The CSMHS
The CSMHS is funded by the School, using a small proportion of the undergraduate tariff from Health Education England applied to the University of Cambridge. It is a non-urgent service, offering psychiatric and clinical psychology input over two/three days, respectively, in a week.
The service is delivered at the Liaison Psychiatry Department of Addenbrooke’s and Fulbourn Hospitals Cambridge. Students on regional placements are supported financially by the School for their travel and are not required to specify the nature of the appointment to placement supervisors.
The referral process of the CSMHS is illustrated in Fig. 1. Students are made aware of pastoral and welfare support systems when they first enter the School. Leaflets describing the CSMHS are also made available. Initially it was designed as a tertiary level service with referral by their University Occupational Health (OH) department. However, students regarded this route as somewhat convoluted, so direct primary care referrals are now accepted. The School does not refer directly, nor are they included in any way in the treatment process, ensuring confidentiality is maintained.
Following an initial psychiatric diagnostic assessment, a management plan is made jointly by the psychiatrist and student. If indicated, a referral will be made either to the CSMHS psychology service for therapy or other appropriate secondary NHS services. Decisions regarding who to refer for psychology are based on student choice and evidence-based guidance for psychological treatment of mental health conditions. Other considerations include presenting suicidal risk and the ability to attend and engage in a course of therapy sessions. If further input is not necessary, the student will be discharged to primary care. Psychiatry review clinics are offered when necessary or requested.
Students referred for CSMHS psychology service will be assessed by a clinical psychologist who develops collaboratively with the student, an evidence based tailor-made plan. The following therapies are available: Cognitive-Behavioural Therapy (CBT), Interpersonal Therapy, Eye Movement Desensitization and Reprocessing, or Cognitive Analytic Therapy. For therapies that are not available within the CSMHS, routine NHS referrals are also available. The length of treatment depends on an individual students’ need.
To calibrate the change in their mental health conditions and their experience of treatment, students complete the Clinical Outcomes in Routine Evaluation (CORE), the Generalized Anxiety Disorder-7 Scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), and the Work and Social Adjustment Scale (WSAS) before and after treatment. After treatment, they also complete an anonymised qualitative feedback form.
Neither the psychiatrist nor the clinical psychologists are involved in assessing or tutoring at the Clinical School or in FTP procedures, to avoid conflicts of interest.
Service evaluation
This service evaluation was registered and approved by the Quality Assurance and Clinical Effectiveness Unit, CPFT and funded by the National Institute of Health Research Applied Research Collaborations Easts of England (NIHR ARC EOE). Based on the Medical Research Council and NHS Health Research Authority guidelines neither separate ethics approval nor consent were required for evaluation of the anonymised dataset. The evaluation assessed waiting times, treatment delivery (intensity, treatment completion and dropout rate), academic outcomes, clinical progress and quantitative and qualitative feedback from the students.
Waiting times were defined as the time lag between initial referral and first psychiatric or psychology assessment, excluding those who delayed assessment due to declining an earlier appointment offered (for example, when students were away from University on placement).
Treatment duration was the total number of psychiatric review appointments and therapy appointments attended by students who completed treatment. Treatment completion was calculated as the percentage of students who had completed the intervention as a proportion of the total number of students who were offered a treatment.
Academic outcomes were assessed by years of intermission from their study, and whether they had successfully moved on to their Foundation Year.
Clinical outcomes in terms of global distress, anxiety, depression and perceived functioning were assessed respectively by CORE, GAD-7, PHQ-9 and WSAS that students completed before (T1) and after treatment (T2). Students’ subjective experience of the service was captured by anonymised qualitative feedback forms.
Outcome measures
The CORE is a 34-item self-report rating scale with good reliability and convergent validity [24]. It measures the global distress of an individual and consists of four subscales; well-being (4 items), problems/symptoms (12 items), life functioning (12 items) and risk (6 items), rated from 0 (Not at all) to 4 (Most or all the time). Suicide risk is measured by the risk subscale. Mean scores are computed for all items and subscales with higher mean scores indicate higher level of difficulty. Validated, gender-specific cut-off scores differentiate those who fall into the clinical range from those who do not.
The GAD-7 is used to measure the severity of generalised anxiety disorder symptoms [25]. It is a validated and widely used self-report scale consisting of seven primary anxiety symptoms. Respondents are asked to rate symptoms in the past 2 weeks from 0 (Not at all) to 3 (Nearly every day). The clinical cut-off is five with higher scores indicating greater levels of anxiety.
The PHQ-9 is a well-validated 9-item self-report rating scale for depression [26]. The clinical cut-off is five with higher scores indicating higher levels of depression.
The WSAS is a validated, 5-item self-report scale which measures perceived functioning across five dimensions; work, home management, social leisure activities, private leisure activities, and family and relationships [27]. Impairment in each dimension is rated from 0 (Not at all affected) to 8 (Very severely affected) with higher scores indicating greater perceived impairment. No validated cut-off is available.
Scores (of the above measures) before (T1) and after treatment (T2) were compared by paired-sample t-tests for those variables with a normally distributed score differences (i.e. T2-T1), or the Sign test (for assessing the consistency of change) and the Wilcoxon signed rank test (for assessing the magnitude of scores differences) for those without a normal distribution. The McNemar test was used to compare the change in the proportion of students falling in the clinical range (i.e. scoring above the clinical cut-offs) of anxiety and depression after treatment. SPSS version 25.0 was used for the analysis.
Student involvement and feedback form
Students were actively involved in the development of the service, including designing the referral pathway. A student on their Student Selected Component (SSC) conducted focus groups to canvass students’ views. Issues relating to a gap in NHS service provision were highlighted. FTP and performance were identified as areas that needed to be kept separate from our service.
When discharged from the service, students completed anonymous feedback forms to indicate how likely they would be to recommend the service on a 5-point scale ranging from 1 (Extremely likely) to 5 (Extremely unlikely), whether it was easy to access support (Yes/No), whether they felt listened to, taken seriously and treated with dignity and respect, whether their views were considered when agreeing a treatment plan, whether the input had helped them to cope with course demand, and the overall rating of the service on a 5-point scale ranging from 1 (Very good) to 5 (Very poor). They also indicated if they would recommend the service to peers, what was helpful and any suggestions for improvement.
The Yes/No questions and the 5-point scales were treated as categorical data and ordinal data, respectively. Descriptive statistics were computed for these questions. Two independent raters, who were not involved in the delivery of the service, analysed the feedback, and identified common themes that occurred in the written text.