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What we know about mental health at university

Student mental health and wellbeing are a growing concern among both higher education stakeholders¹ and the general public.² Indeed, undergraduate students have been found to report substantially lower levels of subjective wellbeing than the general population aged 16 to 24.^3ÌýIn addition, some evidence suggests that students now report higher levels of psychological distress at university than previous cohorts, with an increasing demand for university mental health services.⁴ Between 2012 and 2017, for example, 61% of university counselling services reported an increase in demand of over 25%,⁵ while rates of student suicide and self-injury have also increased during the same period.⁶ Notwithstanding, it is estimated that 75% of students requiring professional support do not access university mental health services.⁷ Minoritised student demographics in particular, such as students from ethnic and sexual minorities, and lower socio-economic backgrounds, evidentially experience additional mental health challenges and barriers to accessing support services at university, resulting in disproportionately poor mental health outcomes.⁸ Emerging evidence further indicates that the COVID-19 pandemic crystalised and accelerated these trends towards increasing mental health demand, complexity and inequality across the UK higher education sector.⁹

Why does mental health at university matter?

Supporting mental health at university is intrinsically interrelated to other institutional agendas, and has important educational and economic implications.¹⁰ Students experiencing mental health difficulties are more likely to withdraw from university, to underperform academically, and are less likely to progress to higher level employment or postgraduate study.¹¹ There is also a significant financial cost to the institution and potential for reputational damage.¹² Alternatively, good wellbeing among students is associated with multiple affective and cognitive academic processes and outcomes, including improved concentration, creativity, motivation, problem-solving and exam performance.¹³

Why we need a whole-university approach to mental health

Against this backdrop, university mental health services are increasingly positioned within a whole-university approach,¹⁴ positing that ‘...isolated interventions or services are inadequate to address the multifactorial challenge of multiple mental health determinants and consequences’, and ‘…a whole university approach means not only providing well-resourced mental health services and interventions, but taking a multi-stranded approach which recognises that all aspects of university life can support and promote mental health and wellbeing’.¹⁰ Informed by dual continua, systems-based, socioecological, and salutogenic theories,¹⁵ mental health and wellbeing are positioned on a continuum, within a whole-university approach, as ‘…the ability of an individual to fully exercise their cognitive, emotional, physical, and social powers leading to flourishing’ in interaction with the environment.¹⁰ Given that no single intervention has been found to be effective for all students¹⁶ and that the majority of students experiencing distress at university do not present to support services,⁷ a whole-university approach may be the most effective strategy to improve mental health outcomes for the whole university community.¹⁷

What does a whole-university approach look like?

The University Mental Health Charter outlines principles of good practice to operationalise a whole-university approach, informing and incentivising UK universities to demonstrate effective university-wide approaches to improving mental health and wellbeing outcomes for the whole university community.¹⁰ Comprising four domains and 18 themes, a whole-university strategy comprises one enabler to ensure cohesiveness of support across the provider, alongside holistic structural and cultural provision.¹⁰ ‘Since a policy provides a basis for all subsequent actions and ensures the sustainability of the initiative, failure to develop a healthy policy can negatively affect all other efforts to become a health promoting university.’¹⁷

What are the barriers to a whole-university approach?

In spite of the growing interest, there remains a lack of clarity and consensus on how a whole-university approach should be implemented and evaluated in practice.¹⁸ The use of inconsistent definitions and measures across research and practice have prevented clear evidence about what works in which context.¹⁹ Furthermore, while there can be no ‘one-size-fits-all’ template, and every university must necessarily develop a whole-university strategy attuned to its institutional context and population, the lack of specific practical guidance on how to create a whole-university strategy is a significant barrier to implementing an effective whole-university approach in practice.¹⁹

How do we create a whole-university strategy that works?

To better support universities to implement a whole-university approach in practice, there is a demand to apply and complement existing policy frameworks with specific, practical, proven and accessible guidance on what, why, how and who needs to be considered when designing mental health policies and/or practices as part of a whole-university approach. Grounded in an extensive and robust review of existing evidence and practical resources, with peer review from across the sector, the Charlie Waller Trust has launched a toolkit for university decision-makers to ‘CREATE’ an effective evidence-based university mental health strategy using the principles of Co-production, Risk Assessment, Evaluation, Accessibility, Togetherness and Embeddedness (see Figure 1).²⁰ Flexible within different institutional contexts, here is why these principles are integral to an effective whole-university strategy.

