Background
This themed issue of Irish Journal of Psychological Medicine focuses predominantly on students in the Higher Education (HE) sector, and also includes several papers which pertain to schools (Columb et al., Reference Columb, Keegan, Griffiths and O’Gara2021; Kenneally et al Reference Kenneally, Begley and Donohue2023). There have been growing concerns about the rise in mental health problems and self-harm among students in HE in the UK and worldwide (Lipson et al., Reference Lipson, Lattie and Eisenberg2019; Thorley Reference Thorley2017: Hill et al., Reference Hill, Farrelly, Clarke and Cannon2020; McManus and Gunnell Reference McManus and Gunnell2020; Senedd, 2023). This is unsurprising given the global burden of disease data which identifies the peak and median age of onset across all mental disorders are in late adolescence and teenage years (Solmi et al., Reference Solmi, Radua, Olivola, Croce, Soardo, Salazar de Pablo, Il Shin, Kirkbride, Jones, Kim, Kim, Carvalho, Seeman, Correll and Fusar-Poli2021). Hence the age at which most young people attend university is the highest risk life stage for the development of mental health problems across the lifespan (Solmi et al., Reference Solmi, Radua, Olivola, Croce, Soardo, Salazar de Pablo, Il Shin, Kirkbride, Jones, Kim, Kim, Carvalho, Seeman, Correll and Fusar-Poli2021). The increase in mental health problems in young people may have been exacerbated following the COVID pandemic which appears to have disproportionately negatively impacted the current cohort of young people, mentally, behaviourally, educationally and socially (Hawley et al., 2020; Clarke et al., Reference Clarke, Mullin, McGrath and Farrelly2021; Savage et al., Reference Savage, Hennis, Magistro, Donaldson, Healy and James2021).
Why is student mental health important?
So why is student mental health and wellbeing so important? Critically, aside from the considerable personal distress that accompanies adverse changes in mental health and wellbeing, there is also a severe knock-on impact on student experience and quality of life when mental health is impacted. Furthermore, mental health problems can detrimentally impact on short- and longer-term educational outcomes including academic performance, student retention, studies completion, labour market success, employment prospects, career success and there is economic impact for individuals and society when these are detrimentally affected, particularly for healthcare students (Kotera et al., Reference Kotera, Jackson, Kirkman, Edwards, Colman, Underhill, Jackson, Baker and Ozaki2023).
The definitions around student mental health can vary from a temporary transient disruption to wellbeing and distress to recognised symptoms of a defined mental health problem or where an individual has received a formal clinical diagnosis to serious self-harm and suicidal ideation. Notably, there have been concerns about over professionalising and medicalising student difficulties which may have arisen in response to problems around transition adjustment, financial concerns and debt, social disconnection, and loneliness (Wessely Reference Wessely2023) or unrealistic personal performance expectations (O’Connor and O’Connor, Reference O’Connor and O’Connor2003). The mental health needs and concerns of students are broad. They can vary from stress related to the lack of accommodation, lack of time to access mental health appointments, a diagnosed mental health disorder requiring clinical intervention and ongoing support, and, for a small number of individuals, an immediate emergency response to a suicidal crisis. It is important to balance this somewhat pessimistic picture with the fact that most students can thrive without support and do well. However, it needs to be acknowledged that some groups and certain demographics do not.
Prevalence of student mental difficulties
Student mental health prevalence rates can vary considerably depending on the data source used which can range from self-report survey data, clinical diagnosis data, counselling service referrals data, to whole population-based data records. HE student counselling databases will certainly underestimate prevalence but can provide a better estimate of help seeking students and what they present with (Howard et al., Reference Howard, Tayer Farahani, Rashleigh and Dooley2021). Estimates will also vary depending on the sampling method utilised and the scale of the research / data source. The scale can range from small-scale research project data to large-scale population-based data (McManus and Gunnell Reference McManus and Gunnell2020; John et al., Reference John, Rouquette, Chim Lee, Smith and del Pozo Banos2024) which affects data reliability and generalisability of study findings. Ideally, we need more population-based studies to be confident about overall actual prevalence rates. International research evidence suggests 1 in 5 students worldwide will experience mental health difficulties in the course of their learning journey (Auerbach et al Reference Auerbach, Alonso, Axinn, Cuijpers, Ebert and Green2016). In Ireland, based on the large-scale My World Survey 2 data, sampling has shown an increase in mental health problems in young people (Dooley et al., Reference Dooley, O’Connor, Fitzgerald and O’Reilly2019), and the mental health problems of 3rd level students is reported to be relatively higher in undergraduate students attending Institutes of Technology than University students (Mahon et al., Reference Mahon, Fitzgerald, O’Reilly and Dooley2022).
