What next for student mental health?

Abstract

When I became President of the UK Royal College of Psychiatrists, I rashly promised to visit every UK medical school to talk with students about mental health. In this article, I share my impressions after concluding this ‘grand tour’ and ponder the dangers of creating the false impression that universities are ‘toxic’ for mental health.

There has never been a time when matters of health and well-being have had such prominence both within and without our universities or indeed schools. It is obvious to all that metrics such as the number of students seeking help, declaring to the university that they have mental health problems or answering affirmatively to similar questions in surveys, are all on the rise and show no sign of slowing down, let alone declining.

It is a moot point if students actually have higher rates of mental disorders than appropriate comparison groups, and the same goes for deliberate self-harm (McManus & Gunnell, 2020). Such questions are best answered by true random population studies, such as the Adult Psychiatric Morbidity Study quoted above, and these are costly enterprises. Working out who is a student is also harder than you might imagine unless you have done such a study – unlike for example farmers, policeman, members of the Armed Forces and so on. Although the enormous expansion in student numbers since ‘my day’ (rather a long time ago) means that proportionately more young people with known mental health disorders are now able to go to university (which is a good, not bad, thing), it is still the case that going to university is not random, and that those at higher risk of poor mental health are less likely to be in full time education. It is for that reason that it was not unexpected that the first national data on student suicide showed a lower, not higher, rate than the corresponding population [see (McLaughlin & Gunnell, 2022)]. And whilst population rates of mental disorders have remained remarkably stable for decades, the only exception to this is in young women between 16 and 24 [APMS] – so whether or not students are at higher or lower risk, the absolute numbers of those at university with mental health disorders are certain to be increasing.

What is indisputable is that more and more students recognise themselves to have mental health problems and are prepared to come forward and ask for help. This has created a crisis in universities. And because there is no consensus what lies behind these changes, other than a near universal cri-de-coeur about social media, there is no consensus on what should be the appropriate response.

Going to university is a time of transition, and like all times of transition, it is accompanied by challenges, strains, upset, turmoil and occasionally frank mental disorder. When I was elected President of the Royal College of Psychiatrists, I made a promise to visit every university with a medical school to talk about mental ill health and psychiatry. I had not realised that there were now 35 such schools, or perhaps I would not have made that commitment, but I fulfilled it. Usually, the venues were packed, and on occasion we needed an overflow room. I say usually, because things did not always go according to plan – a clash with the last surgical revision lecture had a dramatic effect on the audience in one London medical school, and in another the standard offering of pizza for all those attending, including the speaker (some things haven’t changed since “my day”), went wrong because the order was transmitted in the singular, not plural and one pizza was dutifully produced together with one can of coca-cola.

But whilst the unshakable bond between students and pizza has not changed, others have. Most of the student unions I visited had conducted some form of mental health survey, which invariably reported high rates of mental health problems, usually in the 70 to 80% range, well above the 15-20% reported by formal studies using standardised interviews. The stories were varied, but many told stories of loneliness, anomie, homesickness, difficulties establishing relationships, academic pressure, exam anxiety and financial worries especially around debt and so on. These are not normally constructed as ‘mental disorders’, which probably explains the differences in prevalences between epidemiological rigorous studies and others organised more locally. Others talked about the struggle to get help with what professionals such as myself would consider mental disorders, such as eating disorder, obsessive compulsive disorder, or developmental disorders such as autism. Waiting lists for support within the university were sometimes long, especially if help was needed from secondary mental health services within the NHS. And all of this was before COVID, which made all of these issues worse.

I was left in no doubt that if any progress was to made, it was going to have to come from within the university. Also, the scale of the problem means that this will predominantly come from those who are not mental health professionals – in other words the staff and students themselves. Expecting the NHS to come to the rescue for anything other than the most serious of disorders is not going to happen. And even for those at the severe end of the spectrum, with the occasional exception, most universities still do not have enough of the skilled professionals that are required. As for the vast majority, I would go further and say not only will the NHS not come to rescue, it probably shouldn’t for many of the stories that I heard. Starting with our early work on the negative impact of single session psychological debriefing and continuing with our work developing peer led systems of psychological support for the UK Armed Forces, I have spent part of my career highlighting the dangers of over professionalising and medicalising problems. Antidepressants are no cure for loneliness, and counselling will not help student debt.

After a few visits to medical schools, I found the confidence to ask the students how many were experiencing mental health problems, a question that would have been unthinkable in ‘my day’, and a further sign of the changing times. Two-thirds invariably responded, often more. This would precipitate a discussion of what they felt were the issues, which I have already listed. But after a while it was time to change the subject away from mental health, and towards the end I would ask for a show of hands on how many, for example, felt they were making friends who would be life long. Again, at least two-thirds would agree. Likewise I asked how many were being intellectually stimulated by their courses for at least some of the time. The same and then I would ask how many were having more interesting sex lives than when at home. This time I did not ask for a show of hands, but judging by the smiles it was also a majority.

