The Cambridge Mental Health Survey

Looking at the results of the Mental Health Survey, it’s almost impossible to know where to start. There are so many people suffering from so many conditions, and so many of the institutions that are supposed to help them are failing them, to the point that an unacceptable number of students are left in a worse state than that in which they began.

Potential issues with the data, or why the stats are significant

It’s probably best to begin by pointing out the potential flaws in the data. Many people have pointed out to me that the survey may suffer from self-selection bias: the people who are most likely to answer are those who have been affected by mental illness in the past. In response to this, I don’t think it would be over-reaching to say that almost all students in Cambridge will, at some point, have been affected by mental illness, whether it be their own or that of a friend or acquaintance. The results of the survey speak for themselves: if you are in Cambridge, you know someone who is depressed. There is no minority demographic who are affected by mental illness and who answered the survey: the article had 7000 views (many of which will have been repeats) and the survey had 1749 responses. That is not the response of a small number of people with a vested interest in changing the system, that is 15% of all undergraduates in Cambridge. This is not a niche issue.

In addition, the representativeness of the sample is corroborated somewhat by the statistics on degrading (or intermitting, if you prefer) provided by the university. It’s worth noting that these stats are given out incredibly grudgingly, and despite FOI requests the only data we have been able to get hold of is from 2009-10 and 2010-11. These suggest that around 300 undergraduates degrade per year. Cambridge has a population of 12,000 undergraduates. This means that 2.5% of undergraduates degrade per year. The vast majority of our 1749 respondents were undergraduates; the representation of graduate colleges and MCR students was poor. We had a degrading rate of 5-6% amongst survey respondents. If 300 students degrade this means that approximately 900 of the undergraduates in the university at this point will have degraded. This is 7.5% of the student population, give or take. This would appear to corroborate our data. Whilst self-selection bias may be a slight issue, there simply aren’t enough major discrepancies in our demographics to justify calling the sample ‘unrepresentative’.

I’ve only included the colleges, subjects and support structures which had enough responses to be statistically significant. This is why you won’t see any of the graduate colleges being represented, or any of the smaller subjects. Any colleges which sent in less than a total of forty responses haven’t been included in the data displayed in the infographics, and nor have any of the subjects which sent in thirty or less responses. In analysing the data collected from the survey, above all I wanted to make sure that I was fair; you’ll see that when the situation is awful I’m harsh, but I’m not going to hide the areas in which good things are being done for the sake of my own biases.

Depression rates, gender differences, subject divides and stand-out colleges

The headline statistic is that 46% of Cambridge students are depressed. To break this down, 21% have been diagnosed with depression, another 25% think they may be suffering undiagnosed. To put this into perspective, a high-quality systematic review of mental illness put the prevalence for depression at 6.7% (Can J Psychiatry 2004;49:124–138). A recent NUS national survey suggested that 20% of students consider themselves to have a mental health problem. This is a broad categorisation, and less than half of the rate of mental health problems experienced by Cambridge students.

The fact that there are so many students in Cambridge suffering from mental illness, and depression in particular, means that it is absolutely vital that our support systems are up to scratch. Perhaps it is unavoidable under the Cambridge academic system that we have such a high rate of mental illness (I don’t believe this is the case – but that’s another preachy article for another time). However, the fact that it is so means the university has a protective responsibility towards its students, to keep us as sane as possible – an outcome which will benefit not only our personal happiness, but our continuing long-term academic progress as well.

One of the most striking parts of the results is the difference between genders. 58% of respondents were female, reflecting the societal norm that women are more likely to talk about emotional and mental issues than men. This is borne out by the rest of the results, too. The rate of diagnosed to undiagnosed depression amongst women was around 1:1, compared to 1:2 in men, and this is broadly reflected for other mental illnesses. In testimonials, male students often said they felt uncomfortable talking to anyone about their problems, fearing they wouldn’t be taken seriously, or that the issues weren’t serious enough to merit attention. Women are more likely to suffer from depression (49% compared to men’s 41%), as well as panic attacks (17% to 8%) and anxiety (46% to 30%).

