Dr Tim Noble: Mental Health Awareness Week

We are marking Mental Health Week with an article from Dr Tim Noble, head of the University of Kent’s Medical Centre. Dr Noble has been a partner at the University Medical Centre for over twenty-five years where all the practitioners have an interest in student health with an emphasis on mental  health, sexual health and health promotion. In addition to medicine, Dr Noble retains an interest in the arts, gaining a BA(hons) in Fine Art at the University of Creative Arts in 2014. This article is based on a presentation he made to the Canterbury Society in November 2018. 

Is there an increasing incidence of mental health problems among young people? If there is, what are the causes, what are the barriers to seeking help? Finally, what are possible solutions, and what is happening here in Canterbury?

Mental health issues receive much more publicity today than 10 years ago. The Times has reported that 10% of people attending their GP have mental health problems. We now have minister for suicide prevention and one for loneliness. The mental health charity, MIND, reports that 1 in 4 of the population will experience a mental health problem each year and 1 in 6 are suffering each week. 

At the University Medical Centre we are seeing more patients with a wider range of problems. The doctors’ workload has changed over the past ten years as we now have very able nurse practitioners/prescribers who are able to deal with many minor illnesses leaving us to deal with possibly more complex patients. So are there now more depressed and anxious young people?

Student suicides

One of the biggest  headline grabber of last year was the report of an increase in student suicides. In particular the University of Bristol where ten student deaths in 18 months was highlighted although not all were suicides. The University of York reported that over 30% of ambulance call outs to the campus were for incidents of self-harm. The Office for National Statistics reported the rate of suicides in higher education in England and Wales for the twelve months up to July 2017 as 4.7 per 100,00, equating to a total of 95 suicides. More men than women kill themselves and the highest rates were among students that were 25 years. It is not among the freshers coming straight from school.  Two thirds of the students who kill themselves are unknown to support services. However, to put it into context across all ages this rate is half that of the non-student population.

So perhaps we need to look at another source of information. The Higher Education Statistics Agency recorded in 2016/17 around 550,000 students were enrolled as undergraduates. 12% of all new undergraduates self-declared a disability — an increase of 30% in five years. Half of these have specific learning difficulties such as dyslexia, dyspraxia autism and ADHD. Around a quarter declared mental health conditionsAt the University of Kent the percentage of all students with disabilities disclosing a mental health condition, has increased from 5% in 2007/8 to 37.7% in 2017/18 — higher than the national average.

But does self-declaration, which also includes self-diagnosis, reflect accurately the prevalence of mental health problems? The NHS website will direct you to a screening questionnaire if you search depression. People diagnosing themselves does not give an idea of the severity of ill health. There is a spectrum and not everything will be pathological having a significant impact on life. Lumping all mental health disease together is not helpful. Anxiety and depression are not the same as psychotic illnesses for example.

Other information on increases in incidence comes from demands for services such as campus counselling and student support services. There may be an element of self-justification or self-preservation here — the more demand there is, the more we can offer, the safer the funding, etc.

The one thing that seems to be agreed is that there is greater awareness of mental health issues in general with students and their families being a more vocal and an acceptable face for media attention than that among other young people.

Is this greater awareness a good thing?  Professor Simon Wessely the first psychiatric president of the Royal Society of Medicine feels we should end public awareness campaigns about mental health. He points out that services are already stretched and cannot deal with the people we know about now and we may convince some people they are ill when they are not. A recent National Union of Students survey reported 78% of respondents said they had mental health problems with a third saying they had suicidal thoughts!

What are the causes of mental health issues?

What are the drivers for this increase? Aren’t students supposed to be having the best years of their lives?

We can look at possible causes for the increase and break them into (a) general non-specific factors, and (b) those related to this age group in particular.

We are living in an age of austerity and so financial worries are in the picture. Self-declared disability among students has increased by 30% since tuition fees went up to £9,000. They have fears of their student debt. Many have to work to top up maintenance grants. Canterbury’s shops, bars and restaurants would grind to a halt without them.  Austerity may hinder parental ability to help out.  The cost of living is much higher here than for students in the north of the country. There are fears about the lack of suitable graduate jobs — a fear that the time and money spent studying is not being rewarded as promised with the push to increase numbers in higher education.

Social media has a big impact, not necessarily causing depression or anxiety but affecting expectations and changing behaviour.  Certain concerns about social media are common. The way algorithms work can reinforce views limiting horizons and choices as we are at the mercy of unregulated content creators.

“Facebook” envy can lower self-esteem — we compare ourselves to others’ handpicked highlights, with photoshopped pictures to prove what a good time is being had by everyone else. We see lots images of perfect bodies. Our real life does not compare to others’ greatest hits. This is “keeping up with the Joneses” taken to another level. As one of my medical partners put it – it’s your inside comparing itself to someone else’s outside.