Overall, evidence suggests that rates of mental illness among students are increasing over time with a marked increase in numbers and help seeking exacerbated by COVID-19 (Aucejo et al., Reference Aucejo, French, Ugalde Araya and Zafar2020). There has been speculation about the reasons for this which could relate to increased mental health awareness and disclosure (UCAS 2021), increased service usage or media reporting bias (Marzano et al Reference Marzano, Hawley, Fraser, Lainez, Marsh and Hawton2023). Some more recent research suggests that while there are common problems for all young people, there are differences in both type of problems experienced and rates that are unique to higher and further education students compared to age matched peers in the general population (McManus and Gunnell Reference McManus and Gunnell2020; John et al., Reference John, Rouquette, Chim Lee, Smith and del Pozo Banos2024).
Risk factors for student mental illness
Research evidence exploring risk factors (Dooley et al., Reference Dooley, O’Connor, Fitzgerald and O’Reilly2019, Thorley Reference Thorley2017, Mahon et al., Reference Mahon, Fitzgerald, O’Reilly and Dooley2022; John et al., Reference John, Rouquette, Chim Lee, Smith and del Pozo Banos2024) have identified several factors as being linked to higher chances of mental health problems and suicidal behaviour as a student including: being female, deprivation, transition, mental health problems prior to entry, exams and assignments, financial concerns, study with additional employment, social isolation/relationships, social media use, drugs and alcohol use and gambling. Moving away from established family and peer support networks is also a contributor and reduces the ability to ameliorate these other factors. Mental health problems are not evenly distributed across the student population. Mental health is influenced by a variety of personal, social, economic, and physical factors and certain groups may be disproportionately affected and at higher risk for mental health problems. This includes international students, LGBTQ+, ethnic minorities, mature students, disadvantaged students, and individuals with previous trauma, self-harm and mental health difficulties.
Papers in this themed issue explore some of these factors, including motivation to reduce or cease substance misuse (Dockray et al Reference Dockray, Whelan, Dick, Davoren, Heavin, Linehan and Byrne2022), and the frequency of internet gaming and gambling addiction and effects on mental health in secondary school pupils in Ireland (Columb et al., Reference Columb, Keegan, Griffiths and O’Gara2021). In another paper in this issue, a cross-sectional analysis of psychological distress among higher education students (pre Covid) identified higher levels of mental health difficulties in females, transgender, LGBTQ+, undergraduates, students from more deprived backgrounds or those experiencing more financial difficulties (Cullinan et al., Reference Cullinan, Walsh, Flannery and Kennelly2022). Another paper identifies other vulnerable student groups with COVID-19 related stress and found higher risk among females, students with chronic illness and students experiencing monetary concerns (Bhargav and Swords Reference Bhargav and Swords2022). A further interesting study in this issue explores the issue of mental health among medical students who are at risk of experiencing a loss of wellbeing and burnout (Bhugra and Molodynski Reference Bhugra and Molodynski2022). Placement students have also been identified as a vulnerable group requiring more proactive monitoring and support (Universities UK, 2022). There is much less published on the protective factors for students’ mental health. Negative reporting bias may be contributing to this dearth.
