| | |
---
What's So Tough About Taking Insulin? Addressing the Problem of Psychological Insulin Resistance in Type 2 Diabetes
What's So Tough About Taking Insulin? Addressing the Problem of Psychological Insulin Resistance in Type 2 Diabetes -- Posted by Gumbo on 11-14-04 19:47
What's So Tough About Taking Insulin? Addressing the Problem of
Psychological Insulin Resistance in Type 2 Diabetes
Originally Published:20040701.
Patients 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 be relatively common across
multiple ethnic groups and across nations. However, although patients may
express significant reluctance in the abstract, it is not yet known how
often this leads to outright refusal or bargaining when the patient is alone
with his or her provider and an actual recommendation to begin insulin is
made.
Why are so many insulin-naive patients averse to the possibility of insulin
therapy? Six major factors are apparent.
First, insulin is often associated with a perceived loss of control over one
's life. When asked to identify their reasons for insulin therapy
reluctance, 61.4% of patients agreed that, "Once I start insulin, I can
never stop," and 50.6% believed that insulin therapy would restrict their
lives.4 Recent data from the DAWN study point to similar concerns.6 As one
patient explained, "Taking insulin would mean no more spontaneous adventures
for me. It would make it too hard to travel, or eat out, or even have a
life!" In the days before glargine, lispro, and aspart insulins became
available, it was certainly true that insulin therapy often required
significant vigilance and changes to one's lifestyle, but in the vast
majority of cases, this no longer needs to occur.
The second factor is poor self-efficacy about insulin therapy. Approximately
40-50% of patients do not feel confident that they could handle the demands
of insulin therapy, such as determining the proper timing and dosages.4,6
Without proper care and explanation, insulin therapy can at first seem much
too complicated and overwhelming. And when patients do not have confidence
in their ability to perform a particular self-care behavior, it is unlikely
that they will follow recommendations to do so.7
A third factor is that as many as 50% of patients associate insulin therapy
with personal failure.4,6 In other words, insulin is viewed as a
well-deserved punishment for one's own gluttony, sloth, or negligence in
some other area of diabetes self-care. As one patient described it, "If I
have to take insulin, it means that I have messed up, that I haven't done a
good enough job taking care of my diabetes."
The fourth factor concerns perceived disease severity. For many patients,
insulin therapy signifies that their diabetes is now suddenly more serious
and more dangerous.4·6 As first reported by Hunt et al.,5 many patients are
concerned that insulin therapy may cause further health problems. In some
cases, such beliefs may be at least partially correct (e.g., a slightly
increased hypoglycemia risk), while in other cases (e.g., "Insulin will
cause mo Io go blind."), they may be quite wrong. Not surprisingly, if
people are convinced that insulin will worsen their health, they may be very
resistant to begin insulin therapy.
Of interest, Polonsky et al.4 noted a sizeable ethnic split on this latter
issue. While the majority of Hispanics (72.2%) felt that insulin therapy
could cause further health problems, very few non-Hispanic whites (8.1%)
believed this to be so.
A fifth factor concerns injection-related anxiety. Approximately 50% of
patients report being fearful of injections.6 Although this is often
presumed to be the single, or single largest, contributor to PIR, we suspect
that this may be overstated. True injection phobia is rare, even among
insulin-using patients with diabetes.8 Certainly, few people look forward to
injections. But when patients report that they "could never take the
needle," this may often represent a broader reluctance to consider insulin
therapy, reflecting their many negative beliefs about insulin or lack of
knowledge about its use (e.g., the relative painlessness of insulin
injections) rather than simply a fear of needles per se.
A final factor contributing to PIR is the perceived lack of positive gain.
Skovlund et al.6 found that few insulin-naive patients anticipated positive
benefits from insulin therapy. Less than 10% believed that insulin might
help them achieve good glycemic control, improve their energy level, or
improve their health. In total, given the widespread appraisal of insulin
therapy as a negative and perhaps harmful intervention and the lack of
recognition that it might have positive benefits, it is no wonder that PIR
appears to be so commonplace.