Eating disorders, though, are where the gender difference is most marked. A full 23% of Cambridge women either have been diagnosed with an eating disorder or feel that they may have one. Given the fact that eating disorders tend to flourish in competitive, high-pressure environments, this is hardly surprising. That doesn’t make it any less awful. Amongst men the rate of eating disorders was 6% – that’s an infinite percent more than many people think, because body image problems are seen as being a female-only issue.

Once again though, the really awful statistics is the level of diagnosis. In women it’s, once again, about 1:1 diagnosed to undiagnosed. In men it’s 1:5. This reflects not only the fact that men are less likely to come forward with any mental illness at all, but also the massive stigma we attach to eating disorders in men, because eating disorders (and it bears repeating) are seen as only happening to women [Eat Disord. 2012 Oct;20(5):346-55] Women are also far more likely to seek help in general than men, with 51% of men reporting that they had not sought help for mental health issues from any source, whilst only 26% of women said the same. The soundbite to take from this is that 65% of Cambridge students have sought help for mental health issues, though this may be biased somewhat by the larger number of women who answered the survey.

Women are also much more likely to see their GP or the UCS than men, as well as relying on friends and family to a greater extent. Once again, this lends support to the notion that there is a widespread perception that men are not supposed to reveal any emotional or mental insecurity or instability, preventing them from turning to anyone to get the help that they may well desperately need.

Looking at subjects, there is a profound arts/sciences split. Overall, science students have a lower rate of all-cause mental illness than arts students: engineers in particular appear to be bastions of stability, with a 34% depression rate; that said, they are closely followed by the lawyers, who have a 36% rate of depression. English students, though, appear to live up to their stereotype: a full 60% of them are depressed, with 40% of them diagnosed, and their rates for the four other highly-reported illnesses are also extremely high. This is unlikely to be a sampling bias, given that 145 English students answered the survey, the largest number of any subject other than Natural Sciences. One other notable feature of English students is that they utilise their Directors of Studies at a higher rate than almost any other subject, with 23% of them seeking help for mental health issues from this source.

Moving on to look at the prevalence of mental illness in colleges, there are some stand-out statistics. The sample sizes are too small for most of them to be significant to my preferred value of, but that doesn’t prevent them from being interesting. Trinity and Homerton in particular appear to have unusually high rates of depression, as well as all-cause mental illness. Also worthy of note is that Murray Edwards has a particularly high level of eating disorders (28%), higher than the average rate for Cambridge women as a whole. Given that these disorders occur at their highest rates in all-girls private schools, perhaps it’s time to question whether the current provisions in place for eating disorders in all-girls colleges are adequate.

Disparity in college welfare systems leads to mistreatment of students

This ties in well to the next section of the survey, which looks at the welfare services which people use and assesses how well they believe they were supported. Broadly I’ll be talking about those two themes, but there are certain colleges and certain services which have been highlighted in the qualitative answers to later questions who have acted in ways that are unquestionably harmful to students, and I will be highlighting these as we go. The running theme throughout all this is the vast disparity between the welfare support provided by different colleges, due to the lack of any uniform training in how to deal with students presenting with mental health issues.

To start on a positive note, it’s clear that many people aren’t shy about talking to their friends and family about their problems, with almost half of students approaching friends for support, and nearly 40% using their families. Whatever else happens, it’s important to note that people who have solid support structures in place in the way of family and friends generally fare much better in the face of inclement mental weather than those who do not. Of all the support mechanisms, friends and family are consistently rated the most highly by students, with nearly 75% of students saying they felt they were ‘well’ or ‘extremely well’ supported by their friends and parents.

This has to be qualified with the fact that some people don’t feel that their friends or parents understood their problems or took them seriously. Stigma is a serious problem (if not the most serious problem) when it comes to mental illness, but stigma can only be broken down if it is challenged. I firmly believe that mental health is one of the only areas where simply talking about a problem can make it better: if we talk about our mental states more, raise awareness that different people suffer in different ways and that everyone’s problems take up the same amount of space in their heads, then we’re already well on the way to erasing the stigma which has for so long been unnecessarily attached to mental illness.

