Changes

October 2025 — reviewed.  A literature search was conducted in August 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes to the topic, updates to the background information, and basis for recommendation sections in line with the identified literature.

Update

Goals

To support primary healthcare professionals to:

• Be aware of the risk factors for mental health problems and their complications (such as increased risk of suicide) in students.
• Identify students who are at risk of mental health problems, including those with a pre-existing diagnosis.
• Manage any emerging mental health issues in a timely and appropriate fashion.
• Ensure good communication with all mental health professionals involved in the student's current care, any involved healthcare professionals at the student's home location, and (if the student has consented) with their parents/family members.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

Table 1. Indicators that may relate to mental health problems in students in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract.

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Depression in adults

• Adults with suspected depression have a comprehensive assessment.
• Adults with a new episode of depression have a discussion with their healthcare professional about the full range of treatment options.
• Adults with depression who are at a higher risk of relapse have relapse prevention interventions.
• Adults with depression who are stopping antidepressant medication have the dose reduced in stages.
• Adults from minority ethnic backgrounds with depression are supported to access mental health services.

[NICE, 2023]

Anxiety disorders

• People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment.
• People with an anxiety disorder are offered evidence-based psychological interventions.
• People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated.
• People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.

[NICE, 2014a]

Suicide prevention

• Multi-agency suicide prevention partnerships have a strategic suicide prevention group and clear governance and accountability structures.
• Multi-agency suicide prevention partnerships reduce access to methods of suicide based on local information.
• Multi-agency suicide prevention partnerships have a local media plan that identifies how they will encourage journalists and editors to follow best practice when reporting on suicide and suicidal behaviour.
• Adults presenting with suicidal thoughts or plans discuss whether they would like their family, carers or friends to be involved in their care and are made aware of the limits of confidentiality.
• People bereaved or affected by a suspected suicide are given information and offered tailored support.

[NICE, 2019]

Definition

• The most common mental health problems in young people in higher education are depression and anxiety disorders. Other observed mental health problems include:
  
  • Addiction.
  • Psychosis and schizophrenia.
  • Bipolar disorder.
  • Eating disorders.
  • Post-traumatic stress disorder (PTSD).
  • Obsessive-compulsive disorder (OCD).
  • Gambling-related harms.
• Students in higher education represent a demographic that is at high risk of mental health problems:
  • Around 90% of undergraduates in the UK are young adults aged under 25 years.
  • In England, approximately 20% of 17–25 year olds have a mental health condition (30% of women and 14% of men).
  • In around 75% of adults with a mental health condition, the onset of symptoms occurred before 25 years of age.
  • For illnesses such as bipolar disorder and schizophrenia, onset is commonly in young adulthood.
• Students may experience lower wellbeing than young adults as a whole:
  • In 2019, the Student Academic Experience Survey reported that student wellbeing had decreased between 2016 and 2019, with reductions in the proportion of students who considered themselves to have life satisfaction (from 16% down to 14%), that their lives were worthwhile (22% to 17%), happiness (21% to 18%), and reported low levels of anxiety (21% to 16%).
  • By comparison, in 2017/18, the Office for National Statistics (ONS) found that among young people aged 20 to 24 in general, 27% reported positive life satisfaction, 33% that life was worthwhile, 33% described positive happiness, and 37% reported low levels of anxiety.

[GMC, 2015; IPPR, 2017; RCPsych, 2021; NHS England, 2023; Cibyl, 2024; Lewis, 2025; NICE, 2025a]

How common is it?

