Psychological barriers to treatment intensification for type 2 diabetes

Type 2 diabetes (T2D) is a progressive condition and managing it may require using more intensive treatments over time, including injectable medications. Delaying treatment intensification means that blood glucose remains high (hyperglycaemia), which increases the risk of developing or worsening long-term diabetes complications. National and international data suggest that many people with T2D have average blood glucose levels (HbA1c) above their recommended target, and treatment intensification is often delayed. One reason for this is that people with diabetes may have concerns about taking more, or different, diabetes medications.

Dr Holmes-Truscott and Prof Speight lead a program of research which explores psychological barriers to treatment intensification among people with T2D. To date, our work has focused mainly on the barriers associated with insulin therapy. Our research has demonstrated that people with T2D delay insulin for a number of reasons, ranging from concerns about the complexity of insulin therapy and anxiety about using injections, to the belief that they have failed if insulin needs to be prescribed.  We found that a quarter of Australians adults with T2D recommended to start insulin are ‘not at all willing’ to intensify their treatment. This group are more likely to report concerns about insulin therapy and are also less likely to go on to use insulin therapy.

We are currently undertaking research to understand whether similar psychological barriers exist for non-insulin injectable diabetes medications. We are also developing resources and interventions to support people with T2D, and their health professionals, in making informed decisions about their diabetes medications. We included a chapter about psychological barriers to insulin therapy in the National Diabetes Services Scheme (NDSS) Diabetes and Emotional Health handbook and toolkit for health professionals. This includes guidance on how best to assess and discuss concerns about insulin therapy within clinical care. We also developed an NDSS factsheet for people with T2D. Going forward, we aim to develop online resources for people with T2D, which provide balanced information about medication benefits and side-effects, to improve their understanding about of various medication options, and assist in their decision making. In addition, we are currently collaborating with researchers at University of Melbourne to develop and test a clinical support tool which will support shared-decision making in primary care settings.

ACBRD team

Dr Holmes-Truscott is funded by a Deakin University Faculty of Health Dean’s Research Postdoctoral Fellowship (2018-2020).

We acknowledge the funding we have received from the NDSS: a) to conduct the Diabetes MILES – Australia 2011 survey;  b) develop the NDSS Diabetes and Emotional Health handbook, toolkit and factsheets; and c) for the NDSS Type 2 Diabetes: Starting Insulin National Priority Area, for which Professor Jane Speight is the Leader and Dr Holmes-Truscott is the Coordinator. The NDSS is an initiative of the Australian government administered by Diabetes Australia.

We also acknowledge our collaborators across this research program, in particular:

  • A/Prof John Furler (University of Melbourne), led the NHMRC Stepping Up trial, and currently leads the RACGP/Diabetes Australia Clinical Support Tool Development project
  • Professor Frans Pouwer (University of Southern Denmark)
  • Prof Timothy Skinner (University of Copenhagen)
ACBRD Publications
  1. Holmes-Truscott E, Furler J, Blackberry I, O’Neal DN, Speight J. Predictors of insulin uptake among adults with type 2 diabetes in the Stepping Up study. Diabetes Research and Clinical Practice. 2017; 133: 204-210
  2. Holmes-Truscott E, Skinner TC, Pouwer F, Speight J. Explaining psychological insulin resistance in adults with non-insulin-treated type 2 diabetes: The roles of diabetes distress and current medication concerns. Results from Diabetes MILES—Australia. Primary Care Diabetes. 2015; 10(1): 75-82
  3. Holmes-Truscott E, Skinner TC, Pouwer F, Speight J. Negative appraisals of insulin therapy are common among adults with Type 2 diabetes using insulin: Results from Diabetes MILES–Australia cross-sectional survey. Diabetic Medicine, 2015; 32(10): 1297- 1303
Further reading

Click on the hyperlinks above for the key ACBRD publications

Key papers by other researchers in this field include:

Ng CJ, Lai PS, Lee YK, Azmi SA, Teo CH. Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review. International Journal of Clinical Practice. 2015; 69(10): 1050-70

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. Current Medical Research and Opinion. 2011; 27(6): 1169-74

Russell‐Jones D, Pouwer F, Khunti K. The identification of barriers to insulin therapy and approaches for overcoming them. Diabetes, Obesity and Metabolism. 2018; 20(3): 488-496