HUCS CONFERENCE: 9 DECEMBER 2002

“BEAUTIFUL MINDS? STUDENTS, MENTAL HEALTH AND THE UNIVERSITY”

PSYCHIATRY AND UNIVERSITY COUNSELLING

MIKE HOBBS

INTRODUCTION

Because the Royal College of Psychiatrists’ report on student mental health has not yet been published,  I cannot speak for the College as indicated on the programme.  Refreshingly I can speak for myself, a consultant psychiatrist and a psychotherapist in Oxford, a city where 20% of the term-time population are students in further and higher education.  As well as experience of the mental health problems of students in my own clinical practice, I have worked as a psychiatric consultant to the Oxford University Counselling Service, continue to serve on university health committees, and represent the Oxfordshire Mental Health Trust in the Oxford Student Mental Health Network.

In this brief talk, I aim to examine:

• a psychiatric perspective on student mental health
• specific mental health problems in relation to students
• key issues for effective service provision
• the NHS policy context relevant to this subject
• conclusions in relation to future collaborative working.

I look forward also to learning from your experience and points of view.

PSYCHIATRIC PERSPECTIVE

With a few conspicuous exceptions, psychiatrists had not given due attention to the mental health problems of students before the issue was addressed so clearly by the AUCC/HUCS publication ‘Degrees of Disturbance’.  I fear that many mental health professionals still view students as a privileged and essentially healthy, if demanding, population when compared with, say, homeless people suffering severe and enduring mental illness.  Your report highlighted however that an increasing number of students are presenting to University Counselling Services with mental health problems, and a growing number with serious mental health problems.  This must be a matter of concern for us all.

As psychiatrists, we contextualise the mental health problems and needs of students in relation to the mental health of the wider general population, especially of young people.  Here there is evidence of increasing levels of anxiety, depression, alcohol and drug misuse, and the very worrying increase (over the past decade or two) in suicides of young men.

Some definitions are important here.  Mental health can be conceptualised on a spectrum from wellbeing, through subjective distress, mild to moderate symptomatic states, to severe mental disorder.  Obviously our responsibilities lie with the severe end of the spectrum, that is with people who suffer severe mental ill-health.  Psychiatric classification of mental disorder is categorical, that is by diagnostic categories of mental disorder (eg depressive disorder, schizophrenia).  Access to secondary NHS mental health services takes account of both diagnosis and the degree of disability or dysfunction suffered by the individual, and its impact on those around them.

The great majority (90% plus) of people with mental health problems are managed in primary healthcare services, ‘occupational’ services (including university counselling services), and the voluntary sector.  For students in higher education, university counsellors and GPs have a crucial role.

NHS policy, on which I will expand in a moment, expects now that people with “common mental health problems” (mild to moderate conditions including most anxiety and depression) will obtain treatment in primary care services.  Naturally psychiatrists have an interest in primary care provision for these problems.  However, access to secondary mental health services has been restricted progressively in recent years, both by policy directives and serious resource constraints, to people with severe mental illness.  At its worst, this has been equated with psychotic illness alone, such as schizophrenia and manic-depressive illness.  Fortunately, there has been some broadening of access recently, in policy and practice.  Nevertheless people are unlikely to obtain treatment by secondary mental health services unless their psychiatric disorder has already caused significant impairment of personal, social, occupational and/or educational function.

SPECIFIC MENTAL HEALTH PROBLEMS IN RELATION TO STUDENTS

Epidemiological studies have demonstrated a number of risk factors for mental ill-health in students including: previous psychiatric problems; never previously having been away from home; and interpersonal problems, social isolation, academic problems and financial hardship in the college context.

Fortunately there are protective factors too: prior independence; emotional resilience; religious or equivalent faith; and participation in activities involving others.

Let us examine some of the mental health disorders which cause concern:

• The onset of anxiety and depression in students may be associated with specific stressors, such as interpersonal problems and financial pressures.   Some students are more vulnerable to stress than others, of course, so they may be less able to cope with additional challenges.

• We are very concerned about the increased consumption by young people generally of alcohol and drugs, which may contribute physiologically to heightened anxiety and lowered mood.  Sometimes substances are used to mask subjective distress or symptomatic states, but will actually exacerbate them.  Even cannabis, supposedly the safest drug, has now been shown to heighten the risk of schizophrenia and, perhaps more importantly in terms of numbers, of depression and suicidal ideation.  Psychiatrists believe that substance misuse contributes significantly to the increased incidence of anxiety and depressive disorders, although I recognise this link was not borne out by Dr Grant’s study in Leicester.