What causes patients to develop such negative beliefs toward insulin? One
contributor is likely to be patients' personal experiences. Consider the
following story:
"My mother had diabetes, and it was no big deal to her for over 20 years.
She rarely saw a doctor and never paid much attention to it, and it never
really bothered her. But then her doctor finally convinced her to start
insulin and-bam! Over the next year, she started having serious problems
with her eyes, and then there were terrible pains in her legs. In fact, she
eventually lost most of her left leg. No doubt about it, insulin was the
culprit. And now you want me to start insulin? No way!"
In cases like these, it is likely to be the many years of self-care neglect
that is the major source of harm, not insulin. Still, such stories are not
uncommon, and it is understandable-given the chronology-that patients may
come to confuse cause and effect.
Another contributor, and perhaps the major one, is the subtle and
not-so-subtle messages that patients receive from their providers.9 For
example, it is common for insulin-naive patients to be threatened with
insulin, to be told that if they don't work harder to manage diabetes, then
there will be no choice but to start insulin, to "get the needle."
Clinicians may inadvertently influence patients' beliefs about insulin
through the use of such unfortunate terms as "oral agent failure."
And clinicians' own negative feelings about insulin therapy may also play a
role. Many clinicians are, understandably, fearful of the extra time needed
to start and manage insulin therapy, they may be loathe to handle the
potentially unpleasant confrontations with patients who do not want to take
insulin, and they may be concerned about the potential for severe
hypoglycemia, excessive weight gain, or other adverse effects. Therefore,
they may collude with their patients to delay the initiation of insulin
(e.g., "Why don't you take a few more months and try to get more serious
about exercise and weight loss. Maybe you can get those numbers down by the
time we meet again."). As patients witness such actions and hear such
messages repeatedly over the years, the lessons absorbed are 1) insulin is a
bad thing and should be avoided at all costs; 2) if insulin therapy is
necessary, it is because you have failed to take adequate care of yourself;
and 3) insulin therapy is how you will be punished for your lack of personal
success.
Patients, therefore, should not be blamed for harboring such inaccurate
views of insulin. In many cases, they may be merely drawing the best
conclusions possible from what they have learned from their providers.
How should PIR be addressed? To date, there are no published intervention
studies, but it seems evident that the most powerful solution is, of course,
prevention. Type 2 diabetes is a progressive disease, and it is recognized
that as many as one-third of type 2 patients are likely to require insulin
at some point. Therefore, rather than threatening patients with insulin,
patients should be fore-warned early in treatment that the need for insulin
is quite likely to arise at some point in the future-not because of anything
they have done wrong, but because of the nature of the disease.
Long before insulin is actually prescribed, explain to patients that the
eventual need for insulin is linked to the fact that they are currently
healthy, not because they are sick. For example, "Diabetes gets tougher to
handle as the years go by. The longer you live with it, the more likely it
is that you will need powerful medications like insulin to control it. And
because you are relatively young and healthy, you're probably going to live
a long time. So it is fairly likely that you'll need insulin at some point,
just because you're so darned healthy."
When clinicians are faced with PIR, there are eight possible intervention
strategies to consider:
1. Identify the patient's personal obstacles. When patients profess an
unwillingness to start insulin therapy, there is a natural tendency to
immediately respond with helpful comments (e.g., "Injections aren't so bad,"
"Taking insulin doesn't mean your diabetes is getting worse," or "Trust me,
you're going to have so much more energy.") or, perhaps, to jump to one of
the strategies described below. But few of these are likely to be beneficial
unless the intervention matches the patient's perceived reasons for
resisting insulin.
Indeed, patients may be unable to appreciate any reassurances or additional
information until their personal beliefs about insulin are recognized and
discussed. Consider a simple, respectful, open-ended question such as,
"Could you tell some of the reasons why you feel so strongly about not
taking insulin?" Alternatively, to prompt patients' thinking and to engender
a more detailed conversation, administering a brief, self-report PlR
questionnaire might be advantageous.4,6
2. Restore the patient's sense of personal control. When necessary,
introduce insulin as a brief, temporary experiment only (e.g., "I'd like you
to try insulin for just a month. At the end of the month, if you don't think
it has been worthwhile, or if it still seems as awful as you're imagining it
might be, I promise to help you stop."). Of course, patients always retain
this choice whether it is offered or not, but by putting this forward as a
viable alternative that is supported by their clinician, it serves as an
important reminder that insulin does not mean they will lose control of
their lives.
