As increasing numbers of students disclose mental health conditions, this study is the first to examine mental health status as a critical variable in foreign language anxiety research. Using a mixed-methods approach and drawing on data from 262 languages students at the Open University, it systematically compares foreign language speaking anxiety (FLSA) experiences between students with and without declared mental health conditions. Vocabulary retrieval emerged as the primary anxiety trigger common to all learners, however, significant distinctions emerged: students without mental health conditions expressed more academic-focused anxieties, whereas those with mental health conditions faced confidence and identity-based barriers. Students with mental health challenges are less likely to speak spontaneously and undertake spoken assessments, often opting to avoid online synchronous sessions entirely, requiring different coping strategies. The findings are analysed through a Universal Learning Design lens and reveal the need for tailored support and innovative pedagogical solutions, including AI-powered practice environments and self-compassion interventions specifically designed for online language learning contexts, to address the emotional barriers faced by students with mental health conditions. The study offers broader implications for inclusive (language) course design and learner engagement.