• Turning to eating disorders, we know that bulimia is common in young women and usually associated with significant subjective distress. Anorexia is less common and often hidden; but, when severe, it is a serious cause of concern to the individual and those around them, including family and college staff. The person with anorexia may deny their problem and resist intervention, and it is notoriously difficult to manage them effectively as they move back and forth between college and home.

• Deliberate self harm is no more common in students than in the age-matched general population; but, manifesting the individual’s internal distress, it is inevitably distressing and disruptive to others in the college setting.  In a few cases, the individual’s demand for confidentiality may generate serious problems for the student’s peers and college staff, though their interests would be best served by active communication between college and health personnel.

• Serious behavioural problems such as aggression and exploitation, often associated with substance misuse, may not be common in the student population, but can create severe disruption in the college setting.  These individuals test disciplinary policies and procedures to extremes.  Their problems may indicate emerging psychiatric illness or personality disorder, which is difficult to diagnose in adolescence and very difficult sometimes to manage in the higher education context.

• Autistic spectrum disorders, especially Aspergers, are sometimes difficult to identify in a population where class sizes are increasing and eccentricity is an accepted norm; but the characteristic interpersonal awkwardness and social avoidance of people with Aspergers may bring them to attention.  They will require a degree of structure and support to manage university life successfully and to fulfil their academic potential.

• Psychotic illnesses are relatively uncommon in the student population, but will become more frequent as widening access ensures entry to higher education for people who previously may have been excluded.  The onset of schizophrenia is often insidious, and difficult to identify before educational progress has been compromised.  Hypomanic states are floridly obvious, and often highly disruptive; but bipolar affective disorder may present initially with a major depressive episode.  People with psychotic illness require active and determined collaboration between NHS services at the student’s home and college, as well as close cooperation with college authorities.  Unfortunately this is still not always achieved, despite the expectations of the Care Programme Approach (CPA) for coordinating mental health service provision.

• The suicide of a student is highly distressing for everyone concerned.  Despite concern that suicide may be more frequent among university students, the available evidence suggests that the incidence is not higher than in the age-matched general population.  Indeed, especially in male students, the incidence of suicide is probably lower than in the non-student population.  This finding allows no room for complacency, however, for suicide is always highly disturbing to family, friends, and the community of which the student was part; and represents a terrible waste of human potential.  We also know that death by suicide of a young adult is particularly likely to generate complex grief reactions in the bereaved.  Prevention of the tragedy of student suicide is perhaps the most powerful incentive to thoughtful collaboration between all concerned with student mental health.

EFFECTIVE SERVICE PROVISION

The need for effective service provision is highlighted both by the widening access agenda, and by extension of the Disability Discrimination Act to include higher education.  There are a number of related issues here:

• higher education can contribute positively to mental health, and to the recovery from mental ill-health; but …

• concerted action is needed to identify and treat effectively students who develop mental health problems while at university, not least in order to safeguard their academic potential;

• HEIs face particular challenges, as do mental health services, in relation to the access of students with existing mental health problems, whether or not these are declared; for …

• as the HE population widens, so rates of mental health problems will tend increasingly towards general population norms.

There are numerous challenges to effective provision for students with mental health problems.  For example:

• It may be difficult to identify students with mental health problems when direct contact with staff is reducing, and to assess students comprehensively when contact with their family is often precluded by distance.

• Although students are often willing to speak with peers and college staff, they may not choose to seek professional help even from HE counselling services or GPs.

• It is even more difficult to engage students in secondary mental health services, when these are required, because of the perceived stigma.

• There are particular logistical problems associated with the discontinuity of college and home services.

• Students of the healthcare and related professions, including social work and teaching, may be specifically disadvantaged by mental health problems, for the student’s expectation of confidentiality may conflict with the institution’s and the profession’s responsibility to the student’s present and future patients, clients, or pupils.   For example, the guidance of the General Medical Council in relation to medical students is absolutely clear.  “while the safety of patients and the care of students are both important, the protection of patients must always come first”.

NHS POLICY CONTEXT

I will turn now to the policy context in which today’s NHS mental health services are delivered, for this has significance in several ways.

The government’s modernisation agenda for mental health services is designed to ensure enhanced and equitable access for users; the increased responsiveness, effectiveness and acceptability of services; increased attention to the needs of carers; and a comprehensive programme for suicide prevention.

