There’s strong pressure on universities to do something about spiralling student mental health problems, but what is best?
Lucy* hadn’t quite realised how severe her problems were.
She’d fallen in love with the university, in the south of England, as a teenager while visiting her big sister there. When she applied to go there herself, on a geography course, she had high hopes of what she’d do with her career.
“I wanted to help people in the Global South and fight climate change,” she says.
She dreamed of joining the UN or the Intergovernmental Panel on Climate Change once she’d done her degree.
She’d had problems with her mental health before arriving at university, a range of symptoms that she thinks may have been undiagnosed bipolar disorder but generally describes as depression and anxiety.
Over the course of her first year, her mental health got much worse. But she put off going to a counsellor because she struggled to fill in the required forms. In her second year, she finally made that step.
But Lucy didn’t feel the counsellor listened to her. “She didn’t really understand work as a student at all. There was a highly toxic culture of studying so much, but she didn’t seem to understand or give me anything to counteract that. She just said what I was doing was wrong.”
So when Lucy decided she needed some time out, the counsellor refused to recommend it to the university. Her mental health wasn’t deemed bad enough. “By this point,” Lucy says, “I was suicidal.”
Without a note from her counsellor, there was no guarantee Lucy could come back if she took a break. She shared her worries with a tutor. He was an academic, but someone she trusted, who saw pastoral care as part of his role. He suggested she ease up on the effort of studying for a while and see how she felt after term ended.
That summer, he gave her a call to check up. They talked through how she was feeling. A couple of weeks before her final year started, she decided to drop out.
© Libby Scarlett and Georgia Marshall Evangelou for Mosaic
UK universities are in the middle of a mental health crisis. Five times as many students are disclosing a mental health condition to their institution today compared with ten years ago, and the number of students seeking mental health support has also risen – by 50 per cent between 2012 and 2017.
“This isn’t about worried well,” says Gareth Hughes, a lecturer and psychotherapist who is research lead for student wellbeing at the University of Derby. “There’s an increase in students who are significantly mentally ill.” The majority are seeking help for depression or anxiety.
The rise in mental illness among students reflects a broader trend across society. Long-term mental health issues in children and young people are up sixfold in England since 1995, and they more than doubled in Scotland between 2003 and 2014. Exactly what’s behind the increase isn’t clear, though “studies have looked at the impact of social media, or lack of sleep caused by electronic devices, as well as the effects of an uncertain job market, personal debt or constricted public services,” writes Samira Shackle in the Guardian. In England and Wales, suicide is the leading cause of death between the ages of 20 and 34.
Yet when it comes to healthcare provision, young people’s mental health is under-resourced. Only 11 per cent of the UK health budget is spent on mental health, even though it represents 23 per cent of the burden of disease. And of the overall mental health budget, Child and Adolescent Mental Health Services (CAMHS) account for just 7 per cent of spending, despite under-18s making up a fifth of the population. All told, less than 1 per cent of NHS money goes towards the mental health of children and young people. It’s little surprise that former Health Secretary Jeremy Hunt described CAMHS as the “biggest single area of weakness in NHS provision”.
The UK isn’t alone on this. In the USA, depression and anxiety among under-17s is becoming more common, while among college students the demand for counselling has risen sharply. A 2019 study – analysing data from two large national student surveys – found that rates of suicidal thinking, severe depression and self-injury among students doubled between 2007 and 2018. Yet over the same period, the budget of the National Institute of Mental Health didn’t keep up with inflation, meaning its research funding has fallen in real terms.
© Libby Scarlett and Victoria Moyosola for Mosaic
Universities experience the effects of young people’s mental health issues directly. And often they struggle to provide treatment, prioritising interventions such as counselling and cognitive behavioural therapy (CBT) that may work for some but not others. “Some people go into therapy and their mental health will go backwards,” says Hughes. “It’s not without risk.”
But given how much we struggle to treat mental illness in general, we should see universities as an opportunity.
