There are high levels of alcohol in the UK population, with a particularly damaging pattern of ‘binge drinking’. Extreme alcohol use remains embedded in university culture. Since COVID and lockdown, male students, postgraduates and academic staff are likely to have increased their alcohol consumption. Starting university marks a rise in alcohol intake, to reduce social anxiety and ‘belong’ to the prevailing culture. High risk sexual behaviours rise significantly when alcohol is taken. Death by suicide, and deliberate self-harming, are associated with alcohol use. This is an important modifiable risk factor in addressing sexual violence and suicide. Mental disorders are strongly associated in complex interactions with alcohol use. Heavy alcohol use may be associated with other substance misuse and addictive behaviours. Abstaining from alcohol may result in striking improvements in mental health and academic performance. The rights and wellbeing of non-drinkers need to be acknowledged too. Information campaigns and paying lip service to disapproval do not work. The student age group tends to be less risk-averse than older groups. It falls to university authorities in partnership with local communities to control high risk alcohol intake.

This final chapter summarises themes which recur repeatedly when considering mental health in UK universities. It identifies seven key issues in determining the overall mental health of university communities in the UK: transitions, the need to belong, finance, routine and structure, social media, mental illness and intoxication. The rest of the chapter considers their importance and their interactions in the context of many significant changes in both the nature of universities themselves and in current attitudes to the nature of mental health and disorder. It is emphasised that the wellbeing and mental health of staff is also of concern and must be addressed if universities are to achieve their aspirations. The book concludes with a call for thoughtful action, rather than suggesting ‘quick fixes’, and appreciates the potential for mental well-being and human development in university communities.

Current discussions of ‘mental health’ obscure the fact that there are many different recognised different disorders, not all preventable, and not all responsive to the same approaches. This chapter provides an overview of the nature of mental illness, signposting readers for information on specific conditions to chapters elsewhere in the book. It is not appropriate for lay people to diagnose, treat or case-manage a student’s or colleague’s mental illness. However, some background awareness of the nature of mental illnesses can inform helpful responses. Mental disorders bring implications for admissions policies, rights and responsibilities, fitness to study and to practice, information-sharing with parents, provision of services and links with NHS and third sector. ‘Disclosing’ a mental health condition to the university provides rights to support, services and finance – the DSA (disabled students allowance). The key to accessing all NHS treatment is to be signed on with a local GP, but currently General Practices are financed better for elderly caseloads. Networking with university in-house mental health services is essential . Arrangements to hold GP and Psychiatric clinics on University premises are particularly welcome.

This wide ranging chapter examines the relationship of mental health with physical aspects of behaviour such as exercise, eating and sleeping and the consequences of dysregulation for both academic success and mental health. The loss of home and school structures at a time of continued physical and brain development puts the student age group at high risk of dysregulation-related disorders, including the so-called ‘eating disorders’. The author discusses benefits of restoring institutional structures such as canteens and adolescent-friendly timetabling. Physical activity, including outdoor activity is important for physical and mental health of all students and staff, and not just a competitive activity for the prestige of an institution. Universities will inevitably host many young people with eating disorders, given the demographic involved. The UK is underprovided with specialist eating disorders services, so that universities may need to develop expertise to support young adults in association with NHS clinics. However, eating disorders can affect people of any age or gender. Staff as well as students may experience these conditions and should be offered services where their privacy is protected.

This chapter follows on from the previous chapter, now focussing on challenges of transition to university for students already diagnosed with a mental illness. It examines the pros and cons of different options in this situation, highlighting the time involved in negotiating health service transfers. Financial and geographical organisation of health services result in dangerous gaps in treatment and support. Academic studies can be therapeutic and contribute to recovery and self-esteem but high levels of competitiveness threaten success and mental well-being. Wellbeing and pastoral support are important factors in choice of a university for people with pre-existing mental illness. Mental illness can delay the adolescent maturational process. Formal mentoring into and during university life can be particularly helpful for those vulnerable to mental illness. Transitions occurring further on in university life also require careful management. Staff and students with mental disorders who need periods of sick leave should be supported both to leave academia and to return later on. If a return is not possible, as well as at the end of a course or contract, there is a potentially high risk gap where university services are no longer accessible.