The policy agenda is set out in the National Service Framework (NSF, 1999) for the mental health (of adults of working age) and the NHS Plan (2000).  Of particular relevance for student populations are the strategic plans for:

• The further development of primary care mental health services for people with mild to moderate problems.

• 24 hour crisis response services, designed to ensure ready access to assessment and treatment of mental health crises at home, thereby avoiding hospital admission whenever possible.  However, the implementation guidance limits these crisis services to people with severe mental illness, and specifically excludes people with interpersonal crises and personality disorder.

• Early intervention services for psychosis, which are designed to assist early diagnosis of psychotic illnesses and ongoing intensive case management to preclude the more destructive effects associated with untreated or inadequately treated illness.  This might enable students with psychotic illnesses to continue or return to HE more readily than before.

• Enhanced services for people with severe personality disorder.  This policy guidance is expected shortly, and for the first time should support effective treatment provision for this stigmatised and disadvantaged population.  Although its proposals are oriented particularly to the needs of those more severely impaired by PD, it might become possible to identify and intervene earlier and more effectively when students present the destructive interpersonal and behavioural patterns associated with this heterogeneous diagnosis.

• The Care Programme Approach (CPA) is a coordinating programme for intra- and inter-agency mental health provision.  The aims of CPA are to ensure comprehensive assessment of the individual’s mental health needs; including risk assessment; the assessment when appropriate of the carers’ needs; the development of a comprehensive care plan; and effective communication and collaboration between all those who contribute to the treatment and support of the person with mental health problems.  This might include college and counselling service staff; but, be assured, effective CPA should preclude those inexcusable episodes when university counselling staff have been nominated by mental health services, without any discussion, as being responsible for the student’s care following DSH or a psychiatric illness.

• The government’s 2001 paper ‘The Journey to Recovery’ usefully summarises its vision for mental health care for the next decade.  Education is identified as a significant potential resource in securing recovery from mental illness.  We should welcome this recognition; but it is clear that increased access to HE for people recovering from mental illness, however appropriate and laudable, has significant resource implications.

• Lastly I will mention the government policies to tackle drug misuse.  Key aims include to enhance awareness of the dangers of drug use, especially for young people, to reduce the availability of drugs, and to enhance access to effective treatment.  These are multi-agency strategies which embrace education, health services and, the criminal justice system.  In view of the evidence for the relationship between drug and alcohol use and psychiatric disorders, HEIs and the NHS will have a critical collaborative role in informing people, especially young people, of the dangers.

• In all of this, there has been no policy guidance yet about the organisation of services for young people in general, or students of all ages in particular.  We know that various service models work well in different places, such as university-based comprehensive health services or dedicated student mental health teams; but there is insufficient evidence yet upon which to base policy recommendations.

SUMMARY AND CONCLUSIONS

In conclusion, and to promote our discussion, I will set out a few summary points:

• Firstly, the NHS has much to learn from HEIs about provision for the mental health needs of students.  NHS staff require education about the context and needs of HE students, including the importance of a developmental perspective and the significance for service provision of the academic year structure.

• The needs of most students with mental health problems will continue to be met by staff with pastoral and counselling responsibilities within the universities, supported by NHS primary health care teams.  University counselling services are, in effect, the primary mental health care option for most students, and they should be resourced accordingly.

• There is a clear need for local collaborative networks of HEI services, primary health care, secondary mental health services, and relevant voluntary sector agencies in order to coordinate planning and service provision, and to address the needs of students with more complex and serious mental health problems.

• Just as there is value in nominating mental health advisors in HEIs (usually the head of the counselling service), there might be advantage in identifying HE advisors in mental health services, to act as information sources and ‘champions’ of effective mental health provision for students who can smooth the care pathway.  Mental health practitioners with academic roles might fulfil this role.

• PCTs should develop a student mental health strategy in consultation with HEIs and provider agencies.

• Nationally agreed policies should be developed to secure continuity of NHS mental health provision between the student’s home and college services, without conflicts about funding.

• There is no one model of provision for the mental health needs of students, and local services should build on existing good practice: if it works, don’t fix it!  Where the number of students warrants it, however, consideration might be given to a dedicated specialist mental health team for students with serious mental health problems.

• Different models of inter-agency service provision should be evaluated carefully.

• More thought should be given to the development of ‘transitional’ (14/15 – 24/25) mental health services which provide for young people across the traditional age divide to improve continuity and sensitivity to the needs of younger people.

HUCS.mh Dec 2002

ã Mike Hobbs 2002