3. Enhance self-efficacy as quickly as possible. When insulin is first
introduced, the process of insulin use should be demonstrated for patients
while they are in the clinician's office, and they should be encouraged to
practice before returning home. With the support and encouragement of a
caring clinician, the hands-on discovery that injections are easily
accomplished and that insulin therapy is not difficult to master can be an
enormous boost to confidence. This is enhanced even further as patients
first observe the surprisingly small size of insulin needles and realize
firsthand that injections are all but painless.
The number of recommended behavioral changes also should be minimized, at
least at first. If reluctant patients are introduced to insulin with a
dizzying array of additional self-care procedures (e.g., much more frequent
self-monitoring of blood glucose and recommendations to make major changes
in the timing and composition of meals), it should not be surprising if they
become even more concerned that they will not be capable of managing the
demands of insulin therapy successfully (and, thus, even more resistant to
insulin therapy).
Luckily, it is increasingly common for type 2 patients to be first
introduced to insulin as combination therapy. In this manner, when a single
shot of insulin (often nighttime glargine or NPH insulin) is typically added
to the existing or somewhat modified regimen of oral agents, few additional
self-care steps are needed, and there is little further disruption to the
person's lifestyle.
Clinicians need to follow-up quickly with initial insulin dose adjustments
to ensure that patients will quickly see improvements in their glucose
numbers following this new treatment. If a suboptimal dose is started and no
changes are made in this dose until the next visit, the perceived efficacy
of insulin may be undermined.
4. Consider insulin pens. Because pens are easier to operate and appear less
forbidding than the traditional bottle and syringe, they may be more
acceptable to insulin-naive patients struggling with PIR. To date, there is
only anecdotal evidence to support this observation. Many providers have
commented that PIR in their practices has dramatically lessened since they
begin initiating insulin therapy with pens. Not uncommonly, the response
from patients has been, "You mean that's all there is to it?!"
5. Frame the insulin message properly. When talking about the need for
insulin, stay focused on glycemic outcomes, sharing hemoglobin A1c (A1C)
results with patients and explaining that the critical goal is to protect
their health through the achievement of glycemic targets. Ideally,
clinicians and patients should come to an agreement on specific A1C targets.
When those targets are then not being met by a regimen of oral agents and
lifestyle changes, insulin becomes a natural choice, providing patients with
the additional tool they need to meet their goals.
It should be stressed to patients that they have not "failed" with their
diabetes, that they have done nothing wrong, and that insulin therapy does
not indicate that their diabetes is getting worse. As mentioned earlier, it
should be explained that diabetes is now understood to be a progressive
disease-not that the disease is getting worse, but that more or stronger
medications may be needed over time to achieve glycemie targets. And when
such medications, including insulin, are needed, this is a function of the
underlying disease, not the person's failure at proper diabetes self-care.
Removing patients' sense of personal guilt is critical.
Finally, when patients worry about untoward side effects, it may be useful
to remind them that insulin is one of our most "natural" drugs; indeed, it
is far more natural than any of the oral agents with which they may be
familial'.
6. Discuss the real risks of hypoglycemia. Type 2 patients' worries about
hypoglycemia can often be traced to the dramatic tales told by type 1
patients or to hypoglycemic episodes as portrayed in films. Patients should
be told that while severe hypoglycemia (an episode where help from another
is required) may occur frequently in type 1 diabetes, it is quite rare in
type 2, even among patients on insulin. In the UKPDS, for example, the
animal incidence of severe hypoglycemia in insulin-treated patients was <
3.0%.10
Still, events do occur. Patients should be reassured that a modicum of
vigilance on their part and on the part of their provider (e.g., through
more frequent blood glucose monitoring and a careful review of results), as
well as further diabetes education (so that patients become more skilled
regarding recognition and treatment of hypoglycemia), can reduce the risk of
any potential problems even further.
