The following is a composite account of the sort of difficulties university students are likely to present when they refer themselves to a Student Psychological and counselling Service where I work as a Consultant psychiatrist.
Amy, aged 22, is a Masters student coming up to her final dissertation. She referred herself to Student Psychological Services saying she had suicidal thoughts and scored high on the PHQ9. She claims she has never felt confident about her academic performance, despite very good marks in her A levels and a 2:1 in her undergraduate degree. She compares herself unfavourably to the other students in her course, and has fallen back on some of her assignments. She has started to cut her arms to obtain relief, something she had not done since her teens. She has also resorted to alcohol, and occasional use of alprazolam, which she obtained on the internet, as well as MDMA and cannabis. Recently she has been haunted by suicidal thoughts, especially in the evenings, which affect her sleep, taking up to two hours before she can doze off. She has not confided her worries to friends or family. She has held back on acting on her suicidal ideation thinking of the impact on her mother, who suffers from depression, and her two younger siblings.
‘How come so many bright students are contemplating suicide?’
This is a question often asked by educationalists and clinical practitioners based in Higher Educational establishments, finding it difficult to make sense of this rising phenomenon in young people with potentially hopeful careers and futures. Having worked in three University settings in London over the past 11 years I have witnessed changes which lead me to be concerned about the trends, not only in the demand for services to support students to help them complete their academic aspirations, but also in the nature of student mental health problems.
All my assignments as a psychiatrist consisted of joining teams of qualified and experienced counsellors, psychotherapists, mental health advisors and, in the case of my present University, other psychiatrists, offering assessments and brief interventions to students who referred themselves or were referred by others (such as tutors, friends, general practitioners mental health services). Over the years, students have increasingly sought help from these services, rising in the case of my London University, of up to 100 referrals per week on average during the academic year. As a result, waiting times have increased, prompting teams to have to adopt measures to screen the degree of urgency, to explore brief interventions, groups, workshops or online therapies as alternatives to more prolonged one-to-one psychological treatments, and to tighten up liaison with general practice, mental health and other therapeutic organizations which are also experiencing increasing demand.
During our weekly multidisciplinary discussions where we present the results of our assessments and discuss problematic presentations, it is striking to note how often suicidality is mentioned by students. In fact, on their registration form, over 26% state that they are having suicidal thoughts. More worryingly and tragically, we have had students commit suicide. Are we witnessing an epidemic of suicidality in this population? When we analyzed possible contributing factors several issues were highlighted, but it was not possible to pinpoint single or more frequent triggers. International students, under pressure to perform academically by family or government granting agencies and who were not achieving these expectations were particularly vulnerable. Students who decided to defer or interrupt their studies because of academic or other demands who were not in contact with supportive agencies during the hiatus were also susceptible to suicidality. Previous mental health problems often re-surfaced in the pressure-cooker atmosphere of the University, especially when tasked with complicated assignments and the prospects of failure in exams and not being able to achieve the desired degrees. Students who had previous contact with mental health services back home often found themselves unsupported by statutory services when they moved to University, either because local services were difficult to access or because previous services had not made appropriate links to ensure that the student was seen by practitioners and offered support during the academic year. Students often mentioned in their assessments talking to other students who were suicidal, or had accessed Social Media to explore ways in which they could commit suicide. Financial pressures, the prospects of having to pay off loans, and bleak employment prospects post-University may have also contributed, as well as isolation and accommodation problems. Relationship difficulties and loneliness were also regularly mentioned. The use of alcohol and recreational drugs (and recently increasing use of alprazolam -Xanax) possibly also lowered the threshold of acting on suicidal ideation. The loss of pastoral care by tutors was also mentioned, blamed on the expansion of student numbers. Needless to say, this has had an impact on all of us trying to respond in a helpful manner, and discussing it in our multidisciplinary meetings in a frank and open manner allowed us to share the emotional load and gain some understanding and perspective on the issues.
This picture confirms findings from recent surveys and reports. A small online survey carried out by Student BMJ on medical students found that medical students who experience mental ill health feel under-supported by their medical schools. Of the 1122 UK based respondents, 30% (343) declared they had experienced or received treatment for a mental health condition while at medical school. From this group, 80% (276) thought the level of support available to them was either poor or only moderately adequate. Just under 15% (167) of the survey’s respondents also revealed that they had considered committing suicide at some point during their studies. (Student BMJ 2015)
Another report on The State of Student Mental Health found that 1 in 4 students experience mental health issues during their studies, with a 26% increase in students accessing services , reporting the courses being a major source of stress (60%), 44% feeling isolated, 36% experiencing financial pressures, 22% finding independent living challenging and suicide rates doubled in the last 5 years, with financial pressures the main contributing factor. (Encompass Dorset 2018 https://www.encompassdorset.co.uk/nofollow/iqs/dbitemid.154/print.1/rp.1/sfa.view/blog)
As mentioned in previous Report of the Royal College of Psychiatrists in the UK (2011), the spectrum of psychological and psychiatric problems presenting to Student Psychological Services is wide and not too different from requests arriving at local Community Mental Health Teams. It no longer surprises us to find students with moderate to severe anxiety and depressive symptoms, frank psychotic phenomena, Attention Deficit Hyperactive and Autistic Spectrum Disorders, or very disturbed young people with a personality disorders arising from poor early parenting or abusive backgrounds. The difference from patients referred to CMHTs is that many students often seek help, and have the reflective capacity to benefit from interventions. The problem, as in other helping agencies, is to have in place the right degree of experienced resources to respond to these demands with some expediency, and an established point of contact with services outside the University that can offer specialist help when required. It is important to bear in mind that University health services are not replacing traditional NHS mental health facilities, but in my view many students do present with conditions that could benefit from an assessment by a psychiatrist and a prompt referral to CMHTs when this is required.