Mental health interventions for students
The big research gap in this field is the lack of population-based studies and evidence for effective interventions. In this issue, Hunt and Coombes (Reference Hunt and Coombes2021) describe a very small-scale novel time and wellbeing pilot intervention with first year undergraduates (n = 8) but there is a general dearth of large-scale evaluations of interventions that have been introduced in response to increased prevalence and to address the problems identified. This is not helped by wide variability in collection of outcome measures (clinical and academic) relating to interventions by education providers. Several papers in this issue identify interconnected themes to improve ‘whole system’ support (Hill et al., Reference Hill, Farrelly, Clarke and Cannon2020; Surdey et al., Reference Surdey, Byrne and Fox2022). A key message is the requirement for staff training and support involving a ‘whole university approach’ where the mental health and wellbeing of students is the business of everybody in the institution, not just student support/experience services (Hill et al Reference Hill, Farrelly, Clarke and Cannon2020; Wessely Reference Wessely2023). What does this mean in practice? There is a need to review academic policies, procedures and processes and wider decision making (e.g. building design) ‘through the eyes of students’ to reduce stress and improve student wellbeing and mental health. It means considering the potential role and contribution of all staff groups, not just front-facing academic staff. It includes the key role that student peers can play in supporting fellow students. Critically, we need to involve students themselves in meaningful consultation and involvement. Furthermore, involving students in the review and change/modification of processes and procedures that contribute to student stress is important, while still ensuring academic rigour and integrity is preserved. Hill and colleagues (Hill et al., Reference Hill, Farrelly, Clarke and Cannon2020) provide a helpful overview of developing student mental health services in this issue identifying future directions to improve student mental health and wellbeing. This will require broader systems and organisational change developed in conjunction with effective interventions at an individual level.
Systems level changes
At a systems level, in the last six years, we have seen several national mental health and suicide prevention frameworks published, including one in Ireland (Higher Education Authority 2020; Surdey et al., Reference Surdey, Byrne and Fox2022). We have also seen the establishment of research and practice networks (eg. SMARTEN, https://www.smarten.org.uk/), as well as mental health Charters with charter award programmes to support institutions seeking to demonstrate achievement of charter standards (Student Minds University Mental Health Charter Award Programme 2019; Ireland HSE Healthy Campus Charter 2020) and a range of HE specific guidance (e.g. on use of emergency contact information, support of placement students and suicide postvention). However, the drive for implementation can be lacking, and until recently, in the UK, uptake has been variable. These Charters can be published with no absolute requirement for third level institutions to engage with them or implement them, as well as little obvious consequence for failing to do so, despite strong ministerial level encouragement to do so. The applicability of a single approach across HE institutions of very different sizes, structures and focus has been cited as a reason by some institutions for not working towards these charters. More recently, in the UK, adverse media reporting coupled with Coroner’s inquest findings have led to some individual institutions reviewing processes and implementing changes in response. In June 2023, following a parliamentary petition, the UK government established a Higher Education Mental Health Implementation Taskforce led by a HE student support champion (Prof. Edward Peck, Nottingham Trent University) to review and recommend changes in four key areas relating to student mental health and wellbeing, as well as suicide prevention. Existing regulators (e.g. the Office for Students) have not yet sought to use their powers to direct action in this space. These are all potential developments to shift a HE sector system into action. In the current climate, this will require concerted sustained action and prioritisation from institutional leaders and from a policy and funding perspective, supported by consistent messaging and ‘buy in’ from relevant professional and regulatory bodies to successfully achieve tangible system change on a sufficient scale to realistically have an impact on student mental health and suicide prevention. This presents a challenge given other funding priorities and competing concerns for the HE system currently. It also requires cross departmental policy and innovation to facilitate and support education institutions to work with health partners to develop cross-sector, integrated seamless pathways, and formalised relationships with local health services. There are some emerging promising case examples of such improved partnership working, such as in Greater Manchester where a dedicated NHS provided, but co-funded, student mental health service has been running for 5 years. It allows students from any of five HEIs (a student population of nearly 120K) to be referred from the HEI’s own mental health team directly into the service to support students with acute mental health problems more effectively and reduce knock-on demands on emergency healthcare systems.
