Addressing Psychological Insulin Resistance in Patients With Diabetes

Insulin Resistance and Type 2 Diabetes
Insulin Resistance and Type 2 Diabetes
Learn about strategies to reduce a patient's reluctance to initiate insulin therapy, a phenomenon called psychological insulin resistance.

Despite the well-established effectiveness of insulin in managing diabetes, a significant number of patients with type 2 diabetes and, in some cases, their treating physicians are reluctant to initiate insulin treatment, resulting in risky delays. The term psychological insulin resistance (PIR) was coined in 1994 to describe this phenomenon.1

Although most patients accept the need to initiate insulin, even if begrudgingly, it has been estimated that nearly 40% of patients for whom insulin therapy is indicated are completely unwilling to use it.2 In addition, approximately 61% of patients were found to have a moderate degree of PIR in a study published in March 2017.1

One of the main contributing factors to PIR is patients’ inaccurate knowledge and beliefs about insulin therapy.3,4

They might believe insulin is necessary only for patients with severe disease, for example, and thus may perceive the need for insulin as an indication that their disease is worsening. Patients may also have the negative perception that insulin initiation is a sign of personal failure in disease self-management.

In addition, they may be fearful that such a transition will be overwhelming or result in a loss of normalcy, or that they will be perceived differently by other people. Some patients are fearful of hypoglycemia and other adverse effects, as well as pain associated with injections, whereas others may feel incapable of self-administering injections correctly. In research involving geriatric patients with type 2 diabetes, the top fears pertaining to insulin initiation were fear of injection, anticipated disadvantages from insulin therapy, and fear of stigmatization.5

In other results, women and ethnic minorities demonstrated the most psychological barriers to insulin therapy.6,7 Patients who were less reluctant to use insulin had high self-efficacy, believed in the value of tight glucose control, and reported better interpersonal communication with their providers.

On the provider side, there may be hesitance to prescribe insulin for several reasons, including a patient’s PIR. In a cross-sectional study, patient resistance to initiating insulin was cited as a barrier by 64% of PCPs interviewed, and concerns about patients’ ability to self-manage were reported as barriers by 43% of physicians.8

William H. Polonsky, PhD, CDE, an associate clinical professor of psychiatry at the University of California, San Diego, and president of the Behavioral Diabetes Institute, adds that providers may unwittingly contribute to the problem both on an individual level and overall by essentially threatening patients with insulin as punishment for poor medication adherence.

He says that one of the most important things providers can do to reduce PIR is educate patients about how to use insulin. “Simply showing patients an insulin pen and having them take some sort of practice injection, like with saline, will take care of the whole issue for some patients,” he told Endocrinology Advisor. Patients are often surprised at the simplicity of the process. “Don’t just give them a prescription and send them off. Let them have that experience so they know how easy it is.”

One tactic that can be helpful is the “insulin challenge,” in which the provider, upon introducing insulin to the patient, tells them they are asking them to try it for a time-limited trial (of 2-4 weeks, for example), and that if they are miserable after the trial, the provider will help them discontinue insulin. “You’re basically saying, ‘Look, it’s always your choice,’ because many patients fear losing control and experiencing a downward spiral” with their disease, Dr Polonsky explains.

Beyond those key strategies, clinicians should address patients’ misbeliefs about insulin. Some fear not only that will insulin not improve their disease but also that it is actually bad for them. He notes that in these cases, there is often a family story about insulin, such as a relative who never sought treatment throughout decades of living with diabetes, and when they finally did and were started on insulin, their condition declined significantly. This reflects the mistaken belief that the deterioration was a result of the initiation, rather than the delay, of insulin therapy.

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Finally, providers should keep in mind that PIR is very common and respect that “the reasons patients are reluctant to take insulin are rational: they’re not stupid or crazy,” says Dr Polonsky. Their resistance is based on bad information, which providers can help correct. He and colleagues are currently collecting data pertinent to this issue from patients around the world. At the upcoming International Diabetes Federation 2017 International Conference on Diabetes and Metabolism, the researchers will present preliminary data from patients who were previously reluctant to start insulin, but ultimately did, who were interviewed about what their physicians did that influenced this decision.

In terms of future research in this area, Dr Polonsky points to the need for a formal intervention study to examine effective strategies to reduce PIR. Although a secondary analysis study reported that demonstrating injections, addressing patients’ feelings, and positively managing expectations may be successful approaches, a randomized controlled trial on the topic has yet to be conducted.1


A significant number of patients with diabetes are reluctant to initiate insulin therapy, a phenomenon known as PIR. Providers may reduce this reluctance by validating patient concerns, correcting inaccurate beliefs, and adequately demonstrating insulin injections.


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  3. M.M. Funnell. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes. 2007; 25:36-38.
  4. Polonsky WH, Hajos TR, Dain MP, Snoek FJ. Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population. Curr Med Res Opin. 2011;27:1169-1174.
  5. Bahrmann A, Abel A, Zeyfang A, et al. Psychological insulin resistance in geriatric patients with diabetes mellitus. Patient Educ Couns. 2014;94(3):417-422.
  6. Nam S, Chesla C, Stotts NA, Kroon L, Janson SL. Factors associated with psychological insulin resistance in individuals with type 2 diabetes. . Diabetes Care. 2010;33(8):1747-1749.
  7. Machinani S, Bazargan-Hejazi S, Hsia SH. Psychological insulin resistance among low-income, US racial minority patients with type 2 diabetes. . Prim Care Diabetes. 2013;7:51-55.
  8. Ratanawongsa N, Crosson JC, Schillinger D, Karter AJ, Saha CK, Marrero DG. Getting under the skin of clinical inertia in insulin initiation: The Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project. Diabetes Educ. 2012;38:94-100.