The majority of people who develop a mental health condition will have experienced their first symptoms by the time they’re 24. In the UK, this means a significant number of people will be at university during or not long after the onset of mental ill-health. A third of UK 18-year-olds entered higher education courses in 2018. “If you intervene with students now, that’s an incredible public health win,” says Rachel Piper, a former policy manager at the UK student mental health charity Student Minds, noting that if you intervene early in someone’s life and support their mental health, you can stop it getting worse as they get older.
New cohorts arrive at university every year, allowing new initiatives to be tried out and compared in comparatively short timescales. It makes universities a great place to try addressing mental health differently. Instead of asking them to respond to mental ill-health, we should be posing universities a bigger question: how can they help prevent it?
Stuart Slavin didn’t think he needed to worry about his students.
He originally qualified as a doctor and now has a Master’s in education. Until recently, he worked in curriculum design for medical students at the same school where he himself studied medicine: Saint Louis University in Missouri.
Slavin didn’t see student wellbeing as part of his job until, in 2008, he started reading about stress, depression and burnout among medical students. He was shocked by the high rates that he read about, but didn’t think they could apply to his students.
“It was unimaginable to me,” he says. He thought that as a teacher all he needed to do was be kind and compassionate; his students seemed happy, and their satisfaction with their education was high according to the standardised national questionnaire.
But just to make sure, Slavin decided to use validated clinical depression and anxiety scales in surveys of their mental health. When the results came in, they told a different story.
© Libby Scarlett and Jane Catterson for Mosaic
Students were fine when they arrived at orientation, reporting normal levels of depression, anxiety and stress. Just six months later, after their first term, their wellbeing on these three fronts had plummeted. These results were supported by evidence from a number of other medical schools: levels of depression would rise during the first term of university, and fail to fall back to their original levels by the end of first year, or even by the end of medical school.
“I had to get involved,” Slavin says.
He developed a simple model for improving student mental health, one he believes is applicable across education.
“One: this is a primarily environmental health problem, so let’s reduce unnecessary stresses. Two: life is stressful, the world is stressful, so let’s teach students how to cope with that with cognitive and positive psychology. And third was creating space in their lives to find meaning. That was it.”
It seems simple. But when stories of student distress come out, there are often elements that universities have some influence over: accommodation, finances or the pressure of studying.
For Lucy, accommodation was a massive problem in the days after she decided to drop out. She’d moved into halls before the start of term for an internship, but when she notified staff that she wouldn’t be coming back for term due to depression and anxiety, they gave her 48 hours to move out.
“I had friends I could stay with from the moment term started,” she says, “but at the time they were trying to kick me out of my room, my closest friends were away.” She offered to pay extra if she could stay until the end of the week, but the answer was no. She began frantically packing her things to move out on Wednesday.
At 6am on Tuesday, there was aggressive knocking on the door. “They said they thought I’d gone,” Lucy recalls; she was half-asleep when she answered. Luckily, she found a friend to crash with, but she still remembers the stress bringing on a “long, awful anxiety attack”.
University authorities are not parents, but they have enormous power over young people’s lives. When it comes to supporting their students’ mental health, they are in an excellent – and arguably responsible – position. “I think it’s a moral duty,” says Piper.
There’s a common belief that students need a tough, full-on education to prepare them to excel in the competitive world they’ll soon be entering. The pressure is piled on students by a mindset that says ever-increasing amounts of work can only help them succeed.
But there’s evidence that challenges this. In 2018, an analysis of mental health data from across the USA, UK and Canada found that academic worries accounted for a large amount of the variance in anxiety levels in students – more than financial worries. In Florida, a survey found that medical students ranked academic workload and conflicts with work–life balance as their top two stressors. And at the University of York in the UK, a study listed academic difficulty and stress as two of the top reasons students went to counselling, ranking alongside depression, anxiety and bereavement.
Often, though, mental illness is made into a biological problem, to be treated with medication: you are ill because of the chemicals in your brain. But the underlying biology of mental illness can be hard to tease out, and this perspective leaves little room for factors proven to drive mental illness, like overwork, stress and perfectionism, despite multiple studies linking longer working hours to an increased risk of depression and anxiety.
These factors were what Slavin decided to focus on.
