Development of guidelines for tertiary education institutions to assist them in supporting students with a mental illness: a Delphi consensus study with Australian professionals and consumers

Introduction

The 2007 Australian National Survey of Mental Health and Wellbeing estimated that mental illness affects as many as one in four people aged 16 to 24 in any 12-month period (Slade et al., 2009). The age at which most young people are in tertiary education is also the age of peak onset for mental illness, with mental and substance use disorders having their first onset before age 24 in 75% of cases (Kessler et al., 2007; Slade et al., 2009). In Australia, it is estimated that over 50% of young Australians are in tertiary education (Birrell & Edwards, 2007). While many students enjoy and cope well with the transition to higher education, for others it is less easy, possibly due to the competing demands of work, study and family commitments (Andrews & Wilding, 2004). Analysis of data from national surveys reveals that tertiary students are at higher risk of moderate, but not high, psychological distress compared to non-students (Cvetkovski, Reavley & Jorm, 2012). However, having financial problems and working in paid employment increased the risk of distress, an issue that is likely to increase in importance as the participation rate of socio-economically disadvantaged students increases (Cvetkovski, Reavley & Jorm, 2012).

Students with a mental illness face the same challenges as other students as well as unique problems associated with the re-emergence or intensification of symptoms. Mental illness has been shown to affect both exam performance and higher education drop-out rates, with an estimated 86% of individuals who have a psychiatric disorder withdrawing from college prior to completion (Kessler et al., 1995; Andrews & Wilding, 2004; Hysenbegasi, Hass & Rowland, 2005). In an Australian study, Stallman found that Australian students experiencing very high levels of distress were, on average, unable to work or study for eight days within the previous four weeks and had another nine days of reduced capacity for work (2008). Such educational impacts may have lifelong consequences, particularly if students are unable to complete their courses. There is evidence that mental illness in higher education students has increased in recent years, placing pressure on institutions to adequately respond to the needs of the population (Roberts et al., 1999; Kadison, 2004).

Australian tertiary education institutions typically offer a number of services to support students with a mental illness, including counselling services and disability liaison units. However, the great majority of young people with depression and related disorders either do not seek or delay seeking professional help and there is some evidence that they are also reluctant to access formal disability support services in tertiary education institutions (Salzer, Wick & Rogers, 2008; Slade et al., 2009). While depression, anxiety and related disorders are among the leading causes of disability worldwide, the term “disability” is typically seen as relating to physical problems, with the links between mental disorders and disability often poorly understood (World Health Organisation, 2008). Tertiary institution disability services have traditionally been focused on physical disabilities and there is growing acknowledgement of the need for a greater policy and practice focus on support for students with mental illness-related disabilities. This led to the organisation by eight Australian universities of an Australian National Summit on the Mental Health of Tertiary Students in August 2011. The scientific evidence for how best to support students with a mental illness is relatively limited and there is a need to develop and evaluate policies and practices in the area (Salzer, Wick & Rogers, 2008). This is particularly true in the Australian context, as the majority of research has been carried out in Europe and the US, which have somewhat different education systems.

In the context of the limited evidence base, assessing expert consensus offers a way of bringing together available research evidence and best practice in order to enable recommendations and decisions to be made. Such methods have been widely applied in the development of clinical practice guidelines. The most commonly used consensus method is the Delphi process, which has been used to develop mental health first aid guidelines using the expertise of professionals, consumers and carers (Jorm et al., 2008; Kelly et al., 2008; Langlands et al., 2008). These guidelines have been used to revise the content of a Mental Health First Aid training program (Kitchener & Jorm, 2008).

This paper reports on the development of guidelines for tertiary institutions to assist them in supporting students with a mental illness. Once established, the guidelines may be used to inform policy and practice in tertiary institutions.

Methods

Results

The response rate of those who took part in all three rounds was 83% (80% professionals, 85% consumers). See Table 2 for the number of panel members who completed each round.

See Fig. 1 for an overview of the numbers of items that were included, excluded, created and re-rated in each round of the survey. Across three rounds, 155 strategies were rated as essential or important by at least 80% of the both panels (see Supplemental Table 1). Overall, ratings of whether items were essential or important were similar across the consumer and professional panels, with a correlation of r = .75.

One of the authors (AR) prepared a draft of the guidelines by grouping items of similar content under specific headings. The guidelines retained the original wording of the items as much as possible, whilst remaining easy to read. The draft guidelines were then given to panel members for final comment, feedback and endorsement. No changes were asked for by panel members at this stage.

The final guidelines (see Table 3 for a summary and Supplemental Figure 1 for the full guidelines) provide information and advice on how tertiary institutions should support students with a mental illness. They cover policy, measures to promote support services, service provision, accessibility of support services, relationships between services, other types of support and issues associated with reasonable adjustments. They provide guidance on the procedures the institutions should have for making staff aware of issues associated with mental illness, mental illness training, support for staff and communicating with a student with a mental illness. They also cover student rights and responsibilities, the procedures the institutions should have for making students aware of issues associated with mental illness, dealing with mental health crises, funding and research and evaluation.