Universities should recognise neurodiversity as conferring risk for mental health conditions and suicide. Evidence-based support and monitoring can reduce the risk of these occurring and can also reduce dropout and improve academic and psychosocial outcomes for these students and staff members. Staff training in recognition and management of neurodiverse conditions should be delivered at levels appropriate to staff roles. Despite growing interest in both ASD and ADHD in adults, many people who could benefit from diagnosis have not received it. Professionals need to be aware of underdiagnosis of both ASD and ADHD in girls and probably in ethnic and other minority groups. Lack of recognition deprives these vulnerable people of the supports universities can offer to people with neurodiversity. Lay people who take on caring or ‘buddying’ roles for people with neurodiversity need to be well-supported within a helping community rather than expected to shoulder responsibility alone. Waiting lists at many NHS clinics are too long to provide timely assessment for students. University mental health staff may be able to create recognised training programmes and negotiate agreements about diagnosis and prescribing with local GPs.

This, the first of two chapters on the transition from school and home to university, addresses general principles of the nature of transitions. All significant transitions involve normal healthy grieving what is lost (‘homesickness’), alongside rebuilding helpful structures and finding new relationships. Concepts of ‘thresholders’ and ‘transition aged youth’ are discussed alongside growing evidence that dynamic changes in the adolescent brain and mind continue longer than previously thought. Other life transitions are considered from an interpersonal perspective, acknowledging that parents and other family members simultaneously experience disruptive role transitions when a student leaves the family. Individual differences and diverse backgrounds make it difficult to know how much adult capacity can be realistically expected of new students. A list of ‘readiness skills’ is provided for consideration, without the expectation that these will all be mastered before leaving home and school. The author suggests that university need not be the automatic immediate option for school leavers and discusses benefits of using wider criteria than the purely academic to choose a university. Finally induction courses, summer schools and other ways of preparing for university are discussed. These include the peer expectation of using alcohol to manage the inevitable social challenges.

The relatively recent ‘commodification’ of higher education in UK culture has consequences for the overall mental wellbeing of university communities. Students arrive with differing levels of financial confidence. Many graduate with increased financial stresses. Debt and financial concern are associated with poorer mental health and academic under-performance at university and lower levels of well-being after graduation. It is worth sensitively asking troubled students – and staff - about financial worries. More than 40% of UK students with a mental health disorder reported being in debt, compared with 17.5% of those without a diagnosis. Debt is associated with depression, suicide, self-harm, problem drinking, drug dependence, neurotic and psychotic disorders, and eating disorders. The combination of financial stress with maladaptive coping strategies such as gambling, sex working and drug dealing can lead to damaging association with criminal sub-cultures. Students experience vicious spirals as mental disorder and financial concerns interact over their university career. They are more likely to seek timely support when they perceive financial advisors as sympathetic and supportive rather than angry and blaming. Financial ‘savvy’ can be explicitly taught and supported, with benefits for mental health.

Digital technology is ubiquitous in university life. It became indispensable during COVID as a means of delivering teaching and also therapy. University websites and intranets can be valuable repositories of respected health information, signposting and self-help resources, but these need to be kept up to date. There is still a generation gap in terms of being ‘media savvy’ and older people have different experiences online. Society is waking up to the relentless commercial interests driving our online interactions and the psychological conditioning involved. Society needs to protect young brains in particular from exploitation and harm. Long periods spent online mimic psychiatric disorders, by interfering with concentration, causing sleep deprivation, dysregulation, obsessional checking behaviours, body image dysphoria and abnormal interpersonal relations. Unmonitored content and algorithmic amplifications increase distress. Rising rates of deliberate self harm and suicide rates appear to be associated with online experience. Legal and institutional regulation is unlikely to occur without grass roots campaigning. Schools and families usually provides some protection and online safety education. This needs to be reinforced and revisited during the transition to university. Clinicians and others concerned about mental health or wellbeing should explicitly ask questions such as ‘what’s going on for you online?’