One of the things he brought in was a shift from multi-tier to pass/fail grading, which has been found at a number of medical schools to reduce stress, improve group cohesion and have no impact on average scores. But there were other changes – ones that came out of his three-point model, and from listening to what students said they needed – which were unprecedented.
At Saint Louis University, one of the biggest stressors medical students mentioned was the intense human anatomy course, the first they took upon arriving.
“Some 30 students would fail the first exam,” Slavin recalls. “These are the best and brightest students in the US and, you know – welcome to medical school! The distress that causes.”
So they moved the course later in the year, meaning that students would reach it once they had got used to med school, and decreased the course content.
Other problems students identified were long class hours, too much material and strong competition. So they cut the overall curriculum by 10 per cent, setting aside some of the new spare time for electives instead – things like running a foot care clinic for the homeless and a doula training programme.
They also introduced a resilience curriculum, which ended up taking just an hour and a half of student time. “You can teach these skills very quickly, then get out of the students’ way,” Slavin says.
© Libby Scarlett and Victoria Moyosola for Mosaic
The curriculum aimed to take down some of the mindsets that students arrived at medical school with: all-or-nothing thinking (‘If I don’t pass this exam, I’m a failure’), catastrophising (‘If I don’t pass this exam, my life will go off the rails’) and maladaptive perfectionism (‘If I just pass this exam, that’s not good enough’).
The scheme, including resilience classes and extra electives, had a budget of less than $10,000 a year. (Tuition fees at Saint Louis are, for 2019/20, $55,760 per student.) It didn’t require any new staff or faculty.
The proof is in the results.
Over the ten years since its introduction, there has been an 85 per cent reduction in the depression rate and a 75 per cent decrease in the anxiety of first-year medical students. And student satisfaction with wellbeing on the course skyrocketed to 81 per cent compared to the national average of 33 per cent.
For Slavin, it was a huge success. The programme ran for the remainder of his time at Saint Louis.
One of the most astonishing things about his study is what it did to performance. Average scores on the national standardised tests got higher. And the failure rate went down: “It was cut in half,” Stuart says. When they took off the pressure, people did better.
I say this was astonishing. But Slavin doesn’t think the idea of listening to students should be so unusual. “We treat students as if we don’t trust them,” he says. “What does that say about us?”
© Libby Scarlett and Callum Smyth for Mosaic
“I started again,” Lucy says. “Now I’m so much happier.”
After dropping out of university in England, she reset and enrolled at the University of Glasgow, her application supplemented with a reference letter from her old tutor – the one who helped her decide to drop out.
It was the same key factors that Slavin identified at Saint Louis that helped Lucy settle second time around: lowering stress while increasing the ability to cope. The environment at Glasgow was less pressured. As well as being at a different university, Lucy switched from geography to English literature. “The humanities sets are a lot more creative, less rules,” she says.
It also helped that she arrived in Glasgow knowing she needed support and looking for where to find it, and so was much better equipped to handle the stresses of student life. She found the information on where to go easy to find, and it was simple to self-refer.
Although getting appointments was difficult due to high demand and a lack of funding, she got along well with the counsellors. After her favourite counsellor left, she went to the NHS instead. Her experience of both services was similar. “When you get it it’s fine, it’s just being on the waiting list and there’s too many people needing the resource.”
She’s now doing exactly what she hoped she would a few years ago: a strong supporter of Extinction Rebellion, she puts on talks to spread awareness of climate change.
She thinks she’s learned from her university experience.
“I wish I’d realised earlier that my mental health needs looking after, and lack of sleep was not going to help,” she says. “I needed to learn to eat properly. There are so many biological and physiological ways to look after yourself.”
Many student wellbeing initiatives now focus on getting students to that realisation earlier. At the University of Derby, resilience classes for undergraduates have been introduced, with the content tailored to the needs of each course; music students get a class on performance anxiety, while business students get a class on emotional intelligence in the workplace.
They’ve seen an increase in students going to university services for support in the two weeks following the session, which is perhaps not surprising, given that mental health literacy is strongly associated with help-seeking behaviour.
