Avoiding erroneous decisions: evidence, population impact and acceptability of universal mental health interventions in schools - a commentary on Andrews et al.

Foulkes and colleagues argue many 'universal' interventions to prevent mental health problems are harmful ('inflating prevalence' because they raise awareness of mental health problems, encouraging those without such problems to misinterpret everyday concerns as symptoms of mental health disorders, causing avoidance of stressful situations, worsening mental health), relatively ineffective (effect sizes being smaller than for targeted interventions) and/or unacceptable to students, and should be discontinued. These arguments are based on weak evidence. While their 'prevalence inflation' hypothesis is potentially important and plausible when applied to awareness-raising interventions, evidence for it is currently weak and there is a tendency to overgeneralise to broader interventions. Arguments about the relative impacts of universal and targeted interventions fail to distinguish between individual and population impacts. Arguments about unacceptability are based on selected findings from a few studies, not reflecting broader evidence. These arguments could lead to erroneous decisions to discontinue universal mental health interventions in schools when they are most needed.