Families continue to provide immense financial and psychosocial support to their student age children. ‘Estranged students’ and those who are themselves carers suffer financial, academic and social obstacles to a successful university experience. Parents now expect greater participation in the lives of their student children, as financial realities empower them to influence their children’s choices. From age 18 students are deemed ‘adults’, but without adult rights to an independent student loan, or legal compulsion on their parents to provide finance. Parents have little feedback or power over the resource they are asked to finance. Communication between universities and parents has attracted controversy. Universities are experimenting with ways to clarify how nominated carers can be consulted about students at risk. Families may become the unsupported carers when a student has left university in an unplanned way, as well as when the course comes to an end. The chapter considers the value of developing a ‘leavers’ programme’, analogous to freshers weeks, as well as a specific package of supports for students who leave in an unplanned way.

Better nurturing of ethnic diversity can be associated with improved academic achievement as well as more ethical university communities. Despite ‘wake up calls’ such as the Black Lives Matter movement, there is no room for complacency. The UK does not have predominantly black universities, though student cultural societies allow a sense of belonging. Individuals from minority ethnic groups should not automatically have to take responsibility as BAME campaigners. White staff and students need to overcome defensiveness to prevent ‘white fragility’ from blocking progress. In choosing a university, families of all ethnicities can ask whether the institution is signed up to Advance HE’s race equality charter (REC). Staff should assertively support BAME staff appointments and grant applications, and ensure that racial awareness trainings are evidence based. University Disciplinary procedures need to offer greater openness to complaints of discrimination and harassment. In University counselling services appointing more BAME practitioners improves the ethnic diversity of the clinical group, whether or not clients opt to meet with a clinician of non-white ethnicity. BAME students need extra support to return to academia after a mental illness as they are at greater risk of ‘dropping out’.

Substance misuse is already widespread in UK schools, The greater freedoms of university make undergraduates particularly vulnerable to starting or increasing. Legal and medical agencies focus more on forensic consequences of established addiction. University drug use is not only recreational but may be motivated by improved performance or appearance. It is not clear whether the UK actively pursues eradication of non-medicinal drugs or prefers arrangements for safer consumption. Most universities officially ban drug use, but some student unions are permitted to provide facilities to enhance safer consumption. Lessons can be learned from the benefits and challenges of the UK smoking ‘ban’ and the history of alcohol ‘prohibition’. Drug use prevention and management need more rigorous research to discover what works and what doesn’t. Universities are ideally placed to conduct this. Meanwhile regulations need regular review by students, staff and authorities in collaboration. There is paucity of NHS treatment options for substance misuse. Confidential group-based support such as that provided by 12-step groups may provide particular advantages for students living away from home. Students and staff with drug-related concerns can also access advice from University Counselling Services and University Mental Health Advisors.

UK university life lends itself to experimentation in sexual behaviour, orientation and gender identity. The experience of sexual liberation can affect trust and communication with students’ culture and family of origin. Casual sexual encounters (‘hooking up’) are common at first. Those who settle into more monogamous ‘dating’ enjoy better mental health. Mental illness is associated with less healthy sexual experiences. The sexual dimension of life is important to the student age group and should be considered in assessment and treatment. Despite the relatively tolerant environment, university LGBTQ+ communities are at higher risk of mental illness. Students with ASD may also need extra support to negotiate sexual development. Some students have previous sexual trauma, which may still be unaddressed. Some school sex education protects students from gender-based violence throughout university, but classes are often delivered without awareness of pupils’ ethical and relational concerns. Social media provides influential, but often misleading sex education. High reliance on online dating is associated with poorer levels of mental health. Excessive alcohol and drug consumption are strongly associated with both perpetrating gender-based violence and becoming a victim.

Three groups of severe mental illness have disproportionately high rates of suicide – Schizophrenia, bipolar disorder, and anorexia nervosa – but effective treatment can save lives. Despite more positive conversations about mental health, we often avoid the very mention of schizophrenia and psychotic disorders. It is impossible and unsafe to support a seriously mentally ill person unaided. Clinicians and lay carers need to be part of a mutually supportive network. Integrating care involves a series of permissions - preferably arranged in advance – to communicate with confidentiality, privacy and dignity. Effective treatment of acute psychoses involves thoughtful prescribing and monitoring of medication. It is understandable to feel angry and sad about having an illness that interrupts life and education. There are effective treatments even for the most severe mental illnesses that affect young students. However, it takes far longer to see recovery than with most physical conditions. Policies on admissions, fitness to study and time taken out of studies need to take account of this. Students usually need care to be transferred to the location of the family home and later back again. NHS teams may be able to use telemedicine to communicate with a distant University.