• Reported mental health problems in students are increasing in prevalence. Between 2010/2011 and 2023/2024, the number of first-year students disclosing a mental health condition to their higher education institution increased over sevenfold. 
• In 2023/2024, 5.6% of UK students disclosed a mental health condition to their higher education institutions. However, this is lower than prevalence figures obtained from anonymous surveys and is likely to be an underestimate of the true prevalence, due to:
  • The perceived stigma associated with officially declaring a mental health condition.
  • The fact that mental health problems must be declared when applying to university in the ‘disability/special needs’ section of the UCAS form. Some young people with mental health problems may not view themselves as having a disability, do not have a formally diagnosed condition, or do not see their difficulties as long-term.
• Higher rates of mental health conditions have been reported among:
  • Women compared with men — in 2023/24, 7.2% of female students and 3.3% of male students reported a mental health condition.
  • Undergraduates compared with postgraduates.
  • Full-time compared with part-time students.
  • Those in their second or later years of education compared with first-year students.
• A 2023 survey of 4000 UK students found that the most common mental health difficulties were:
  • Anxiety (61%)
  • Depression (54%)
  • Suicidal thoughts (39%)
  • Eating disorders (28%)
  • Obsessive compulsive disorder (10%)
  • Bipolar disorder (3%)
• In a 2024 survey of 12,644 of students and recent graduates from over 145 universities in the UK:
  • 75% stated that they regularly worry about their mental health.
  • 33% reported that they were experiencing mental health difficulties at the time of the survey, while an additional 23% indicated that they had experienced mental health difficulties in the past.
    • For nearly half of people with mental health problems, onset was prior to university, with 11% developing difficulties in their first year of university.
    • The most common conditions reported among those with a pre-university diagnosis were anxiety (43%), depression (34%), eating disorder (13%) and attention deficit hyperactivity disorder (ADHD, 12%).
  • 32% reported some thoughts of self-harm, with 15% first starting to self-harm whilst at university.
  • 14% reported that they had experienced suicidal thoughts for the first time whilst at university.
• Similar results were found in a 2016 YouGov poll, which questioned 1061 students and reported that 27% experienced mental health difficulties (higher among LGBT students [45%] and 34% women, but lower among men [19%]).
• The prevalence estimates provided by such polls are, however, likely to be imprecise due to factors including: 
  • People with mental health conditions may be more motivated to participate than people without, meaning that overall prevalence estimates may be artificially elevated.
  • Particular demographic groups may be over-represented among participants, meaning that the results may not be generalizable to the student population as a whole.
    • For example, international students and those from BAME and LGBT communities were over-represented in the 2024 survey.
  • In some demographic groups (such as males and people from particular cultural backgrounds), recognition and/or candid expression of mental health problems may be less likely. 
  • International students participating in this type of research must have a good command of English, and be particularly motivated by the topic of mental health, and therefore may not be representative of the whole international community. 

[IPPR, 2017; BPS, 2020; RCPsych, 2021; Cibyl, 2024; Lewis, 2025]

What are the risk factors?

• In addition to the increased risk of mental illness due to the typical age of students, the risk of mental health problems is thought to be further exacerbated in students by factors including:
  • Moving away from home — coping with living independently, loneliness, and the absence of familiar social and emotional support networks are associated with a higher risk of mental health conditions.
  • Developing a new social identity — thought to be a potential stressor. Many students find it hard to adapt and to make new friends, and can become isolated as a consequence. Loneliness in student populations has been linked with greater anxiety, stress, depression, poor general mental health, paranoia, alcohol or recreational drug misuse, and eating disorders.
  • Workload pressures — both from academic demands (including academic examinations) and, in some cases, the need to coordinate jobs and studying. Students who are focused on the possibility of failure, experience imposter syndrome, perfectionism, or low academic self-efficacy are also more likely to develop mental health problems, including anxiety. 
  • Financial pressures — including managing own finances for the first time, the rising cost of living, worries about debt, and in some cases, poverty. 
  • Other factors:
    • Chronic physical health problems are a significant risk factor for depression.
    • Social deprivation — the number of students from disadvantaged backgrounds is increasing, and mental health problems are more common among people from more deprived socioeconomic backgrounds.
    • International students may face unique challenges relating to isolation, integration, cultural expectations, and concerns about funding.
    • Mature students may feel more isolated because they are unable to engage socially, may have parental care or other responsibilities, and may have greater financial pressures. 
    • Moving beyond the first year of university has been identified as potentially challenging possibly due to an absence of support initiatives that were present in the first year, as well as moving out of halls of residence, and increased workload.
    • Pre-existing neurodevelopmental conditions such as autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) may increase the risk of mental health problems, particularly at times of transition and change.
    • Identifying as non-binary or ‘other’ gender have been associated with greater risk of mental health conditions in a large survey of 21,000 students.
    • Female sex — in common with the general population, female students are more likely to report mental health symptoms or conditions than male students. Among women, a higher prevalence of childhood sexual abuse, sexual victimisation, and abuse perpetrated by intimate partners may contribute to this sex discrepancy.
    • LGBT students and BAME students have been identified in some studies as experiencing lower wellbeing and poorer mental health.
    • Misuse of alcohol or other recreational substances — some students may experienced significant peer pressure to misuse alcohol and drugs, which can increase the risk of mental illness and other health problems.
    • Poor sleep quality or insomnia — both have been associated with depression and anxiety among students.
    • Poor diet — a higher quality diet has been associated with improved student mental health, including small to moderate reductions in the incidence of depression, anxiety, stress and improvements in general mental well-being.
• In addition, young people with pre-existing mental health conditions:
  
