Oxford has a high proportion of students in its population. We estimate that there are around 40,000 students in Further and Higher Education in Oxford.
This chapter is intended to help inform the work of a wide range of healthcare staff, whether they are working in Primary, Secondary or Tertiary care services. It is based on interviews, discussions and meetings held with healthcare staff themselves, as well as students and staff in academic institutions.
What do you need to know if you have a student as a patient?
It is difficult to generalise about students as they come from many different backgrounds. There are increasing numbers of:
- mature students
- international students
- students from socio-economic and ethnic backgrounds not previously associated with further and higher education
Research studies are showing consistently high levels of anxiety and depression in student populations compared to the population in general and to young people in particular. For example, one UK study found that students were 1.64 times more likely to experience symptoms of mental ill health than the general population (Harrison et al 1999).
Nationally, university and college counselling services are reporting an increasing number of students presenting with severe psychological difficulties and this is borne out by our research locally.
Care services used by students
Students experience the same range of mental health problems as encountered in the general population of their age group. Our local support map shows many of the services and sources of support used by students at an informal and Primary Care level.
Students also use Secondary and Tertiary Care level services. These services include:
- Community Mental Health Teams
- Hospital wards (especially Vaughan Thomas and Ashurst)
- Department for Psychological Medicine
- Department of Psychiatry
- Psychotherapy Department - Warneford Hospital
- Highfield Family and Adolescent Unit
- Crisis Resolution and Home Treatment Team
- Specialist Community Addictions Service
- Oxford Adult Eating Disorders Service, Cotswold House
Students' living arrangements
Many students are living away from home for the first time and this brings its own pressures combined with a danger of social isolation. Issues around sexuality often come out at this time. Their living situation may be isolated in a bedsit, or quite closely involved with other students in a shared house, hall of residence or college. Continuity of health care may be difficult where students only have accommodation during term time. All these factors have implications for their mental well-being.
Drugs and alcohol
In common with many young adults, students live in a culture where drugs and alcohol are readily available and peer pressures can be difficult to resist. Research shows that a large proportion of students drink in excess of the recommended levels for healthy living. If a patient who is a student needs to avoid alcohol or drug use as part of their recovery plan, they may need extra support in doing so.
Pressure of exams
Exams can be very stressful events and healthcare staff may notice an increase in referrals around exam times. (Student counselling services often have a high level of expertise in helping students deal with examination stress).
The assessment patterns vary. Undergraduates at Oxford Brookes take exams for their modules each term.
In contrast, at the University of Oxford the period between first and final examinations is usually two years, but when they occur these examinations are often in a concentrated form with several papers being taken on consecutive days.
Students at Brookes can re-sit exams, but can only resit one module in a term. Allowances may be made for personal and medical factors which affect the student's performance at the time of the examination. At the University of Oxford students may well be advised to take time out and sit the exams at a later date if their performance is likely to be seriously affected by health difficulties. Students at the Oxford and Cherwell Valley College are assessed by a variety of means including exams, continuous assessment and performance assessment depending on the courses taken.
Special examination conditions
It may be possible for the student to negotiate to take the exam away from the public examination room. Since this requires special invigilation, notice of this will normally be required well in advance.
Students may request a medical note explaining why their performance in an examination may have been impaired by their condition.
Financial pressures and paid work
With the removal of grants, most students take out student loans, have overdrafts and run up credit card debts. It is estimated that the average student leaves university with £15,000 of debt. These high levels of debt have been associated with raised levels of anxiety and depression. Many students are now working part-time and having to juggle the need to make money with the other demands of student life. If a student has to suspend their studies they may become liable to Council Tax thus increasing the financial pressures on them.
At an informal level, some students may approach student-led sources of advice and support. Examples of this type of support include: college-based student welfare representatives, residential assistants, student union welfare officers, lesbian, gay and bi-sexual representatives, and Nightline. These sources of support encounter a lot of common mental health issues and may be used by the student independently of, or in addition to, formal help.