Discussion

The project aimed to identify strategies that could be used by tertiary institutions to support students with a mental illness. Overall, 155 strategies were endorsed from a comprehensive range of suggestions. The endorsed strategies were written into a guidelines document which is freely available to tertiary institutions in order to inform policy and practice.

With 90% of the original items rated as essential or important by both panels, there was a high level of agreement between consumers and professionals on the importance of the items. One notable area of difference related to the statement that support service hours should include regular evening and weekend hours. This was endorsed by 73% of consumers but only 40% of professionals. Other areas of difference also related to services provided to students, including the recommendation that the organisation’s support services should be one organisational unit; that the institution should offer short courses for students with a mental illness on how best to manage their illness while fulfilling the student role; that students with a mental illness should be provided with individualised support for their education goals; that students with a mental illness should have access to vocational support; that students should have the opportunity to join an ongoing peer support group; and that funding should be available for students who have had a period of hospitalisation due to mental illness to catch up with their studies. All these items received notably higher endorsement ratings from consumers than from professionals. It is likely that these differences reflect health professionals’ views (many of whom were student counsellors or disability service officers) on what is practical in their organisations given available resources. It may also reflect the views expressed in a number of comments that such services should be available for all students, not just those with a mental illness. Several respondents commented that they thought students with a mental illness would not want to be singled out in this way.

The issue of what is practical in an institution may also explain differences in endorsement ratings of items relating to research and evaluation of services. More consumers than staff endorsed items relating to research into the prevalence of mental health problems in students; research into the needs of those who are typically more reluctant to access services; research into new models of service delivery; and the establishment of a working group to raise, discuss and advocate on issues affecting students with a mental illness. There were several comments about the applicability of general community research to those in tertiary institutions and for the need for inter-institutional collaboration in this area.

Items that received notably lower endorsement by consumers than professionals included those recommending that campus security procedures should exist to deal with students in a mental health crisis; that the institutions support service should have a way of prioritising appointments for urgent situations; and that there should be collaboration (with a student’s permission) with external mental health agencies. The recommendations that all staff receive mental health training and that teaching staff should let their students know they can be approached if the students have problems also received notably lower endorsements from consumers than professionals. This may reflect a limited belief in the helpfulness of lecturers or teachers as sources of help for mental health problems, something that has been seen in general community surveys (Reavley & Jorm, 2011).

While the guidelines provide guidance for tertiary institutions on how to support students with a mental illness, how they are implemented is critical to their usefulness. This will obviously vary according to institution. In August 2011, an Australian National Summit on the Mental Health of Tertiary Students, organised by representatives from eight universities was held in Melbourne. Summit attendees included student counsellors, disability service personnel, researchers and senior management from the majority of Australian universities and some Technical and Further Education institutions. Implementation of the guidelines was discussed by working groups and a number of ideas emerged, including the use of the guidelines as a way to evaluate current practice, with a focus on accountability and evaluation of success. There was a suggestion that they could be incorporated into the process of planning and prioritising activities in the area of mental health and wellbeing and some groups recommended their inclusion into an institution-wide approach. The guidelines were welcomed as a source of new ideas, evidence and opportunities for benchmarking. Future research should investigate the impact of the guidelines on policies and practice in tertiary institutions and may also be used as a basis for designing interventions aimed at improving mental health in tertiary students.

A number of groups felt that the guidelines could be used as a tool to engage senior management and help them understand the importance of mental health issues. Given the necessity for funding to support the implementation of some of the recommendations outlined in the guidelines, senior management support is critical. It was also felt that they would be useful in getting buy-in from other staff members, including academic staff. The recruitment of “champions” to consider how the guidelines may interface with existing policies was a further recommendation.

Strengths of the Delphi approach include the ability to include individual panellists across diverse professional and geographical locations without the need for face-to-face meetings. Moreover, the anonymous nature of the Delphi process ensures that no single expert can dominate the consensus process, a factor that may be particularly important when including both professionals and young consumers. However disadvantages of the approach include an inability of panellists to meet and discuss uncertainties or ambiguities in, for example, the construction or wording of the questionnaires used. The success or otherwise of the Delphi process depends on the panel of experts chosen to participate and lack of diversity in panel members may limit the usefulness of the findings. In this study, male consumers, who may have different attitudes to help seeking for mental health problems to female consumers (Reavley, McCann & Jorm, 2012) were represented in low numbers.

Conclusions

In conclusion, the guidelines provide guidance for tertiary education institutions on how to facilitate improved educational outcomes for students with a mental illness. It is hoped that they be used to inform policy and practice in these institutions. Further research should assess the implementation of the guidelines in a variety of institutions, including universities and TAFEs.

Supplemental Information