Student mental health: appendix 4

The recognition and management of students' emotional problems

This is an appendix to the Student mental health policy.

Emotional experiences are a normal part of everyone's life. The way an individual reacts to life's stresses will vary according to their personality, their life experiences and to the situation itself. University is a period of considerable change for students. Before they start university they are usually dependent on family and friends they have known since childhood; school will have offered a consistent, structured environment, where expectations were reasonably straightforward and clearly set out. After they leave university they will enter a world where there is likely to be far less security, where they will be expected to demonstrate initiative and where others will be dependent on them. The maturation that takes place during their time at University requires both intellectual and emotional development, each of which reinforces the other. Not surprisingly, therefore, students will experience a considerable range of emotional reactions during their University life, most of which will be normal.

A number of students, however, will experience emotions that are excessive and that are likely to impede their capacity to mature. As a consequence they may be unable to study effectively, or to engage in an enjoyable social life, or both. This may happen for a number of reasons, which usually reinforce each other. Broadly, these reasons reside either within the individual or are external; this balance between an individual's vulnerability and the nature and severity of the stressful experience underpins all emotional disorders.

Types of emotional disorders

Adjustment disorders and stress induced disorders

Emotional reactions in students are particularly likely to reflect the intensity of new relationships, loneliness, and study and examination pressures. They usually manifest as depression and/or anxiety and are generally self limiting, although they may continue for up to 6 months. These used to be called reactive depression or anxiety and are now termed adjustment disorders. Sometimes these reactions can be particularly severe or long lasting and call for active treatment. Increasingly, these diagnoses are characterised by the nature of the stress that has induced them. For example, post-traumatic stress disorder is applied when the stress is unusually severe and/or extended and bereavement disorder is applied to a major loss.

Dependency disorders

The recreational use of drugs and alcohol is increasing, not least because they are both easily available and cheap. University offers students an opportunity to experiment; about ideas, about relationships and, not surprisingly about drugs and alcohol. In many cases this will cause little harm, and even if it does, this will often be temporary. However, excessive use can result in personality change, poor concentration and deteriorating social functioning.

Serious mental illness: mood disorders and schizophrenia

Although serious mental illness is much less common, it can present for the first time in this age group. The two categories are mood disorders (depression and mania) and schizophrenia. About 10% of the population will experience a mood disorder at some time in their life, and for schizophrenia the figure is 1%. However, schizophrenia is particularly likely to develop in the young.

Developmental and personality disorders

When someone exhibits lifelong, pervasive, specific, dysfunctional attitudes or patterns of behaviour that fall outside the pattern found within their cultural and social norms they are said to have a personality disorder. This diagnosis always requires serious thought, because it has considerable implications regarding treatment and prognosis. It should rarely be made in a student population, whose personalities are still in the process of developing. Consequently, the majority of students who present with this sort of problem will have a developmental disorder.

Vulnerable students

Most students manage university life effectively and learn to manage complex situations and their emotional reactions to them. This is an essential part of their maturation and development. Nevertheless, the pressure of university life may be particularly great for individuals within certain groups, who may be more likely to experience severe emotional reactions or mental health problems. Examples of such groups include mature students, overseas students, students with a previous history of emotional problems, and students with a disability. The induction process for these groups could militate against this if it takes account of their specific needs. For example, students from overseas are particularly likely to feel isolated and lonely and therefore to benefit from active social support and advice. There may also be factors in an individual's upbringing that may make them particularly vulnerable, but these are likely to be hidden.

How to recognise emotional disorders

When it is obvious it is easy. However, it is often extremely difficult to distinguish between a brief, understandable emotional reaction from something more serious. The most obvious manifestation is usually a change in behaviour and or appearance that may not always be easy to recognize. Often it is recognized by other students who bring it to a tutor's attention. Examples of such changes include deterioration in academic performance, increasing requests for help, change in appearance, or obvious mood changes such as distress or aggression.

How to respond to someone who is  distressed

All students should be treated with dignity and respect, in order to ensure they feel listened to and understood. Such meetings should take place in private setting with adequate time made available. Even if initial contact takes place at the end of a lecture, for example, an appointment should be arranged to fulfil the above criteria. We would strongly recommend that a colleague knows about the meeting and is easily available, because there are potential risks associated with these situations, to both the member of staff and the student.

Perhaps the most helpful response is to listen. A student may give a clear picture of their difficulties if left to talk about them without interruption or to show they are upset. However, it is important that the listener takes some control of the overall situation and it may therefore be necessary to interrupt. For example, they may want to clarify something, or to draw the meeting to a close, or to suggest specialist help is indicated. There are no cast iron rules for how to do this, but it is probably better to be honest and explain why you are interrupting. To suggest meeting a counsellor does not preclude arranging to see the student again, which would enable you to talk it over with a colleague.

Finally, you may be seriously concerned about a student's mental health, for example because their behaviour is unpredictable or you begin to wonder whether they might be a danger to themselves or to others. Under these circumstances you may be recognizing a psychiatric emergency. This is a serious situation that may require immediate attention from a specialist. The objective of any intervention will be to get the student either assessed by the emergency doctor or taken to the A&E department at UCLH with as little fuss as possible. Certain situations require constraint and firmness. When this is necessary you will probably need to contact security.

Who you should consult and why

If the problem seems reasonably straightforward, but you still feel the need to discuss it with someone, it is probably better to do so with a colleague whose opinion you value. With increasing seriousness it will become necessary to seek advice from someone more senior or to contact the counselling service directly.

Keep records

It is always advisable to keep a brief record of any meeting with a student who is distressed.