Psychological Insulin Resistance

1. Psychological Insulin Resistance Sue Ruedebusch, RN, BS, CDE Paul Ciechanowski, MD, MPH

2. Supported by Cooperative Agreement • The project described in this slide set was supported by Cooperative Agreement Number 1C1CMS331048-01-00from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. • Its contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

3. Psychological Insulin Resistance • People’s beliefs, emotions and concerns regarding insulin treatment • negative self-perceptions • attitudinal barriers • fear of side effects and complications • lifestyle adaptations/restrictions required • social stigma • Around issue of initiating or intensifying insulin treatment - patients may delay, refuse, bargain, or even drop out of care.

4. Psychological Insulin Resistance • UKPDS - 27% of those randomized to insulin therapy refused. • DAWN - 55% of insulin-naïve patients worry about the possibility of insulin therapy.

5. Psychological Insulin Resistance Polonsky, 2007

6. Lack of Fairness “I have worked hard to follow the rules - but now I have to start insulin”

7. Permanence “Once I start insulin, I can never stop”

8. Restrictiveness “I will have to give a shot when I am out in public”

9. Low Self-Efficacy about Insulin Therapy • 40-50% of patients do not feel confident they could handle demands of insulin therapy such as proper timing or dosages.

10. Personal Failure "If I have to take insulin - it means that I have messed up and not done a good enough job of caring for my diabetes” • Patients are threatened with starting insulin if they don't work harder to manage diabetes. • "Oral agent failure” – also, “beta cell failure”, “treatment failure”….

11. Illness Severity • Insulin is perceived as meaning that a one’s diabetes is suddenly more serious and dangerous. • Many patients think that insulin therapy will cause further health problems, which may be partly true (i.e. hypoglycemia). • Also, using insulin might result in other people, e.g. co-workers, friends, finding out about the person’s diabetes diagnosis. They may be subjected to criticism: “You can’t eat that – you’re a diabetic!” (e.g. of ‘food police’)

12. Anticipated Pain/Injection Related Anxiety • 50% of patients report being fearful of injections. • True injection phobia is relatively rare.

13. Expected Harm “My aunt had diabetes for 20 years and died 3 months after starting insulin” • i.e. confusion about cause and effect, but also fear of hypoglycemia.