7. Tackle injection phobias. In cases where patients are truly too fearful
of needles to begin insulin therapy, clinicians may want to consider
referral to a mental health provider familiar with cognitive behavioral
therapy, especially the well-documented approach to phobias known as
"systematic desensitization." Needle phobias can usually be resolved quite
rapidly."
8. Pass along the good news. Once patients' personal obstacles have been
addressed, it may be worthwhile to review the positive benefits associated
with insulin (to be more precise, with better glycemic control). Patients
need to know that they may soon notice improvements in their mood, sleep,
and energy level and that better glycemic control means that they are making
a sizeable investment in the protection of their long-term health.
Summary
In insulin-nai ve patients with type 2 diabetes, PIR is not uncommon. It is
likely that PIR contributes to unnecessarily long delays for initiating
insulin and, consequently, to extended periods of hyperglycemia.
Patients' reasons for avoiding insulin extend far beyond a simple fear of
needles and often involve deeply held beliefs about insulin and the nature
of diabetes. It appears that clinicians' standard method for talking about
insulin, in which insulin therapy is used to frighten patients toward taking
better care, may be a major contributor to PIR.
The good news is that PIR can be overcome when patients' personal obstacles
to insulin therapy are recognized and addressed. Most importantly, it seems
likely that the majority of PIR cases could be prevented if clinicians began
to introduce the possible need for insulin early in treatment, refrained
from using insulin as a means for threatening or blaming patients, and
helped patients see insulin as a possible friend rather than a foe.
(C) 2004 Clinical Diabetes. via ProQuest Information and Learning Company;
All Rights Reserved
Related
Discussion:
pharmacists on statins (6 posts)
by outrider - Last post on: 04-29-05 21:55
http://pharmacy.king-online.com/Pharmacy_20050420/index.php
Patients Find Statins Can Have Side Effects
Guidelines for cholesterol control recently have become much more
stringent. For millions of Americans, achieving the new targets
requires strong medicine.
Over the past decade, prescri... (Read More)
Atherosclerosis Begins Early in Type 1 Diabetes Patients (1 posts)
by Gumbo - Last post on: 11-14-04 19:51
Atherosclerosis Begins Early in Type 1 Diabetes Patients
on Tuesday, November 02 @ 12:51:37 EST
Study shows that atherosclerosis, begins early and that it relates to
abnormalities of lipids and to diabetes complications.
New study findings provide more evidence that atherosclerosis begins ea... (Read More)
Single Payer Universal Health Care (1 posts)
by Sarah - Last post on: 05-22-04 22:09
Download and print these trifold brochures to help promote single payer
Universial Health Care
http://www.kucinich.us/supporter_resources/otherpdfs/HealthCareBrochurePetition.pdf
http://www.kucinich.us/supporter_resources/otherpdfs/HealthCareBroch_NoPetition.pdf
Learn More:
http://www.k... (Read More)
How does homeopathy differ from conventional medicine? (1 posts)
by Daniel - Last post on: 02-26-04 02:31
How does homeopathy differ from conventional medicine?
How does the concept of homeopathy differ from that of conventional
medicine?
Very simply, homeopathy attempts to stimulate the body to recover
itself. Let's
look at an example: the common cough.
First, we must accept that all symptom... (Read More)
Top
Discussions From Our Archives
WOW! I HAVE FOUND THE BEST WAY TO SAVE ON MY PRESCRIPTION MEDS
Systemic Enzymes might change your life
Low Testosterone Linked to Diabetes
www.goodlife2000.co.uk -- 6 in 1 diet supplement 0674
Methotrexate..... Whats it like????
The Amazon Acai Berry Featured On The Oprah Show
Other
Discussion Categories
Diabetes Symptoms
Warning: fopen(http://www.tentsamerica.info/index.xml): failed to open stream: HTTP request failed! HTTP/1.1 404 Not Found
in /home/xtrack/domains/xtrack.net/public_html/xml/XmlParser.class.php on line 127
Oops!!! Unexpected Error While Reading the Feed
|
|
