Prevention and early intervention — district design MEQ

(i) Gordon levels. Universal: whole population without risk selection (e.g. curriculum-based school skills programmes; alcohol policy).[1][4] Selective: elevated-risk groups not yet the target disorder (e.g. intensive support for high-risk first-time parents; targeted perinatal pathways).[1] Indicated: subthreshold symptoms or high-risk mental states (e.g. brief psychological programmes for subthreshold depression; UHR monitoring and CBT-informed care).[1][3][5]

(ii) Rose and the planning dispute. Population strategies shift risk for everyone; high-risk clinics treat the tail. The prevention paradox is that many future cases arise from average-risk people, so beds-only or clinic-only plans miss population impact. A single wellbeing day is a weak universal gesture with likely small or transient effect if fidelity and continuity are absent — not a substitute for multi-level design.[2][4][9]

(iii) Indicated pathways. Subthreshold depression: brief CBT/IPT-informed prevention can reduce incidence (meta-analytic relative reductions in the order of ~20% in classic synthesis); step up if full MDD emerges.[3] UHR: structured assessment; treat anxiety/depression, sleep, substance use; CBT-informed care; monitor conversion; do not default to long-term antipsychotics given minority conversion and uncertain superiority of any single preventive package.[5][6] Escalate immediately if frank psychosis or imminent risk.

(iv) EIS and DUP. Multi-element package: assertive case management, low-dose antipsychotic strategy with physical monitoring when indicated, family work, psychological therapy access, substance intervention, vocational/educational support. EIS outperforms TAU in meta-analysis.[8] Longer DUP associates with worse early outcomes — reduce delays via public/GP education and low-threshold entry; 12-month median DUP is a quality gap, not an inevitability.[7]

(v) Implementation risks. Examples: (1) manuals without workforce/fidelity funding; (2) equity failure (advantaged schools capture programmes); (3) overmedicalising UHR; (4) measuring only beds filled not coverage/function. Public mental health often fails at implementation rather than total absence of evidence.[9][6]