Many students do not want other students to know that they have mental health problems. However, living in close proximity to others makes this hard to achieve. If the student has displayed any behaviour which marked them out as odd or difficult this will have been noticed within their community. Naturally the student may feel quite anxious about returning to a situation in which other people have witnessed the results of their ill-health. Students may also be reluctant to have a CPN visiting them in Hall or College as these are very public arenas.
Students are very concerned about the effect that a mental health diagnosis will have on their future career prospects. This concern combined with the general stigma attached to mental health issues seems to delay students' presentations for help and treatment.
Fit to return to study?
When is a student fit to return to their studies? This will vary depending on both the student and their institution. With Modular Degree courses such as those at Oxford Brookes, it may be possible for the student to take a term out and/or reduce the pace of their studying to a part-time pattern. At the University of Oxford, a prolonged absence may result in the student having to take the remaining part of the year out and then return to complete all or part of the missed year. The student can get advice from the Disabled Students Advisor/ Disability Officer in their University about any ways in which the institution can make reasonable adjustments for their mental health problems.
Many students have completed their courses and gained good qualifications despite experiencing severe mental health problems.
What support is available within the educational environment?
When students are discharged from psychiatric treatment, the responsibility for their ongoing medical care rests with the GP. An area that can cause confusion is whether an educational institution is in a position to provide regular monitoring of the student's condition.
Whilst local educational institutions do provide a range of support options for their students, one thing must be made clear: these institutions do not provide designated mental health workers who are in a position to accept medical or clinical responsibility for the student. Therefore students cannot technically be discharged into the 'care' of their university or college. There are student counselling services who may well be involved in regular supportive or therapeutic activities after discharge but they are not able to take on a case management role or substitute for psychiatric support.
Similarly, personal and subject tutors may be involved in providing pastoral support for the student, but this support has its boundaries.
If a student needs ongoing psychiatric support this needs to be provided by healthcare staff. However, with the student's permission, it is helpful to liaise with staff within the educational institution so that they can support the student's academic and therapeutic progress and to ensure that their residential arrangements are satisfactory. The map of local support options indicates the range of support available.
Who can you contact in the educational institution?
If the student is willing, it can be very helpful to make contact with a member of staff from their college or university in order to facilitate the return to academic life, or discuss other options. In exceptional circumstances it may be necessary to make contact even if the student is not willing, e.g. if there is concern about attempted suicide, or potential harm to others. This concern would have to be very marked for a member of healthcare staff to override a patient's wishes, issues of confidentiality are paramount. In some cases the student may know who is the best person to contact, or you may have developed your own contacts. If you are not sure who to approach, suggested contacts for each institution are as follows:
The University is made up of around 40 individual colleges and contact could be one of a number of staff members including the college Dean. However, as a Dean often has both a welfare and a disciplinary role, the student may wish for some other member of staff to be contacted. In some cases there will not be a Dean. Contact details for the individual colleges and their staff can be found by visiting http://www.ox.ac.uk/colleges.
Oxford Brookes University
The first port of call at Brookes is Student Services. They can be contacted at 01865 484658.
Oxford and Cherwell Valley College
Contact Student Services in the first instance via the College's main switchboard on 01865 550550.
The student's family
Most students in universities are 18 or over and are thus considered to be independent adults who can choose who should have information about a mental health problem. They may well choose not to give information to even the most supportive families. This can occasionally lead to difficulties when for example students living in university accommodation don't want their families to be involved, and the university or college is reluctant to have the student back until they have made a substantial recovery. There is no easy solution to this situation, but it can help with the student's permission to involve a representative of the educational institution in the discussion of options available.
Problems can occur when parents' input is needed e.g. due to a suicide risk or if the student faces being send down for a year and needs to be sent home. Some students will refuse contact with parents and I then face complicated three-way situations involving GPs, colleges and parents. Where parents cannot be involved, it may be possible to tolerate a higher threshold of disturbance before the students have to leave, but it lowers the threshold when you are dealing with self harm, aggression, romantic harassment or stalking behaviours.
Details of resources for staff working in the healthcare field can be found on the resources page here