  • May find relocation particularly stressful if they have cultivated a positive relationship with their GP, or a primary or secondary mental health practitioner, at their home location.
  • May be at particularly high risk of exacerbation if they have not been able to access appropriate support prior to starting university.
  • Students with experiences of trauma in childhood appear to be at increased risk of developing poor mental health whilst at university.

[RCPsych, 2021; Campbell, 2022; Gardani, 2022; Thompson, 2022; Solomou, 2023; Cibyl, 2024]

What are the complications?

• Students who have declared a mental health condition to their higher education institutions are less likely than average to:
  • Continue beyond their first year. The number of students with mental health problems dropping out of university more than doubled between 2009/2010 and 2014/2015, when 1180 such students gave up their studies.
  • Achieve a first or upper second-class degree.
  • Secure 'higher level' employment.
  • Study as a postgraduate.
• Mental health problems can increase the risk of suicide:
  • 1554 students died by suicide between 2000 and 2020.
  • The lowest suicide death rate for a decade was recorded in the 2019/2020 academic year, with 3 deaths per 100,000 students (64 suicides).
  • Between 2017 and 2020, there were 319 student deaths by suicide (3.9 deaths per 100,000). Males were more likely to die by suicide (5.6 deaths per 100,000) than females (2.5 deaths per 100,000).
  • The suicide rate was also higher among older and White students, rather than Black or Asian students.
  • In 2017, it was reported that only 12% of students who died by suicide were seeing student counselling services.
    • However, between 2017 and 2020, the suicide rate in the general population (12.5 per 100,000) was considerably higher than among the student population (3.9 deaths per 100,000).
    • Suicide rates were also higher among the general population when stratified by age (age 17 to 20: 8.4 versus 3.1 deaths per 100,000; age 21 to 24: 9.8 vs. 3.6 deaths per 100,000; age 25 to 29: 11.3 vs. 4.6 deaths per 100,000; age 30 to 64: 13.4 vs. 5.5 deaths per 100,000).
  • Students with experiences of adversities in childhood (such as maltreatment, family violence, physical punishment physical or emotional abuse and neglect) may be at increased risk of suicidal behaviour and self harm whilst at university.
• Poorly controlled mental health conditions may increase the risk of other health complications including:
  • Substance misuse.
  • Unsafe sexual behaviour
  • Violence.
  • Increased risk of communicable and non-communicable diseases.
  • Injury.

[IPPR, 2017; RCPsych, 2021; Campbell, 2022; ONS, 2022; Cibyl, 2024; Lewis, 2025]

What is the prognosis?

• The prognosis will depend upon the person's specific mental health problem(s) and their severity, as well as the support and management provided. For information on prognosis for the most common diagnoses, please see the CKS topics on Depression and Generalized anxiety disorder.
• Engagement with initiatives provided by the student's higher education institution may improve the overall prognosis by offering some protection against the development/exacerbation of mental health problems. Depending on local availability, these may include:
  
  • Mental health teams.
  • Counselling services.
  • Disability services.
  • Social support networks, to engender a 'sense of belonging'.
  • Peer support initiatives.
  • Provision of personal tutors.
  • Groups/workshops to build resilience and promote wellbeing.
  • Approaches to minimize academic exam stress — such as revision workshops.
  • Approaches to improve wellbeing and healthy behaviours — such as increased exercise and outdoor activity, healthy eating and sleeping, minimizing screen time, and discouraging alcohol and drug misuse.
  • Approaches to encourage engagement in university life — such as social events which do not involve drinking alcohol, and a range of extra-curricular activities beyond sports.
  • Making reasonable adjustments for students with mental health problems — including flexibility around factors such as class hours or structures, physical environment, and working practices.