Gathering and recording of basic reliable demographic and contact data is essential in this process, especially if referral to other services is the outcome. Particularly important are details of general practitioners and any other mental health services that may be involved, the results and findings of previous assessments and interventions that have been tried, as well as medication that is currently being taken or has been taken in the past. We have experienced problems when students are being treated closer to home, return back during term breaks, and need ongoing support from their local GPs as well their University GPs, with many practices not supporting dual registration.
Emotional dysregulation in young people is to be expected, partly as many are still in the process of maturation, with doubts about their strengths and capabilities, not helped by real uncertainties about what the future holds in terms of careers and employment. What I have come to realize is that the experience of emotional dysregulation is catching, and affects not only the students we see, but also those they are in close connection with, including ourselves as practitioners. I am also aware that during adolescence and young adulthood emotional dysregulation is not only understandable but perhaps a necessary phase, allowing students to explore and learn about their frailties and vulnerabilities, if opportunities for reflection are offered.
When I first see a student who has been referred to Student Psychological Services, usually presenting with high levels of disconnected emotions, I am mindful of two things. One is that I have to be ready not to be rocked into the maelstrom, tightening up my virtual seatbelt for the ride. The other thing is staying with it, accepting it, waiting for the storm to subside until somehow the student gains perspective. My role is not as an assuager, I simply am an accompanist, stating by that my interest in being connected to them and that these situations can be handled, eventually. In this I am also communicating that I am exploring with them their own internal sources of strength and resilience and not assuming that they are just simple feathers in the wind. This is not to dismiss the need to explore other underlying factors, such as depression and anxiety, which may require targeted interventions.
Recent studies in the British Medical Journal poured cold water on the value of risk assessments leading to stratification in suicide prevention (Large et al 2017). However, they do conclude, as so many other authors have pointed out, that those presenting with a mental health problem require a thorough and sympathetic assessment with the aim of negotiating an individualised treatment plan, and that those acknowledging suicidal thoughts or behaviours should be offered evidence based therapies for the treatable problems associated with suicide, such as substance misuse disorder and depression. They also remind us that the overwhelming majority of people who might be viewed as at high risk of suicide will not die by suicide, and about half of all suicides will occur among people who would be viewed as low risk. These suggestions for assessments are being followed assiduously by our clinical practitioners, but usually it falls on the psychiatrists in the team to become involved and to give advice or put in place measures to minimise risk. It has been helpful to provide contact information of services available out of hours (such as the Samaritans), print out cards offering suggestions to students on what they can do if they are overwhelmed by suicidal feelings, link up with local GPs, Community Mental Health Teams and Accident and Emergency services, discuss responses with tutors and warden supervisors, and offer emergency slots for those deemed to be requiring urgent assessments.
So in my example how could I have responded to Amy’s difficulties? I am mindful that Student Psychological Services in Universities have limitations on what can be offered as they do not have the comprehensive resources to respond to psychiatric emergencies. However, I do believe these Services often offer a first port of call for students in distress, and that they do have a role in hopefully preventing bad outcomes or in directing students to services where help can be obtained.
Amy had filled in her Registration form on-line giving a brief account of her difficulties and her expectations of the help that she was seeking. That helped the triage team to allocate the assessment to the most suitable practitioner in the team. Her high score on PHQ9, her suicidal ideation and use of alcohol and drugs led the triage clinician to allocate her to me.
I needed to give Amy a chance to express in her own words her difficulties, understand when she first experienced them, whether she could identify any triggering factors. I would also ask her to tell me the nature of her suicidal thoughts, when they arise, how far had she gone into imagining not only how she would act on them, but also to let her tell me what stopped her from carrying them out. I would acknowledge the positive step she made in requesting help and disclosing her innermost worries. I would enquire whether she was living in Halls, or a shared flat, or with her family, and if she had confided her distress with friends or flat mates. I would listen carefully to occasions when she did not feel so burdened, whether she had developed strategies to manage them, exploring her own strengths and reflections. I would also ask her if she had thought what specific help she was seeking by coming to Student Psychological Services. After taking a personal and family history focusing on her early memories and relationships, I would explore the nature of her affective disturbance and exclude any other factors which could trigger off an impulsive act. This approach often manages to contain worries for students, particularly if followed by practical suggestions of where they can obtain assistance, day or night, but also acknowledging that they have internal strengths and resources which they often believe have failed them. Obviously there are instances when more immediate action needs to be implemented, and a letter and a phone call to the Local CMHT or a visit to the A&E Department may be required when there is a serious risk of self-harm and deterioration.
Dr. Leonard Fagin
Consultant Psychiatrist