Now on to the negatives.Students have been treated by their tutors, DoSes, supervisors, counsellors and even college nurses in ways that reveal a startling inadequacy in the way we train those who are in pastoral contact with the student population. Students suffering from clinical depression have been told that they must be fine because they’ve been seen smiling and laughing with their friends; college nurses have displayed profound insensitivity regarding serious issues such as schizophrenia and suicide. These are not isolated cases, and these are the tip of the iceberg. As we go through the rest of the welfare provisions available for those with mental health issues, I’ll continue to illustrate with some of the very best and very worst of the support offered to Cambridge students.

The University Counselling Service: the good, the bad and the waiting lists

The University Counselling Service is the single most widely used service for mental health issues in Cambridge, with over a fifth of students reporting that they had used it at one time or another for this purpose. Reports on the quality of service that students received are mixed, with some saying that it was everything they could have hoped for, whilst others reporting that they were treated poorly to the point that their condition worsened, which is not ideal for a service which is supposed to provide welfare. In all of the reports people have given on the service, there are a number of running themes. The first is that the waiting time for an appointment is typically on the order of several weeks – a situation which is unacceptable when there are many students (and staff) in need of urgent attention. Many students also say that they have fallen foul of the session limits: typically students are only given four or eight sessions with the UCS, and after this they are asked to seek private counselling which is often prohibitively expensive.

Both of these problems can be traced back to the fact that for a service which supports 20,000 students and thousands of staff, they have only 13 full-time qualified counsellors, and are grossly underfunded. They also rely heavily on Cognitive Behavioural Therapy, which is effective in a large number of cases but is not ideal for everyone – many students complained of their inflexible approach to solving their issues. A not insignificant number also reported that they felt lost after using the service, as they had been given no real advice on how to make things better, having only been made more aware of the issues that they had.

Other students have faced different problems with the UCS. Some have been turned away because their problems were considered “too severe” for the service to handle. Others have been told, after a number of sessions, that there is nothing more that they can do for the students, with no advice being provided as to where to look for continuing care. Many have said that they were put off by the pre-counselling form, which is long and demanding, making it extremely difficult to fill out for people suffering from conditions which make it difficult for them to concentrate or work through something which is a highly emotionally exhausting task. Students have reported ineffectual treatment, or worse, being given treatment that was actively harmful.

This is a clear indication that the UCS – as is clear from their annual reports – attempts to do the very best it can with limited resources. However, our survey shows that the service is understaffed and underfunded, and is in dire need of assistance.

College counsellors and nurses

Continuing on the theme of counselling, college counsellors are a resource not available in all colleges – but feedback has been extremely variable from the colleges in which they can be accessed. This form of counselling necessarily receives mixed reports – it is not a service which is always going to be of use to everyone. However, in certain cases well over half of those who have used a college counsellor have reported that they were unhelpful, and quite often there is no method of recourse if the quality of service is sub-optimal. This is clearly not an acceptable status quo.

Having said this, certain counsellors have received some glowing reports, with the services at Homerton, Murray Edwards and King’s coming in for praise in the survey responses. Unfortunately, certain colleges’ services also left a great deal to be desired. Some counsellors received feedback which strongly suggests that there is something amiss, with students reporting counsellors appearing “shocked and overwhelmed” by their accounts, being “patronising”, “judgemental” and receiving treatment that was “old-fashioned and unhelpful”.

Confidence in the college nursing system appears to depend entirely on the individual nurses provided by each college. The college nurse at St John’s comes in for universal praise, with the only criticism being that she is leaving this year and students are therefore worried that the quality of care provided will drop. The nurses at Pembroke and King’s also received excellent feedback. In contrast, some nurses were slammed by students, who have, among other things, been told that they are a “burden to their friends” or that they are “attention-seeking” or “time-wasting”; they have been “ignored”, informed that they are a “danger to themselves and the college”, and had their friends told to “stay away” from them.