[Williams, 2015; IPPR, 2017; BPS, 2020; RCPsych, 2021; Campbell, 2022; Gardani, 2022; Solomou, 2023; Universities UK, 2023; Deyo, 2024; Lewis, 2025]

How can I identify students at risk of mental health problems?

GP practices looking after large numbers of higher education students could consider:

• Ensuring that all relevant personnel receive regular training in the assessment and management of young people with mental health problems, and are aware of the risk factors. 
• Routinely assessing mental wellbeing when students join the practice (e.g. using short questionnaires) or when they first present for any reason.
  • A general mental health and wellbeing measure, such as the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS), may be appropriate.
  • If depression or anxiety are suspected, consider assessing for these. For further information on how to specifically assess for depression and anxiety, please see the CKS topics on Depression and Generalized anxiety disorder.
• Reviewing the history of students joining the practice to identify those with a pre-existing mental health diagnosis. 
  • For students already receiving treatment, communication between their ‘home’ mental health team and any clinicians involved with management at the student's new location is strongly advised to ensure continuity of care. 
  • In order to identify those at particular risk, be aware that young people with pre-existing mental health conditions:
    
    • May find relocation particularly stressful if they have cultivated a positive relationship with their GP, or a primary or secondary mental health practitioner, at their home location.
    • May be at particularly high risk of exacerbation if they have not been able to access appropriate support prior to starting university.
• Asking students about their mental wellbeing opportunistically. 
• Students whose mental health is deteriorating, or who are at risk of relapse of a pre-existing mental health condition may routinely be notified to primary care by student counselling services and/or other relevant locally available services. 
  • Note: in order to facilitate reciprocal referral pathways, practices with a significant student population should ensure that arrangements are in place to allow rapid and effective liaison with local student counselling services, and that clear information-sharing protocols are in place to facilitate a response to risk. 
• Parents or other family members may also occasionally notify a GP if they are concerned that a registered student is experiencing a mental health crisis.
• Practices could therefore consider the use of targeted mental wellbeing questionnaires to some students, providing information on their websites about the range of available support services for students experiencing stress and mental health issues, and ensure that (where clinically appropriate) mental health is routinely discussed during contact with students.

Assessment

• Where a mental health problem is suspected, assess the person to determine the diagnosis and to rule out other causes. Consider asking about:
  • Psychological symptoms — perceived changes to mood, thoughts, emotions, resilience, perception, and behaviour. Also, attempt to establish the severity and duration, and any previous history of psychological symptoms.
  • Physical symptoms — may be a feature of a psychological illness, or may suggest a differential diagnosis.
    • Use clinical judgement to determine whether an examination and/or further investigations are necessary.
  • Academic performance — declining academic performance can be associated with a burgeoning mental health problem. Perceived failure can also be a trigger for mental health problems in some students. Be aware that a student's cultural background may affect their perception of the importance of success, and feelings of failure and shame.
  • Sleep patterns — poor sleep is commonly seen alongside mental health problems in students and in some cases may be at least partly causal.
  • Co-morbidities — such as chronic illness causing functional impairment, which has been associated with increased risk of some mental health problems.
  • Use of over-the-counter or prescribed medications, whose adverse effects may include changes to mood and behaviour.
  • Misuse of alcohol or other recreational substances — may contribute to symptoms and/or may be misused as a result of the person's psychological difficulties.
  • The person's psychosocial situation — to determine whether there are any risk factors for particular conditions, and identify triggers for current psychological distress. These may include:
    • Difficulties with previous or current interpersonal relationships.
    • Recent or past experience of stressful or traumatic events.
    • Problematic living conditions, debt, employment situations, loneliness, or social isolation.
  • Personal and family history of mental health problems — to determine the presence of risk factors.
• Be aware that in students in secondary education, the most common mental health problems are depression and anxiety.
  
