Introduction

In 2024–25, Australians consulted GPs 167.2 million times4, underscoring both the GP’s role as the first, and often only, point of mental health support, and the critical role GPs have in addressing Australia’s growing mental health needs. By providing whole-person

care that includes detection, treatment, review and coordination, GPs can reduce the risk of people ‘falling through the cracks’.

In addition, GPs are uniquely placed to provide continuity, coordinate multidisciplinary support and champion equity. This is particularly important for groups experiencing additional barriers, including people in rural and remote communities, culturally

and linguistically diverse populations and Aboriginal and Torres Strait Islander peoples, who hold unique strengths, cultural knowledge and community-based support systems but have faced adversity through colonisation and intergenerational trauma. 

The need to update the original Stepped Care Guide

Since the original Stepped Care Guide was published, substantial progress has been made in a number of areas, including telehealth, consumer and carer engagement and the use of targeted approaches for specific populations.

This updated guide has incorporated relevant changes to language, roles and care models, and also includes improved information and advice about how to:

• empower consumers and carers
• meet the needs of priority populations
• deliver care in rural and remote contexts
• use telehealth effectively
• measure outcomes.

It also clarifies the respective roles of GPs and PHNs and the use of the Initial Assessment and Referral Decision Support Tool (IAR-DST) and MHTPs to support the use of stepped care.

Starting point: A consumer does not need to begin at the lowest level of intervention: instead, they need to be directly matched to the most appropriate level of care based on clinical presentation, risk, preference and functional impact5. Tools like the IAR can help you do this.

Non-linear/flexible movement: As stepped care aims to match the least intensive, most effective intervention to a consumer’s current need, it might include non-linear steps (eg sideways, as well as up and down) as the consumer’s circumstances change.

Continuity of care: Ideally, a consumer will predominantly use one GP (or one GP clinic), which will help to ensure continuity of care, including while they are receiving treatment from other health providers. As such, stepped care also means creating a meaningful, trusting relationship with your consumer so they feel comfortable to keep returning.

Variations: Because each PHN serves diverse populations and local contexts, including Aboriginal and Torres Strait Islander communities with distinct cultural strengths and locally led health structures such as ACCHOs, what they offer will vary across regions, based on community needs, service gaps and workforce availability.

Network of care: A consumer achieves the best outcomes when they have a network of care6: people such as their GP, support person or carer, family and so on, who are equally engaged alongside them in working towards their recovery. This means identifying the consumer’s minimum sufficient network – the set of people, supports, services and interventions required to safely and effectively meet their needs at their current level of complexity and risk. However, if the consumer does not have a carer or support person, the GP is the support person.

The Stepped Care Model aims to:

• broaden the range of accessible, evidence-based care, while promoting affordability and equity
• offer a range of support options from low to high intensity, that can be matched to each consumer’s current needs
• provide clear pathways between options as a consumer’s needs change, thereby integrating services provided by GPs, allied health professionals, specialists, community organisations and digital supports
• improve collaboration and integration across local services, and improve connections to non-PHN options where appropriate
• uphold self-management principles (eg digital programs, brief GP interventions, community resources)
• achieve a sustainable system

Care provided under the Stepped Care Model can include:

• use of digital mental health tools and self-directed programs
• low-intensity or guided interventions initiated by a GP
• community-based psychosocial supports
• structured therapies of moderate intensity
• high-intensity clinical care that is coordinated and involves multiple professionals.

The following table shows the assessment outcomes, possible interventions and referrals for each level (step) of care.

Figure 2. Stepped care matrix, developed by the GPMHSC Stepped Care Working Group 2025

The following examples show how the Stepped Care Model can be implemented for different levels of care. Note that these in no way provide a full picture of services that consumers can be offered.

Low intensity

• A consumer presents to their GP with mild symptoms. The consumer works full time, so is keen to explore online options. The GP creates an MHTP and uses eMHprac (or a similar resource) to provide the consumer with e-therapy information. The GP arranges follow-up with the consumer in four weeks’ time.
• After six face-to-face counselling sessions with a mental health professional, a consumer’s symptoms have improved considerably. They do not want to have any further sessions but, based on past history, they are at risk of relapse. The GP discusses online e-therapy options or refers them to PHN-commissioned low-acuity telephone-based care. 

Moderate intensity

• A consumer has moderate symptoms and is keen to consider face-to-face psychological treatment. The GP creates an MHTP and refers the consumer to a private psychologist or a PHN-commissioned face-to-face psychological service for no-fee access.
• A consumer from a vulnerable demographic group describes moderate symptoms but has not previously engaged well with face-to-face psychological care. The GP creates an MHTP and refers the consumer to a PHN-commissioned stepped care service for an initial assessment to determine appropriate treatment and eligibility criteria. Appropriate treatment may include support from a range of service providers such as credentialled mental health clinicians, care coordinators and peer workers.
• A consumer describes moderate symptoms and requires disability support to aid in their recovery. The GP accesses disability and social support available through PHN-commissioned services, or if not available in that area/state, social workers, occupational therapists (OTs) and psychologists.

High intensity

• A consumer presents with severe and persistent mental health symptoms, significant functional impairment and escalating risk, requiring intensive and multidisciplinary support. The GP undertakes immediate risk assessment and management, creates (or reviews) an MHTP and refers the consumer to high-intensity services such as specialist mental health services, acute care teams, or PHN-commissioned high-intensity psychological therapies. Care may involve psychiatrists, clinical psychologists, mental health nurses, social workers and other allied health professionals, with active care coordination and regular GP follow-up to support continuity of care and safe transitions between services.