medwireNews: Insulin manipulation, the practice of deliberately under- or overdosing insulin, is strongly associated with psychiatric comorbidity in children and young adults with type 1 diabetes, Austrian research shows.
The association was particularly strong in women and was associated with significantly higher glycated hemoglobin (HbA1c) levels and a higher rate of diabetes complications, Gudrun Wagner and colleagues from the Medical University of Vienna report in Pediatric Diabetes.
For the study, 241 patients aged 10–22 years (mean 14.4 years, 42.5% male) underwent two diagnostic interviews – the Diabetes Self-Management Patient Interview and Children’s Diagnostic Interview for Psychiatric Disorders – to assess insulin adherence and psychiatric comorbidity, respectively.
Overall, 29.5% of patients were intentionally manipulating their insulin doses and the same proportion had a clinical and/or subclinical psychiatric diagnosis.
Almost half (46.5%) of patients with insulin manipulation had psychiatric comorbidity compared with 17.5% in patients who were adherent to the prescribed insulin therapy.
During the interviews the researchers found that reasons for skipping insulin included desired weight loss, denial of diabetes, fear of hyopglycemia, and self-destructive behaviour, a reason also given for insulin overdosing, along with wanting to binge eat and suicidal intentions.
Indeed, the rates of depression (18.3 vs 4.9%), specific phobias (21.1 vs 2.9%), social phobia (7.0 vs 0.0%), and eating disorders (12.7 vs 1.9%) were all significantly higher in patients with insulin manipulation compared with those who were adherent to treatment.
Furthermore, psychiatric disorders were significantly more common in women than men (37.7 vs 18.4%) and were associated with increasing levels of non-adherence to insulin in women but not in men.
Investigating the effect of insulin manipulation on diabetes control, Wagner and team found that HbA1c was a significant 0.89% higher among the patients who reported insulin manipulation compared with those who were adherent to therapy.
Compared with adherent patients, those in the manipulating group also had numerically more hospital admissions for ketoacidosis (mean 0.63 vs 0.26) and severe hypoglycemia episodes (mean 0.79 vs 0.52), and significantly more outpatient visits to a diabetes center (4.77 vs 4.07).
Wagner and colleagues point out that they originally contacted 715 patients to participate in the study but 393 refused. These patients were more often men, were older, and had a higher HbA1c.
“One can hypothesize that these patients are the less adherent [and therefore] our study might even underestimate the rate of non-adherence with insulin therapy,” the researchers remark.
The team concludes that diabetes teams need to be conscious of “secret behavior” in young patients with diabetes.
They add: “Most psychiatric problems start at young age and tend to persist into adulthood. So, early detection of psychiatric comorbidity and insulin-manipulation is essential and may be of long-term value.”
By Laura Cowen
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