What's So Tough About Taking Insulin? Addressing the Problem of Psychological Insulin Resistance in Type 2 Diabetes

Abstract

P atients with type 2 diabetes are often reluctant to begin insulin and, in many cases, delay the start of insulin therapy for quite lengthy periods of time. Patients may refuse insulin outright (“Look, doc, there is just no way I could take the needle.”), bargain with their health care providers for more time (“Please, I just need a few more months to see if I can drop this weight.”), or even drop out of treatment altogether. Sadly, actions such as these can lead to chronically elevated blood glucose levels, possibly for considerable periods of time, raising the risk for long-term complications. But what do we really know about such cases of “psychological insulin resistance” (PIR)? How often do they occur, why do patients harbor such powerful misgivings, and how can busy clinicians respond most effectively? While clinical lore suggests that PIR is quite common, there has been little formal study in this area. In the United Kingdom Prospective Diabetes Study (UKPDS),1 of those type 2 patients randomized to insulin therapy, 27% initially refused. Early reports from the international Diabetes Attitudes, Wishes, and Needs (DAWN) study2 indicate that the majority (54.9%) of insulin-naive patients worry about the possibility of insulin therapy. Okazaki et al.3 reported that 73% of type 2 patients beginning a diabetes education program where insulin was to be started were reluctant to do so at first. Finally, in a recent survey of insulin-naive type 2 patients,4 24.7% of respondents reported being not willing to take insulin if it was prescribed. Furthermore, the survey showed that Hispanic patients were much more frequently unwilling than non-Hispanic whites (55.6 vs. 21.5%). Qualitative data from Hunt et al.5 also suggest that PIR may be common in the Hispanic population. Overall, these data suggest that PIR may …