Figure 1: Principles to CREATE a whole-university strategy to mental health

Co-production

Effective mental health policies should be designed, disseminated and evaluated with input from a diverse range of students and staff.¹⁰ Advocated in the University Mental Health Charter, the Five Year Forward View, and the NHS Long Term Plan, evidence shows that co-production can ensure mental health initiatives are relevant to student needs, increasing responsivity, efficiency and effectiveness of delivery,²¹ while also producing beneficial wellbeing outcomes for participants, including self-efficacy, help-seeking and social connectivity.²² The toolkit provides evidence-informed guidance on how to implement co-production during inception, implementation and evaluation of mental health-related provision within a whole-university strategy.

Risk assessment

Effective mental health policies should specify procedures for alleviating, managing and responding to risk, including appropriate information-sharing systems.¹⁰ While student suicide rates remain lower than the general population,²³ 3% of students report attempting to end their lives and 25% report experiencing suicidal ideation annually.²⁴ Students with friends who end their own lives are more vulnerable to dropping out of university, underperforming or developing suicidal ideation.²⁵ Evidence shows that, where risk is not responded to appropriately, it presents elsewhere within the university environment and has an impact throughout the community on staff and peers.²⁶ Universities need procedures, systems and relevant expertise to respond appropriately to risk, and effective triage in place, to ensure that those at risk are identified and responded to in an appropriate timeframe by a suitably trained member of staff.²⁷ Therefore, while a whole-university strategy promotes universal wellbeing, it remains imperative to retain specialist counselling provision with clinical expertise,¹² in addition to developing external partnerships with NHS services for students at greatest risk.²⁶

Evaluation

Particularly given that mental health interventions have the potential to cause harm in certain circumstances,²⁸ regular evaluation should be embedded within university mental health policies and used to inform ongoing development of innovative provision that is appropriate for the specific institutional context and population.²⁹ The Theory of Change model³⁰ can be used to identify the evidence required to evaluate a specified impact of a complex intervention by aligning inputs, processes, outputs, outcomes and impact. In this way, evaluation can examine how outcomes are produced indirectly through interrelated and interacting factors, to understand ‘…not only whether a policy or initiative works, but how programmes work (or why they fail) in particular contexts and settings’.³¹ The toolkit provides evidence-informed practical guidance on how to evaluate mental health provision within a whole-university strategy.Ìý

Accessibility

Effective mental health policies should ensure accessibility for diverse student and staff experiences, needs and challenges, including structural, personal or cultural barriers to maintaining mental wellbeing.¹⁰ Indeed, evidence shows that students from minority backgrounds, such as black and minority ethnic students, international students, LGBTQ+ students, mature and postgraduate students, disabled students and distance learners, experience both practical and psychological challenges in the university environment that negatively impact on mental health, and are barriers to accessing or benefitting from existing mental health support.^32–34 While universal design can effectively incorporate diverse student needs and reduce the need for targeted adjustment,³⁵ a series of targeted interventions have been shown to be effective in improving mental health among minority groups.³² Additionally, academic staff
experience specific stressors and challenges that can benefit from targeted support.³⁶ A whole-university strategy should seek to deliver suitable provision to enable equitable outcomes across the diverse university community.

Togetherness

Effective mental health policies should be clearly coordinated, together with relevant university strategies, policies, procedures and external services. Alongside student services,³⁷ existing evidence shows that the whole culture and environment, from teaching, learning and assessment,³⁸ to the built environment,³⁹ to social relationships⁴⁰ and university accommodation,⁴¹ can have a significant impact on wellbeing and should be incorporated into a whole-university strategy.¹⁰

In addition, external partnerships with NHS and social care providers can significantly improve the efficacy of a whole-university strategy.²⁶ Pilot interventions have identified five priority domains to develop effective partnerships between university and NHS services, namely co-production of new services and policies with students; developing effective data collection, sharing and evaluation systems; implementing procedures to manage risk when students transition between services; measuring psychological outcomes for all students through services; and creating a service evaluation strategy.⁴² The toolkit provides guidance to plan effective and coordinated implementation of a mental health strategy using relevant research evidence, aligned with the University Mental Health Charter Principles of Good Practice, if appropriate.

Embeddedness

Effective mental health policies should be proactively embedded in the culture and environment of the university. Socioecological theories of health have demonstrated how health and mental health-related choices are framed and constrained by the wider institutional culture and environment.⁴³ Interventions to promote mental health require coordinated and consistent cultural and environmental cues that model, promote and enable positive mental health-related choices and behaviours.⁴⁴ A whole-university strategy thus necessitates ‘…the creation of appropriate social conditions which underlie or facilitate health-promotive behaviours’,⁴⁵ encompassing ‘…broad environmental change as well as individual behaviour change’.⁴⁶

The toolkit

Taken together, these CREATE principles provide a robust evidence-informed framework to support the implementation of an effective whole-university mental health strategy that can improve mental health outcomes across the whole-university community. Going forward, university policymakers and practitioners should adapt the CREATE guidance, in alignment with local institutional needs, to alleviate pressure on service delivery.