What’s changed for UK university mental health?

Dr Jane Morris, Chair of RCPsych in Scotland looks at the current state of affairs in mental health in Scottish higher education.

As I wrote my book Improving University Mental Health, the commonest question people asked was ‘who is the intended audience?’ If you are reading these words, then the answer is ‘you are!’ Did you go to university? What was your experience of emerging into adult life? What can we do better? Readers seeking simple answers will be disappointed, though. I’m disappointed myself – I wish I could have produced a definitive manual on How Governments Can Legislate For Mentally Healthy Universities.

I was the first person in my family to get a university degree, and since then I’ve been the daughter, sister, cousin, mother, aunt, friend, colleague and teacher of students and staff in higher education institutions over half a century. University life fascinates me. My own experience of university was intense and positive, but many of the people I met described painful or damaging experiences.

When, as a child psychiatrist, I said goodbye to patients embarking on university, I worried despite rejoicing. I had read Toxic Childhood (Palmer, 2006) in which a school teacher warned of the loss of traditional childhood freedoms and routines. She flagged the dangers of the online ‘electronic village’ where children roamed unprotected by their elders. I recognised these phenomena in our patients and their peers. In writing this book I’ve observed how many of the problems have intensified rather than resolved. Today’s psychiatric clinics see not only the direct results of mental ‘disorders’, but the interactions of vulnerability with environmental factors.

We are not the first society to worry about these ‘emerging adults’, ‘thresholders’ or ‘transition-aged youth’. As I considered the effects of social media on developing brains, I learned that the ancient philosopher Socrates condemned the technology of writing as catastrophic to youthful memory. Later sages predicted dire consequences of printing. At the University of Heidelburg I visited an old student prison for misdemeanours involving a culture of toxic masculinity – aggression and intoxication. In 1256 Cambridge University was sufficiently concerned about the moral and social welfare of its students to fund two full-time chaplains. There was already a contrast between gentlemen students, enjoying life as they prepared for a place in elite institutions, while poor scholars worked as university servants to fund their serious studies.

Plus ca change? Students at those ancient universities were in their mid teens or younger, though in those days that age represented emerging adulthood. The concept of adolescence is only a century old, and life expectancy is longer today. My book constantly debates the question of whether young adults should be expected to shoulder full adult responsibilities, or whether we are buying too much into The myth of maturity (Apter 2008). Those students were exclusively male: indeed when I attended Cambridge in the 1970s, only one in ten of us was female. Today women students slightly outnumber men. This brings bio – psycho- social considerations which still challenge us.

The sheer scale and acceleration of change is breathtaking. When my mother started university after the second world war, she was supported by a generous grant, seen legally as a child because she was under 21, and guided by staff ‘in loco parentis’. She had to belong to the Church of England and to leave her studies when she became pregnant. In the 1970s, we still had free tuition, government grants and institutional canteens and facilities, but we were legally adults with political powers, and felt entitled rather than privileged.

My children went to university this millennium, alongside virtually all their classmates who had stayed on after the age of 16. Half the UK population now attends university, where the teaching of young students is the dominant business. Scholarship for its own sake is a rare luxury, and research perhaps valued more for its business potential than as the core task. The shift to tuition fees and the replacement of grants by loans is another factor in the ‘commercialisation of universities.

Students face pressures to be ‘consumers’ of education, accommodation and other aspects of a student lifestyle, yet they receive only patchy training and support to manage their finances. Debt and financial concern are associated with poorer mental health and academic under-performance at university and after graduation. The combination of financial stress with maladaptive coping strategies such as gambling, sex working and drug dealing can lead students into criminal subculture.

Despite the financial costs, a broader social spectrum now accesses higher education. This includes people in minority groups in terms of ethnicity, neurodiversity, sexual preference and gender identity. Can Universities find ways to celebrate and exploit the riches of diversity whilst mitigating the disadvantages for people who live with difference in a powerful mainstream culture?

More students than ever disclose a psychiatric diagnosis (Universities UK, 2015). One international study found that a fifth of university students had a mental health issue. Four fifths of these had been diagnosed before they started at university (Auerbach, 2016). What are we to make of this? It may not reflect increased rates of mental illness so much as increased willingness to receive supports, services and finance – the DSA (disabled students allowance). The option of mental health mentorship, funded by DSA, can be transforming.

There are effective treatments for even the most severe mental illnesses that affect young students. However, it takes far longer to see recovery than with most physical conditions. Mind and brain take a long time to recover and heal – months and years even. Students who have to take time out of academic studies – or who need to leave their course – need extra monitoring and support, as this is a time of high risk. We increasingly recognise the significance of the huge transition into university life, but fail to plan for the further transitions involved in returning home, ‘dropping out’, taking extended sick leave, or the further life transition when students graduate.

The very ways we conceptualise and diagnose mental illness are changing. In 2022 the UK moved from old diagnostic systems to the new World Health ICD11 classification. This dry fact reflects enormous amounts of debate and research, advancing attitudes to the very nature of mental illness and its management. Universities have hosted much of the research, often recruiting students themselves as study samples.

‘Student mental health’ is not a standalone issue. Academic and support staff, are more likely than students to have a diagnosable mental condition but far less likely to ‘disclose’. Staff wellbeing is crucial for university culture and the capacity to provide pastoral care. Ironically, the increased burden of pastoral care is a big factor in staff distress.

Parents bereaved by suicide have campaigned for greater family involvement for students in crisis. Their financial stake in choice and support of their child’s University is powerful too. Alumni are finding a voice that comes with financial contribution, indeed all of us UK voters are stakeholders in our universities. But maybe it’s false to see a dichotomy between ‘us’, the adults, professionals and investors, and ‘them’ the vulnerable young students. We’re all likely to develop a diagnosable mental disorder at some point in our lives (Caspi. 2020), whether we are politicians, professors, parents, vice chancellors, domestic staff, secretaries or students.

Most recently, students – the people at lowest physical risk from COVID – paid the highest psycho-social penalty. Lockdown restrictions overshadowed the very years when they had expected to live out a major life transition. The pandemic experience saw a flexible expansion of telemedicine, but it has not so far fulfilled its potential to streamline care for the mobile university population. Emerging research suggests broad gender differences in the response to lockdown. Women students, spending more time on social media, suffered amplification of society’s preoccupation with body image. Universities inevitably host many young people with eating disorders, given the demographic involved. Specialist eating disorders services have reported a further increase in referrals since the pandemic.

Meanwhile, male students and staff were more likely to drink more. Despite an overall reduction in the amount of alcohol consumed by students, there is an engrained and culturally endorsed culture of deliberate acute intoxication. Use of alcohol and other substances is a predisposing factor to an individual’s risk of suicide, and alcohol and substance use overwhelmingly occur around the time of death. Sexual violence is also linked to intoxication for victims and perpetrators. As I researched the book I became convinced that significant reduction in binge drinking could result in improvements in many areas of wellbeing and in academic performance. The message is not about demanding a new temperance movement, but a focus on the acute risks of the entrenched binge culture. But how can we even speak of these uncomfortable truths with young people and be heard?

The Royal College of Psychiatrists, to which I belong, says ‘There is no health without mental health’. The mental health of today’s students and their peers determines the social, emotional, academic, economic, physical and spiritual health of our future, as a human race and as a planet. Could there be any more worthwhile investment?

This piece was originally published in the Cambridge University Press.