Organisational level changes
At an organisational level, a ‘whole institution approach is required (UUK and PAPYRUS 2018) with integrated support systems and clear pathways for supporting mental health needs. However, this needs to be considered and solutions found which also address the interconnected factors contributing to poor student mental health and stress. These factors include housing, finance, loneliness, academic deadlines, assignment and exam processes, addictions, as well as the way in which institutional policies and procedures are enacted. The mental health and wellbeing of students should be the ‘letters in a stick of rock’ and a lens through which an institution’s policies, procedures and processes are reviewed. Internal processes and procedures (for example, mitigating circumstances requests, academic misconduct, fitness to study, disciplinary processes, as well as communications with students) all need to be reviewed to ensure sufficient consideration is given to students’ mental health and wellbeing and how processes can be enacted with humanity and compassion while also ensuring students are adequately supported throughout. The culture of universities needs to centre around the needs and wellbeing of students to enable them to flourish and achieve their academic potential. This requires proactive intervention and support, from first contact and particularly, when transitioning from secondary education, for vulnerable high-risk groups and at times in the academic year when students may be particularly vulnerable to stress and poor mental wellbeing (e.g. during exam periods). There needs to be sufficient and sustained investment in a range of online and face to face student support provisions with clear signposting to enable students to be able to access these at their point of need and determine which may be most appropriate. Staff require training in how best to support students within the limits and constraints of their roles and to know what support is available to students and how to access this. Student mental health and wellbeing needs to be in the job descriptions of all staff not just those staff directly involved in student support. A broad range of staff including academic, administrative, security and catering staff need to be helped to communicate concerns about individual students through accessible triage and daily report systems to trigger a follow up contact or ‘safe and well check’. The design of campus buildings, accommodation and outside spaces also needs to have student wellbeing needs as a primary consideration. Student Unions, similarly, have a role to play in encouraging clubs and societies to appoint welfare leads and consider what actions clubs and societies can take to support and promote student mental health and wellbeing and to address associated risk factors.
Individual level changes
At an individual level, we need to consider students support at key times in the learning journey from the initial transition into higher education and through the various transitions at university. These include placement support, and graduate preparation for leaving higher education and entering employment. Although UCAS applications show mental health declarations are increasing, there remain a significant number of applicants who choose not to share information about their mental health with their university (UCAS 2021). More applicants need to be encouraged to share knowledge of pre-existing mental health conditions and support needs. We need to build mental health and wellbeing literacy through embedding mental health modules within the academic curriculum of all students, not just those students on health or social care professional training courses. We need to address the known risk factors contributing to mental health difficulties and reduced wellbeing, particularly, to build social connectedness and alcohol and drug use. We need to routinely offer wellbeing interventions and encourage healthy study habits, healthy eating and exercise, and highlight the importance of routine, structure and good sleep management. We need to cultivate a culture of caring and the potential of peer support and the importance of looking out for colleagues such as flatmates and fellow learners (e.g. Student Minds ‘Look after your mate’ training). We also need to consider the role social media can play both in supporting individuals and signposting them to available support (eg Safezone) but also seek to establish systems which help to protect individuals using tools like RiPPLE (https://www.ripplesuicideprevention.com/), and through education around ‘Chat safe’ guidelines and compliance with the requirements of the new online safety bill.
Conclusion
Key to achieving the culture shift that is required is an intentional commitment to move away from rhetoric and short-term, small-scale initiatives by committed individuals to large-scale prioritisation, investment and action. This requires leadership, cross departmental working and investment at a national and organisational level setting out expectations, realistic resourcing and cultivating a culture in which students can thrive rather than survive to enable them to achieve their academic potential and enjoy their learning experience. Critically, this cannot be achieved by institutions working in isolation. We need to learn from each other sharing international examples of effective practice through practice collaboratives and research networks. We need to learn from serious incident review findings. We need to review and modify practice and procedures based on review recommendations. Most importantly, we need to learn from students themselves, involving them and co-creating with them to help shape a student-centred experience in which they can flourish.
Acknowledgements
The author would like to thank Dr Simon Merrywest, Director for the Student Experience, University of Manchester, for his insightful comments and suggestions in response to an earlier draft of this paper and the Editor and reviewers for their helpful feedback and careful reading of the final manuscript.
Financial support
This editorial research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
None.
Ethical standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
