it was more frequent and had a much higher score in group 2 than in group 1 (P = 0.000).

There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the subscale of fear of insulin side effects as it was more frequent and had a much higher score in group 2 than in group 1 (P = 0.000).

There was no significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the sex of the patients (between men and women) ([Table 2]).
Table 2 Comparison between groups 1 and 2 regarding sex and education

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There was a highly significant statistical difference between group 1 (no PIR) and group 2 (PIR) regarding the level of education of patients, with a much higher level of education among patients of group 1 (60% of them were university graduates, whereas 40% of the patients in group 2 were illiterate). This means that a higher level of education is associated with less incidence of PIR.

The most important barriers to insulin therapy are perceived illness severity (100%), perceived restrictiveness (100%), and perceived personal failure (100%). These were followed by low self-efficacy (95%), anticipated pain (90%), and lack of fairness (85%). The least important factors affecting the patient decision about insulin therapy were expected problematic hypoglycemia (75%), permanence of insulin therapy (once taken cannot stop it) (60%), and lastly the expected harm from insulin therapy (40%) ([Table 3]).
Table 3 Attitudes and beliefs regarding insulin therapy among patients with psychological insulin resistance (N = 40)

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There was no correlation between the perceived illness severity and age, sex, education, or the duration of illness.

There was a statistically significant negative correlation between perceived restrictiveness and the age of the patient (i.e. the younger the patient, the more the feeling that insulin therapy will restrict his/her activity) (value = 6.667a, P = 0.01).

There was no correlation between perceived restrictiveness and sex, the educational level, or the duration of diabetes.

There was no correlation between a lack of fairness and age, sex, the educational level, or the duration of illness.

There was a statistically significant correlation between anticipated pain of insulin injection and female sex (value = 6.593a, P = 0.037).

There was no correlation between anticipated pain of insulin injection and age, the educational level, or the duration of illness.

There was no correlation between expected problematic hypoglycemia and age, sex, the duration of illness, or the educational level of patients.

There was no correlation between perceived personal failure and age, sex, or the educational level of patients.

There was a statistically significant positive correlation between perceived low self-efficacy and the duration of illness (i.e. the longer the duration of illness, the greater the perceived low self-efficacy) (value = 16.000a, P = 0.003).

There was no correlation between perceived personal failure and age, sex, the educational level, or the duration of illness.

There was a statistically significant negative correlation between expected permanence of insulin use and the educational level of patients (i.e. the lower the educational level, the higher the expectancy of permanence of insulin therapy) (value = 11.778a, P = 0.019).

There was no correlation between expected permanence of insulin therapy and age, sex, or the duration of illness.


  Discussion Top


PIR refers to psychological barriers to insulin use on several levels (e.g. anxiety about the coexisted impact on daily life, depression, or guilt associated with needing insulin): cognitive (e.g. distorted beliefs about insulin treatment), behavioral (e.g. unpleasant negative consequences such as pain, bruising, hypoglycemia, weight gain), and relational (influencing factors from the medical health team).

Our study found that about 40% of diabetic patients refused insulin when it was prescribed due to uncontrolled diabetes.

Several studies have been done on the prevalence of PIR eg Polonsky et al., 2005 and Larkin et al., 2008 showed a prevalence of 50.7%.

However, a study on diabetic patients in Bangladesh showed PIR in patients with poorly controlled type 2 diabetes mellitus; a study conducted in east London showed comparable results, wherein 42.2% of the patients refused insulin when first recommended.

The differences in magnitude of PIR was emphasized in the Diabetes Attitudes, Wishes and Needs (DAWN) study conducted in 13 countries in Asia, Europe, and North America, which showed that beliefs about insulin were related to the culture and the healthcare systems of different countries (Peyrot et al., 2005).

The negative attitude that prompts patients to refuse insulin were mainly related to perceived disease severity and personal failure. For many patients, insulin therapy signified that their diabetes was suddenly more serious and more dangerous (Polonsky et al., 2003, 2005; Khan et al., 2008; Larkin et al., 2008).