Gareth Hughes helped introduce the workshops at the University of Derby and has overseen their success.
But beyond the resilience workshops, Hughes says that both Derby and Student Minds – for which he’s an adviser – are taking a lot of interest in curriculum change. Both echo the sorts of changes that Slavin introduced at Saint Louis. “There’s research literature that shows the way you assess students, and particularly the way they feel about grades, has a big impact on them.”
On this point, there’s a big split between what Hughes calls deep learners and surface learners. Surface learners are in it to survive. He describes their thinking as “What do I need to get through this? What grades do I need?” This attitude is linked to lower wellbeing.
Deep learners, in contrast, don’t tend to think about grades. “They’re focused on their learning and their passion for the subject.” And as a result, their wellbeing is higher.
“A lot of this is about the meaning and control that they take out of their learning,” Hughes says, again echoing Slavin’s approach in the US. “How do we move students who are maybe coming from a surface learning practice they’ve picked up in school into deeper learning? That’s something we’re still trying to figure out.”
Recent years have seen a growth in higher education of what’s known as the whole-university approach – a philosophy that says every part of an institution is responsible for student mental health and wellbeing. It’s based on an approach developed by the World Health Organization that’s been applied most widely in cities, but hasn’t yet seen significant translation to universities.
But this could be changing.
At a 2015 conference in Canada, people from 45 countries drafted the Okanagan Charter, which calls for universities to transform the way they promote health by getting them to embed it in all aspects of university life, academic and non-academic.
Two years later, Universities UK – the representative organisation for the UK’s universities – released #StepChange, a report calling for all universities to adopt a whole-university approach. Now 78 UK universities have publicly affirmed their commitment to the Okanagan Charter, and the number is growing.
Simon Fraser University helped to lead the development of the charter in Canada. Its own work to become a healthy university has taken direction from what students say they struggle with. For example, its Department of Engineering has reduced the required number of hours in the first year, in response to students saying they felt overwhelmed. The department has also added preparation classes before courses with high failure rates.
These kinds of curriculum changes haven’t yet spread far outside of a few stand-out universities, even though they have demonstrable evidence from places like Saint Louis to support them. But in the UK, Student Minds is hoping to drive universities to think about a whole-university approach. The charity has done a road trip around the country and a large online survey to consult on development of a University Mental Health Charter, and soon a pilot is starting at Derby and a few other universities, before rolling out more widely.
Hughes has been collaborating on the development of the Student Minds charter. “The events were fantastic,” he says, pointing to a big turnout and positive response as evidence that universities are committing to change. “Universities care about their students and they want to do well. There’s so much gap it’s difficult to know what the right thing to do is. We can go in and provide some structure.”
He says the point of universities is to enable young adults to solve difficult problems like mental health. Students who know how to look after themselves learn better, and they can go on to bring that learning into their communities after graduating. “They can go out and be champions for wellbeing.”
The focus on student mental health is finally beginning to move beyond providing medical solutions such as pills or counselling. The goal now needs to be making sure that preventative measures that have been proven to work are discussed and adopted more widely. These solutions are still exceptions rather than the rule.
Lucy thinks the conversation on student mental health has, though, moved on a lot in recent years. “I’m so impressed now by how much people talk about it,” she says. Thinking back to when she was first at university, she believes it would have helped if she’d been able to talk more about her worries and realise others were struggling too. But the coverage she sees now in the media reassures her that things are changing.
“The stories I’ve read seem to say I’m part of something bigger, I’m not alone in this,” she says. “It’s a large-scale problem, and by talking about it, we’re part of the solution.”
* Some names have been changed.
Wellcome, the publisher of Mosaic, is funding work to transform research and treatments for mental health.
Find out more about how artist Libby Scarlett illustrated this piece with the help of students from Manchester School of Art.
With thanks to the Manchester School of Art students who participated in the illustration workshops: Jane Catterson, Amber Denneny, Hannah Goodall, Georgia Marshall Evangelou, Devon Jacques, Evie Moss, Victoria Moyosola, Darcy Owen-Towe, Millie Robson, Callum Smyth, Ciara Tee.