This is shocking treatment from individuals who are supposed to be the first port of call for those with health issues, whether they be physical or mental. To expect students to feel comfortable talking to the college nurse when there is the possibility they will be lambasted as an “attention seeker” or told that they don’t deserve their place at Cambridge is laughable. The level of ignorance and lack of understanding of mental health issues displayed by some nurses suggests that minimum standards of competence for all college nurses would not go amiss.

Directors of Studies live up to their academic focus

Directors of Studies are typically supposed to be approached over academic issues, but the poorly delineated welfare structure which Cambridge has means that students do often approach them over mental health worries, particularly those affecting their work, with 13% of students talking to their DoS about these issues. Once again, reports tend to vary a lot, with individual DoSes at individual colleges coming in for praise or criticism. Murray Edwards has a particularly high rate of women talking to their DoSes, and the service provided appears to be exemplary, with nearly three quarters of students saying they felt ‘well’ or ‘extremely well’ supported.

However, the academic focus of DoSes has in some cases meant the level of understanding and support they provide is inadequate, with students being told that all that mattered was academia: how long it would be before their essays were done, that they need to find a way to deal with their mental health so that their work won’t suffer, or being asked, ‘Don’t you think you should have waited to do all that until after exams are over?’. In some cases they appear to me more concerned about the potential for one of their students to achieve a bad grade than anything else, with several students reporting that they were encouraged to degrade as soon as they opened up about mental health problems, and one student was told there was “already someone on their course (who they named) who was depressed and he was worried about the grades of our year group”.

Whilst the function of DoSes is not necessarily pastoral, the fact is that they will come into contact with students in a pastoral context and therefore they need to be adequately prepared to deal with the not insignificant number of students who will inevitably come to them with mental illness.

Tutors and college administrations: negligence, confidentiality breaches and disrespect

Staff who do necessarily have a role in the pastoral care of students, however, are tutors. The quality of support provided by tutors is more variable than any of the other welfare services, with individual tutors ranging from heroic to downright despicable, and college tuition systems ranging from well-organised and efficient to non-existent. Individual stories of tutors who have single-handedly supported students through awful times contrast with those of tutors who have been allegedly sleeping with freshers show the massive disparity in the quality of pastoral care which Cambridge provides. In some colleges there are students who don’t even know their tutor’s name, and yet tutors continue to be paid large sums of money to administer their flock of students. This cannot continue. There must be some form of regulation for who can become a tutor and who cannot, as well as a well-delineated role for what kind of support tutors should be providing, and mandatory training in how to deal with issues which are incredibly likely to come up when dealing with students.

Some Senior Tutors and college administrations appear to be guilty of further mistreatment of their students. Reports from the survey suggest that students have been “patronised”, “forced to degrade”, to obtain prescriptions for drugs and stay on drugs in order to graduate; they have been subjected to confidentiality breaches wherein members of the college staff have passed on information about their condition without their consent, as well as speaking to their friends – without the student’s knowledge, and after specifically telling the student that they must not talk to their friends for fear of burdening them – regarding their mental health, and with no regard for the burden of secrecy this places on those friends.

This is not to say that every single person in every welfare system in Cambridge is doing a bad job – or, if they are, that they are doing so intentionally. There is every bit of evidence to suggest that, in spite of the egregious treatment of a large number of students, many people are doing everything they can to make Cambridge less stressful.

This is not an attack on any one individual. This is an indictment of the system as it stands. Cambridge is a place which is plagued by high rates of mental illness – higher than many of us feared. Whether this can be changed or not is a matter for another discussion. What is important is for the systems which are in place to support students who have mental health problems to work as well as possible. At the moment, this is simply not the case.

The things that will have made you the angriest in this article will have been the individual cases, the times when one student was treated appallingly badly by one person. This anger is justified; if you could read all of the things that I’ve read in the process of coordinating the survey, you would be furious. What’s important to remember, however, is that it’s the system within which people work which allows these awful things to happen.

The Vice Chancellor said recently that mental health training is the responsibility of each individual college. This uncoordinated approach has allowed us to reach the terrible status quo you see today. This is what we must endeavour to change. We cannot go on like this. We deserve better.

This is the full version of a post on the Cambridge Tab, which can be found here. The original details of the survey can be found here.