  • Depression is characterized by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms. In young adults, depression can have a more insidious onset, and may be characterized by irritability and low mood. 
  • Generalized anxiety disorder (GAD) is characterized typically by disproportionate, pervasive, uncontrollable, and widespread worry and a range of somatic, cognitive, and behavioural symptoms that occur on a continuum of severity. Be aware that:
    • People with depression and GAD may present solely with associated physical symptoms. The person may be unaware that these are caused by a mental health problem, or may not readily report psychological distress.
    • Anxiety in students may present in a variety of guises and may sometimes present very specifically (at least initially), for example, as social anxiety or exam anxiety.
    • For further information, please see the CKS topics on Depression and Generalized anxiety disorder.
• Other mental health problems where onset or exacerbation is common among young people include:
  • Addiction — should be considered if there is misuse of alcohol, illicit drugs, or the person reports compulsive behaviour such as gambling, excessive shopping, or spending large amounts of time using the internet or gaming. For further information, see the CKS topics on Alcohol - problem drinking and Opioid dependence.
  • Psychosis/schizophrenia — suggested by alterations to a person's perception, thoughts, mood, and behaviour. Features may include hallucinations and delusions; paranoia; lack of spontaneity, mood, drive, and/or pleasure; attention deficit; and/or impoverishment of speech and language. For further information, please see the CKS topic on Psychosis and schizophrenia.
  • Bipolar disorder — suggested by major depression that is accompanied by, or interspersed with, mania, hypomania, or mixed episodes. For further information, please see the CKS topic on Bipolar disorder.
  • Eating disorders — suggested by persistent disturbance of eating or eating-related behaviour that leads to altered intake or absorption of food and causes significant impairment to health and psychosocial functioning. For further information, please see the CKS topic on Eating disorders.
  • Post-traumatic stress disorder (PTSD) — suggested by anxiety caused by exposure to reminders of past trauma. The person may report feeling as if they are reliving these events through flashbacks, nightmares, etc. For further information, please see the CKS topic on Post-traumatic stress disorder.
• Also be aware of the clinical features of:
  • Autism spectrum disorder (ASD) that, in some cases, may remain undiagnosed and can be associated with mental health problems. Features can include difficulties in social interaction and communication, and rigid and repetitive behaviours, but in some people may be subtle, and particularly in females, may be masked. For further information, please see the CKS topic on Autism in adults.
  • Attention-deficit hyperactivity disorder (ADHD) — suggested by inattention and hyperactivity-impulsivity symptoms that started in childhood. May be associated with elevated stress, burnout, anxiety, depression, substance abuse, and, especially in females, may be mistaken for, or diagnostically overshadowed by, anxiety.
• If appropriate (depending on clinical features), assess the person's risk of suicide. Ask them:
  • Do you have thoughts about death or suicide? 
  • Do you feel that life is not worth living? 
  • Have you made a previous suicide attempt? 
  • Is there a family history of suicide/has anyone close to you taken their own life?
  • If the answer to any of these questions is yes, ask about their plans for suicide: 
    • Have you considered a method?
    • Do you have access to the materials?
    • Have you made any preparations (for example, written a note)?
  • Also ask about any protective factors, for example: 
    • What keeps you from harming yourself? 
    • Is there anything that would make life worth living?
    • Do you have adequate social support, and know who to contact in an emergency?
• Identify risk factors that increase the risk of suicide — these include: 
  • Previous suicide attempts or self-harm.
  • Active mental illness.
  • Family history of mental disorder, suicide, or self-harm.
  • Male sex.
  • Physical health problems.
  • Living alone.
  • Drug/alcohol dependence.
  • Problem gambling or gambling disorder.
  • Feelings of hopelessness.
  • Exposure to suicidal behaviour.
  • For further information on assessing the risk of suicide, see the CKS topic on Depression. 
• If the person is exhibiting symptoms of bipolar disorder, psychosis, or schizophrenia, also assess the risk of harm to others. For further information, see the CKS topics on Bipolar disorder and Psychosis and schizophrenia.
• Assess the severity of any identified mental health problems to determine appropriate management strategies. For further information, see the CKS topics on Bipolar disorder, Depression,  Eating disorders, Generalized anxiety disorder, Post-traumatic stress disorder, and Psychosis and schizophrenia.

Management of students with mental health problems

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on the management of student mental health in primary care. 

Search dates

August 2020 - August 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 21st August 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

• Anxiety+/  Depression/  Mentally Ill Persons/  Mental Disorders/
• mental or depress* or anxiety or psychosis or psychotic or suicid*.ti,ab.
• Universities/  Students+/
• student* or universit* or higher education or tertiary or post-secondary or further education.ti,ab.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug & amp; Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalkonline
• BMJ - Patient Journeys
• Patient.co.uk - Patient Support Groups

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.