Constant updates can make it seem life is happening somewhere else. There can be the need to obtain validation from other people to boost self-esteem and self-confidence. It can affect how we remember things — there is a distortion of recall focusing on the destination, not the journey.

Sleep can be affected — the light from devices can affect our body clock, and the need to constantly check for updates in fear of missing out can stop us switching off.

It can have an effect on behaviour if we try to increase our “likes” or emulate those we compare ourselves too, and of course cyberbullying- especially among teenage girls- can have direct effect on mental health. The need to have lots of “friends” means our information is shared outside our close circle and the potential for misuse of this is increased.

There is some evidence that happiness and life satisfaction drop the more we use social media.  Although you can have many friends this can come at the cost of a reduced ability to forge close personal relationships, we lose the human connection- a powerful tool which helps build lifelong skills including empathy and compassion.

The role of loneliness

Loneliness is a factor. A recent BBC survey of 55,000 found 40% of 18-24 years old reported often experiencing loneliness compared to 27% in those over 75 years old. It is more than just being alone. People reporting loneliness are in poorer health. It is more common in those who feel discriminated against and is associated with feelings of shame and reduced trust in others. It is a relatively modern construct, a product of how we think about the self and society and a shift away from the concept of community as a source of common good.

Are health professionals to blame?

Voltaire said “The art of medicine consists in amusing the patient while nature cures the disease.”  Before the second world war, apart from surgery, there was little doctors could do to actively ease suffering. Surgical breakthroughs came on the back of the development of antisepsis and anaesthesia and pain control. Most improvements in life span and reduction in disease burden are down to public health measures — better housing, proper drainage, clean water and so on.

Unfortunately, medicine has forgotten this art on the way and although it has always classified diseases, there now seems a move to label everything and a tendency to medicalise and professionalise human behaviour. Oh, and doctors prescribe things. Pharmaceutical companies always search for new  business opportunities. The medical profession can aid and abet them in this. DSM — the diagnostic and statistical manual is a “comprehensive classification of officially-recognised psychiatric disorders, published by the American Psychiatric Association, for use by mental health professionals to ensure uniformity of diagnosis”. Its 2013 incarnation — DSM5 —caused controversy by  pathologising toddler temper tantrums, gluttony, grief and forgetfulness in old age amongst others. We are in danger of medicalising normal behaviour and becoming less accepting of the reality of being normal human beings.

As a profession we are guilty — in part it is because we all want to help and be liked but also because we are becoming more risk averse and defensive. We are fearful of complaints which have a significant negative impact on doctors and the way they practice medicine. Patients are more informed, which is a good thing, and misinformed, which isn’t. Both can affect the outcome of the consultation. It can be difficult to confront or challenge a patient’s beliefs at times if worried about complaints or an adverse comment in the feedback surveys.

And drugs?

There is little evidence that drug abuse is causing problems in among students. Some use alcohol and drugs to self-medicate to reduce symptoms of anxiety and depression for example, and every year psychotic illnesses are precipitated by drug misuse. But these can be counted on one hand as could students with significant alcohol dependency. Recent reports also suggest that adolescents are drinking less than their parents’ generation.

Changing family structures

The breakdown of family-life is a burden for many. We often hear of parents separating when the child leaves for university having stayed together up until then to reduce the fall out. This can mean loss of the family home and its support network — sometimes parents relocating miles away so that for the student nowhere is familiar or home. We sometimes see the student being ‘piggy in the middle’, hearing things about each parent from the other they don’t need or want to know. They can be encouraged or forced to take sides. Sometimes the relationship is unhealthy- “best friend” instead of mum or dad- which may help the parent but is not good for the child. They may feel responsible for their younger siblings left at home and feel guilty for leaving them behind. Not happy at home and not happy at university.

Widening participation with nearly 50% of school-leavers attending higher education does mean more attending who may have been precluded in the past- possibly because of disability or mental health conditions. There is also evidence that those who are the first in the family to attend university struggle more than others. It is quite a jump- perhaps being away from home for the first time, miles away from one’s support network and a different way of teaching and learning. The expectations of those back home and meeting people from different backgrounds all add pressure.

50% of long-term mental illnesses have presented to doctors in the teenage years and 75% by the age of 25 years. This is an age where significant illnesses such as schizophrenia, bipolar affective disorder and personality disorders first become manifest. We see more students attending with pre-existing mental illnesses who have often been well supported by the child and adolescent mental health services (CAMHS) but are now transplanted away from that support. In Canterbury the adult mental health services are struggling and handovers between child and adult services non-existent or poor which can then precipitate crises. Many still need support and some should have been advised not to come away from their home communities as they are still struggling. The lack of continuity of care does this group a great disservice.

This can be a time when sexuality is first explored and there seems to be a lot more to choose from now compared to my student days. Mixed in with this is the issue of gender — another area of self-declaration — and the effect this can have on mental health. We are certainly seeing more transgender patients and some seem to have mental health co-morbidities including anxiety and depression.

