Regulatory bodies need clear, policies and pathways for fitness to practise concerns. Many FTP regulations conflate by implication the ideas of mental illness and irresponsible behaviour. Policies and protocols should be regularly reviewed, redeveloped and publicised in collaboration with students and recently graduated trainees as well as faculty policy makers. Most people experience mental illnesses at some point in our lives, so it’s impractical as well as unethical to exclude students from professions on such grounds. It is illogical to regard suffering from a mental illness as a disciplinary matter, although failure to address illness in a responsible way is unacceptable. Close-knit student cultures within professional specialities may encourage unhealthy coping strategies and put up obstacles to accessing treatment. Stigma and mistrust have passed into the culture, with a risk of untreated mental illness leading to avoidable suffering and impairment. The most intractable issue in FTP concerns is where a practitioner lacks insight into the consequences of their own behaviour. However, there is positive experience in managing episodic loss of insight during a known mental illness, using advance planning.

Students and staff are provided with a range of mental health supports, many of them boasting excellent outcomes, but not always adequately connected up. Counsellors, Mental Health Advisors and Mental Health Mentors are available without fee to most university students. These are well researched and evidenced in the treatment of mild to moderate mental illnesses and in the support of people with longer term disorders. Chaplaincy takes many forms and is also a widely available but less well evidenced. There is still much work to do in terms of integrating different services around a vulnerable student. The challenge is greatest when NHS as well as in-house university services are needed. Students with severe mental disorders require longer courses of therapy than university Counselling services routinely offer, and arrangements for treatment during vacations are essential. Integrative models such as that piloted in Greater Manchester show promise, but smaller, less urban universities need different solutions. More than half of universities have no GP on campus. Workforce shortages and funding anomalies make it ever more difficult for GPs to co-ordinate the care of their university patients.

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.

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.

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’.

This introductory chapter sets out the need for a handbook of university mental health. It considers the health of staff alongside that of students, and that does not presume American systems of education and healthcare. Far more of the UK population expects to attend university, with a consequent expansion in the size and numbers of institutions. Financial constraints mean that universities can no longer run as elite communities of self-governing scholars, but are now governed according to business models, with implications for the wellbeing of all involved. In the context of population-wide increases in mental disorder and demand for treatment, more students than ever now disclose a psychiatric diagnosis. The recent COVID pandemic and lockdown disproportionately threatened the well-being of students and may have changed for good some of the ways in which education and healthcare are delivered. The author summarises her own personal and professional of UK university life and describes the motivation for embarking on the production of a single author handbook on this topic. A wide readership is welcomed to the book, which will provide a series of interlinked but standalone chapters to be consulted piecemeal as well as read as a whole.

Depressive symptoms may be the observable features of several different mental conditions, which require different treatments. It is particularly important to identify bipolar vulnerability. Alcohol and other recreational drugs can cause or worsen depression and anxiety. Eating disorders can be manifestations of depression or anxiety, but can also bring about these conditions. People with autism may be particularly vulnerable to anxiety disorders. Students suffer from depression and anxiety disorders at around the same rate as the rest of their age group but have unique difficulties accessing treatment. They can benefit from access to psychotherapies alongside medication to enhance benefits. There is a wide range of anxiety disorders, and anxiety is very often present alongside depression. In such cases higher doses of the so-called ‘antidepressant’ drugs are required. Students and staff may have both genetic and environment predispositions to mental disorders. Treatments which have helped a family member may prove most effective. Prescribing for female students and staff should consider safety during any future pregnancy. Students with more severe depression or anxiety disorders require longer therapies than university counselling routinely offers. Discussions with local NHS clinics are needed. Arrangements for treatment during vacations are essential.

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.

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.