Similarly, Hunt et al. (1997) reported that many patients were concerned that insulin therapy may cause further health problems.

In some cases, such beliefs may be at least partially correct such as increasing hypoglycemia and weight gain, whereas in other cases, such as the belief that insulin causes blindness, the idea is wrong. If people are convinced that insulin will worsen their health, they may be very resistant to begin insulin therapy (Meece, 2006; Peragallo-Dittko, 2007).

Most patients expressed several reasons for avoiding insulin therapy rather than just one. The DAWN study also found that about 58% patients with diabetes mistook the need of insulin as an indication for their noncompliance, and that they had failed to manage their diabetes or that it was a punishment (Polonsky et al., 2005).

These results lead to several implications for clinical practice. PIR typically presents as a set of beliefs about the implication of insulin therapy. First, patients may be unable to overcome their insulin therapy reluctance till their personal concerns were recognized and addressed. Second, patients need to be made to understand that the failure of therapy is not their fault, but it is due to the progressive nature of the disease, and thus the use of insulin is both appropriate and necessary in many patients with type 2 diabetes mellitus.

Third, the benefits of insulin therapy are to increase vitality and reduce the risk and complications of uncontrolled diabetes (Meece, 2006; Peragallo-Dittko, 2007; Gavin et al., 2010).

This study has some limitations. Our patients had relatively good diabetic control on oral medications; therefore, the results of this study may not be generalized to patients with severe hyperglycemia.

Further research on a larger number of patients is needed to understand PIR.


  Conclusion Top


When patients are reluctant to use insulin, PIR should be explored. Providers might begin by questioning patients about their knowledge of insulin therapy and their underlying beliefs.

Exploring why the patient is unwilling to take insulin can help one to address their specific fear of therapy.

Insulin should be viewed as a valuable therapeutic tool for early intervention that allows patients to attain and maintain target levels of glycemic control.

A collaborative doctor patient relationship can lead the patient to understand and accept the importance of insulin therapy to maintain proper control of their illness.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.[10]

 
  References Top

1.
Gavin JR, Peragallo-Dittko V, Rodgers PT (2010). A new look at established therapies. Diabetes Educ 36(Suppl 2):26S-38S.  Back to cited text no. 1
    
2.
Hunt LM, Valenzuela MA, Pugh JA (1997). NIDDM patients' fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care 20:292-298.  Back to cited text no. 2
    
3.
Khan H, Lasker SS, Chowdhury TA (2008). Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled type 2 diabetes in East London. Diabetic Med 25:1108-1111.  Back to cited text no. 3
    
4.
Larkin ME, Capasso VA, Chen CL, et al. (2008). Measuring psychological insulin resistance: barriers to insulin use. Diabetes Educ 34:511-517.  Back to cited text no. 4
    
5.
Meece J (2006). Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ 32(Suppl):9S-18S.  Back to cited text no. 5
    
6.
Peragallo-Dittko V (2007). Removing barriers to insulin therapy. Diabetes Educ. 33(Suppl 3):60S-65S.  Back to cited text no. 6
    
7.
Peyrot M, Rubin RR, Lauritzen T, et al. (2005). Resistance to insulin therapy among patients and providers results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 28:2673-2679.  Back to cited text no. 7
    
8.
Polonsky WH, Fisher L, Dowe S, Edelman S (2003). Why do patients resist insulin therapy? [abstract]. Diabetes 52:A417.  Back to cited text no. 8
    
9.
Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV (2005). Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care 28:2543-2545.  Back to cited text no. 9
    
10.
Snoek FJ, Skovlund SE, Pouwer F (2007). Development and validation of the Insulin Treatment Appraisal Scale (ITAS) in patients with type 2 diabetes. Health Qual Life Outcomes 5:69.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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  In this article
Abstract
Introduction
Aims
Patients and methods
Results
Discussion
Conclusion
Acknowledgements
References
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