Research projects

Pathways of care for socially-marginalised people with depression and related disorders

Principal Researchers

Professor Joe Graffam, Professor Marita McCabe and Dr David Edwards1

Collaborators: Ms Elizabeth Crowther and Mr Mark Lamont2


1School of Psychology, Deakin University

2 Mental Illness Fellowship



Award Type

Beyond Blue Victorian Centre of Excellence.

Project completion year



Research indicates that socially-marginalised people have impaired access to health and community services and worse mental health compared with socially well-integrated people1. The National Mental Health Plan2,3 has acknowledged that less than half of people in need of mental health services access them.

This study aimed to:

  • identify mental health care needs of socially-marginalised people in two community settings and barriers to care that exist for them
  • identify the manner in which local primary care providers operate and examine ways partnerships and operations may be enhanced to improve pathways of care
  • examine existing clinical and community educational materials on depression to enhance their applicability and availability to socially-marginalised people and care providers.

Semi-structured interviews were conducted with a range of service providers (n=32) and with socially marginalised people (n=27). Existing materials from mental health services, community psychosocial rehabilitation support services, Divisions of General Practice and government sources were also evaluated.

The study was conducted at two locations; the outer eastern metropolitan region of Melbourne and the Bass Coast region of Gippsland. Although the sample was small, a diverse range of socially-marginalised people was included in the study.

Key findings

Most socially-marginalised participants reported an array of personal, social and material conditions which

inhibited their access to care. Other findings included:

  • a majority had chronically poor physical health and attendant disability
  • more than one-third reported also being a carer
  • almost all reported unemployment and low income
  • in the rural region, most reported lack of access to public transport as a major impediment to accessing care
  •  both participant groups considered cost to be a major barrier to accessing care. Restrictions on both bulk-billing and Pharmaceutical Benefit System (PBS) subsidies were identified as cost issues
  •  counselling was considered financially prohibitive for people living on social security benefits
  • lack of knowledge and lack of information about depression and related disorders was widely reported. Over 25 per cent of socially-marginalised participants reported not knowing where to get information, and 59 per cent of service providers considered lack of information a barrier to care.

Several issues were identified related to the knowledge and practice of general practitioners (GPs) and other primary care providers. Interest in mental illness and mental health literacy among GPs was reported to vary markedly. Issues raised were:

  • lack of understanding of the complexity of conditions
  •  lack of empathy
  •  inadequate treatment regimes.

Several interviewees asserted that primary care providers treating patients for a single health issue often do not explore the possibility of a co-morbid depressive disorder and issues associated with such a condition.

Shared care and cross-referral practices appeared to be inconsistent in both locations. To confound this, the bio-psychosocial model of care did not appear well understood by interviewees generally, and service providers did not appear to have sound knowledge of services available in their region nor of appropriate pathways of care for socially-marginalised people.

Our review of existing clinical and community educational materials indicated that no existing materials addressed the needs of socially-marginalised people as a primary focus. Further:

  • most educational materials have not been tailored to meet the unique needs of specific community groups
  •  most materials were not considered easily adaptable
  •  the majority of materials are Anglo-Celtic orientated with extremely limited culturally-sensitive materials developed to reach Australia’s multicultural community
  • much of the material uses professional terminology and requires advanced English literacy for comprehension, rather than simple language that most members of the community would be likely to understand.

Implications for policy and practice

Development of treatment models relevant to socially-marginalised people is needed. This includes:

  • the expansion and enhancement of local partnerships to foster easier access to care and improved shared care
  • development, evaluation and refinement of an ‘outreach and integration’ intervention/treatment model should be trialled, supported by wider system mechanisms for improving access to care for socially-marginalised people
  • more attention to community-education materials to redress low levels of mental health literacy among socially-marginalised people, health professionals, local government and social welfare agency staff
  • adaptation, development and delivery of more user-friendly public education and training materials should be undertaken by government and service organisations.

Future directions

Further research is needed to identify the level of untreated depression and related disorders among socially-marginalised people together with thorough documentation of their health care system involvement and total support needs.

About the researchers

Professor Joe Graffam is interested in issues of community integration for people with mental illness and other disabling conditions. Professor Marita McCabe has a long and prolific record of research into several aspects of depression and related disorders. Dr David Edwards has had a career in both mental health service delivery and research. Together they bring an interest and passion to addressing questions of depression and co-morbidity among socially-marginalised people.


Australian Health Ministers. (1992). National Mental Health Plan. Canberra: Australian Government Printing Service.

Australian Health Ministers. (1998). Second National Mental Health Plan: 1998-2003. Canberra: Australian Government

1 Shaw, M., Dorling, D., & Davey Smith, G. (1999). Poverty, social exclusion and minorities. In M. Marmot & R. G. Wilkinson (Eds.), Social Determinants of Health (pp. 211-239). Oxford: Oxford University Press.

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