The current generation of students are interested in metrics and outcomes. They have been measured throughout their schooling with pressure on them to help the school move up the league table- SATs, 11+, Ofsted inspections, GCSEs and A-levels, and can view anything other than a first class degree as a disappointment. For some the outcomes are more important than the process. An emphasis on getting the best mark to get the best job can lead to frustration, low self-esteem and depression if unachievable goals are inevitably missed.

Higher education as a contributor
There is evidence that the nature of higher education affects mental health. Larger class sizes adversely affects health but more lectures and structured timetabling has beneficial effects. The move away from the personal tutor system has not helped as there is a lack continuity or anchor for many. A more personalised approach acts as an early warning system. Wellbeing support is good but needs to be opted into which is not easy if you are feeling anxious, depressed and isolated.

Another risk may be entering university through clearing- the disappointment of missed grades, ending up in somewhere unexpected and on a different course- possibly in a place that has not been investigated.  Calling the clearing hotlines can be stressful and with universities competing for students and their money there is a danger that call staff can be too persuasive.

Social media can reduce empathy and compassion. Is this exacerbated by a move from communal catered halls with shared facilities to self-catered en suite accommodation, with some new builds having studio flats- reducing the opportunity for face to face interaction. This may also explain the difficulties experienced by some housemates when they move out to privately-rented accommodation usually in the second year, when previously unknown habits of friends come to light and have to be endured.  Fallings out between housemates can create great difficulties especially when you are tied into a contract with no way out of the situation until the following year.

Resilience

One final theme that seems to crop up is resilience, or perceived lack of it. Some say that young people need to develop the ability to cope with difficulties themselves rather than expect others to solve their problems. Students can see this as a synonym for strength, whereby lack of resilience equals weakness. Resilience is better defined as the ability to recover, to bounce back from misfortune and to adjust easily to change and is obviously useful skill. In part this may stem from the desire for instant gratification — this hard-wired need for a result rather than the process of learning —taking us back to social media again. Perhaps the increasing focus on the mental health of students and the solutions offered are part of the problem. Individuals don’t learn how to manage life’s disappointments if they are encouraged to attend seek help from services and become reliant on these rather than accepting these episodes as normal. Helicopter parents who hover over their children paying close attention to their experiences and problems may contribute to this lack of resilience.

Is Canterbury different?

Are there specific factors here in Canterbury? The university promotes itself as the UK’s European University and as such 10% of students are from the EU and 15% are from non-EU countries. This adds another level of stress, with cultural differences in health seeking behaviour and beliefs. We are a small city and this causes hardship for those coming from larger metropolitan areas. Here, there is less diversity and fewer opportunities to be able to express oneself.

Kent University has a disproportionately higher rate of self-declared mental illness compared to the national benchmark. The way the university is set up with a medical centre on campus and a dedicated student health service (possibly the only place in the country with this) and the excellent Wellbeing service may all be factors. Students with existing mental health difficulties may actively choose to come here because of the support available. This has a potential to distort the local health economy.

Obstacles to recovery

What are the barriers to getting help? The nature of anxiety and depression can prevent people reaching out — often the onset is insidious and the illnesses affect all aspects of thinking — we can feel we deserve to feel this way and that nothing can be done anyway. We tend to shy away from people and become more withdrawn — its often at the prompting of friends or family that leads to the first step towards help. There is the sense of shame. Mental ill health continues to carry with it a stigma — that one is weak, that it occurs because of some kind of failing in the individual, that one is lazy and should be able to pull themselves out of it. There are lots of celebrities —royalty, actors, models, pop-stars- all very glamorous — talking about their struggles which helps bring publicity and funding but may distort the message. There can be concerns about mental health problems being “on their records” and whether this will affect future employment. Continuity of care can be difficult if time is split between university in term and home during the vacations.

There is a lack of NHS funding in proportion to the burden of disease. Mental health problems account for 23% of the illnesses but only receive 11% of the funding. This has been increased recently but it is nowhere near enough. There are staff shortages so recruitment is a major problem and it takes a long time to develop experienced skilled professionals. Locally we find it very difficult to get patients that are high risk either to be seen or if seen to be  taken on by the community mental health team. One consequence of this shortfall in funding is long waiting lists for help.

The universities are working hard to help their students but there is an argument that they are places of education with an academic mission and should not be expected to be fully responsible for the emotional and psychological needs of their students. We should of course remember that the majority sail through this important stage of life without problems and some who achieve great things despite significant set-backs in their lives. Graduates are in better overall health than non- graduates and their earnings are higher over a lifetime.

But there is much more to be done. Celebrities, Royals and the media are reducing the stigma attached to mental illness. Even so, the social, psychological, emotional and factors involved in mental illness confirms it will continue to be an inherent feature of modern society.

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