Those responses would then lead to a final reflection on the theme of our time at university being a time of change and challenge. My crude straw polls did make the point that it is possible and indeed probable that most people will experience both the highs and the lows of university life – for very few, the experience would be uniformly negative or positive. I would for the first time then share my own experience (I learned early on the folly of ever kicking off with anything that sounded like ‘back in my day’). I had moved from a Northern State school to an Oxbridge college, encountering for the first time in my life public school boys (and it was boys, this was the era when only two colleges were not single sex). My first term was not happy. I felt excluded, gauche and lonely. Half way through I had returned home, miserable and wondering if I should carry on. After a week, my parents gently persuaded me to return. Things picked up as I realised that I had the same right to be there as everyone else, and socially gauche I might have been, but academically inferior I was not. Music and a minor talent at comedy writing created social networks, some of which still survive. So after a stuttering start I had settled down and started to enjoy myself. Love would take a little longer – when I publish my memoirs of my undergraduate days it will be called “Sex, drugs and rock and roll – where were you?”.

And the point is what? Not to bemoan the lack of informal support from my peers on arrival, although that was true and would have made a difference. Nor the fact that my college did not register what was going on – also true, but I am still unsure if that would have helped much. My unhappiness was related to feeling out of place and some loneliness, but time and growing self-confidence seemed to do the trick.

But I used my own experience to tell my modern audiences that that university is a time that changes nearly all fortunate enough to experience it. The experience is complex, but in the end we know that the benefits usually outweigh the problems. Perhaps the worse thing we can do is create the impression that a university is a ‘toxic environment’ for health and well-being, which runs the danger of becoming self-fulfilling. And the second worse thing is to pretend the opposite – that it will be a nirvana whether everyone will smile, achieve their full potential and thrive all of the time. Because it will not be that either.

So what should be the way forward? There is no real consensus at the moment, and there are disagreements – nothing wrong in that, because the state of the evidence, especially around interventions, does not at the moment support such certainties. For example, my own experiences and more formal research suggest that increasing awareness may be less of a priority than it once was – surveys suggest that the current student generation are far more aware of mental health issues than any previous generation, and that stigma is not the principal barrier to help seeking, much as we have shown in for example military populations (Sharp et al. 2015). Believing that ‘I should be able to sort this out for myself’ ranks higher, as does a lack of confidence, sometimes misplaced, sometimes less misplaced, in our interventions and services to sort things out.

My student audiences always were convinced that the first issue that needed addressing was the shortage of counselling services, and probably every university has responded to this. But there is little sign that demand has now levelled off and every indication of the opposite. And the gradual realisation that whilst counselling definitely has a major part to play, especially if it can be provided speedily, and also respond to the increasingly diverse student population, we cannot on its own counsel our way out of this problem.

What is now being talked about, and increasingly adopted, is more of a public mental health approach, looking at populations rather than individuals, or as it is called in the Higher Education sector, the ‘whole university approach’.

This approach I would summarise as putting mental health and well-being at the heart of what a university does – but without needing to make that explicit. Creating an atmosphere in which social networks flourish will do more to counter loneliness and isolation than provide therapy. Likewise encouraging cultural diversity. Teaching good learning and examination techniques and skills does not require mental health training. And let us not even get into issues such as the built environment, accommodation and so on.

There is now an increasingly persuasive literature including, I am delighted to say, numerous randomised controlled trials, on the effectiveness of interventions such as music, theatre, arts, sport, volunteering, and much else besides, in which the only shared characteristic is that these involve widening social networks, and do not have a mental health professional in sight.

And then we have the workforce who really deliver not just the teaching, but the culture and ethos of the university. Most of those in the Armed Forces never meet a General or Admiral, just like in any office few people meet the chief executive or Board. Instead they interact with the junior officers, NCOs, middle and line managers and so on. It is just the same in a university. Few students know or even need to know the name of their Vice Chancellor,  Heads of School or Department are also dim and distant. What matters are the lecturers, tutors and so on. We have shown in the Armed Forces, and others have shown in the office or in Blue Light organisations, a little bit of mental health training goes a long way when given to the right people.

And even more important than training is the well-being and morale of those in those ‘frontline’ jobs as we tend to call them. This is one topic that we can for once say that no further research is needed. For example, in health services around the world, a work force that is well supported and has good job satisfaction delivers better clinical care and makes fewer mistakes than one that is not. In the NHS, we are constantly told to ‘put the patient at the heart of everything that we do’ – true enough, but the easiest way to do that is to pay more attention to the morale of the workforce, sort that out, and the rest follows. I doubt that universities are different.

So no one now doubts the importance of mental health, and most accept the importance of taking a whole university approach to the issue of mental health. It is, however, worth emphasising that this must be owned at all times by the university itself. It should not be farmed out to external organisations, no matter how glossy their brochures.

And finally if you are reading this issue, you probably believe that going to university remains a life enriching experience. And you are right, it is.