
Mental Illness Is an Equal Opportunity Employer
Key Takeaways
- Affluence can lead to mental health challenges, including stress, anxiety, and a lack of purpose, despite financial stability.
- Wealthy individuals may face achievement pressures and isolation, contributing to mental health issues like depression and substance misuse.
How does affluence impact mental health outcomes?
TALES FROM THE CLINIC
-Series Editor Nidal Moukaddam, MD, PhD
In this installment of Tales From the Clinic: The Art of Psychiatry, we discuss affluence. Contrary to popular belief, affluence may be a double-edged sword in terms of mental health outcomes. Anecdotal reports suggest more difficulty managing stress and
Case Study
“Mr Lenny” is a 23-year-old man with a past psychiatric history of depression and anxiety. He has had multiple psychiatric admissions since his teenage years. He is admitted to a private psychiatric facility for worsening depression, anxiety, and
Mr Lenny was offered and received electroconvulsive therapy (ECT), which provided short-term resolution of depressive symptoms. He has a history of multiple medication trials, including 3 different selective serotonin reuptake inhibitors, antipsychotics for augmentation, and most recently esketamine, transmagnetic stimulation, and psylocibin microdosing. Prior to admission, he had not engaged in long-term psychotherapy because his parents felt “talking won't help.”
During admission, he attended individual
Discussion
Affluence refers to an individual's or household's economic and financial advantage compared with others. Affluence may be assessed through either income or wealth, and the
We look to Mr Lenny’s 6-week admission at this private psychiatric hospital to explore this notion. Compared with patients admitted to the psychiatric unit of the safety-net hospital just blocks away, the private patient population seemed, on a superficial level, protected from the psychosocial factors that plague patients of lower SES. These patients had financial stability, did not face homelessness, and had never experienced decreased access to food. Yet, like Mr Lenny, still endorsed elevated levels of anxiety and depression that have been linked to economic stressors and limited social resources.3
Recently, researchers have paid increasing attention to the relationships between SES and mental health, including not only less prevalent disorders like schizophrenia, but more common ones like major depressive disorder. In 2003, multiple studies of affluent students yielded interesting results: teenagers from high-income families are more likely to experience substance misuse, anxiety, and depression than their lower-income peers.4 In another study, an analysis of 264 suburban youth and 224 inner-city students found that 1 in 5 affluent 16-year-old girls had clinically significant depressive symptoms (3 times higher than their inner-city counterparts). The prevalence of anxiety produced similar results, with 22% of wealthy girls reporting symptoms and 26% of affluent boys, as compared with 17% of inner-city kids. Substance use was particularly significant, with 59% of suburban boys using illicit drugs compared with 38% of inner-city adolescents. It was discovered that amongst the affluent youth, substance misuse as a means of self-medication was far more frequent.4
A deeper dive into the distress of affluent children reveals a duality of stressors: achievement pressures and isolation from adults.5 In affluent communities, children are often pressed to excel at multiple academic and extracurricular pursuits to maximize their long-term academic prospects—which may inevitably lead to high stress levels. More recently, pop culture has highlighted the lengths some affluent parents are willing to go to secure their child’s spot at a prestigious university.6 This type of unrelenting pressure to excel has been associated with stress-related symptoms such as insomnia, stomach pain, headaches, anxiety, and depression.7 The term “affluent neglect” describes the correlation between the commitment to professional development often required of affluent parents and the sense of isolation experienced by their children.2 The term describes how a lack of psychological closeness with caregivers can impact the attachment states of children and adolescents, ultimately affecting their adult lives. Disrupted attachment states have been linked to low frustration tolerance, feelings of entitlement, reduced empathy, and lack of appropriate coping skills.3 Considerably, a similar form of neglect has been described in children of low SES, whose caretakers may have to work long hours or multiple jobs to meet financial needs. These young individuals endure the pressures of disproportionate family responsibilities such as caring for younger siblings, preparing meals, and even securing a job to contribute financially to the household.8 Which of these scenarios, with parallel experiences of neglect from adults, is more conducive to mental wellness and resilience in young adulthood?
There is certainly room to explore the effects of affluence on mental health and mental health treatment. One psychologist described his experience treating billionaire clients, in which he highlighted struggles with lack of purpose, and, interestingly, how money was often wrapped in feelings of guilt, shame, and fear for these clients.9 This author challenged the perception that money can immunize against mental health problems by highlighting that, for his clients, wealth likely made them more susceptible to issues. A better understanding of how material wealth affects the development of secure attachments, sense of self, emotional regulation, and mental resilience may greatly impact the way we conceptualize mental health recommendations.
In Mr Lenny’s case, increased financial means may have inadvertently led to the overutilization of newer, more expensive treatment options, before an adequate trial of the gold-standard combination of medication and psychotherapy. For providers, understanding how affluence (and access) may influence mental health treatment is imperative when making treatment recommendations. For example, a 2017 study examined the sociodemographic trends of ECT use in Texas and found that White patients use more ECT than African American, Latino, and Asian patients in both Harris County and Texas. The study hypothesized that access to care, among other factors including, cultural beliefs, stigma, and patient knowledge of ECT contributed to this disparity.10
Concluding Thoughts
Considering the important topic of countertransference, health care providers and trainees may feel a sense of disconnect, frustration, difficulty expressing empathy for a patient who is extremely affluent. Most mental health care providers are trained to consider the circumstances of patients with limited resources in treatment recommendations and discharge planning. They may find difficulty recognizing the effect of unlimited resources on these aspects of treatment planning. Without awareness, trainees and seasoned providers may be unprepared to manage feelings of inadequacy that arise when treating patients whose education level, achievements, affluence, and influence may far exceed their own. Providers may even feel pressured to offer newer, more aggressive treatments to combat those feelings of inadequacy. The exploration of how affluence affects mental health and mental health treatment will hopefully turn a spotlight toward gold-standard treatment practices, regardless of affluence.
Dr Egbe is a PGY-3 general psychiatry resident at Baylor College of Medicine. Dr Smith is an assistant professor in the department of psychiatry & behavioral sciences at Baylor College of Medicine.
References
1. Bink A. Here’s how much income it takes to be among the top 1% in your state. News Nation. January 30, 2022. Accessed December 19, 2024.
2. Velten J, Scholten S, Brailovskaia J, Margraf J.
3. Wealthy family mental health risks. Paracelsus Recovery. November 2, 2022. Accessed December 19, 2024.
4. Novotney A.
5. Luthar SS.
6. Luthar SS, Sexton CC.
7. Ettman CK, Adam GP, Clark MA, et al.
8. Ondersma SJ.
9. Cockrell C. I’m a therapist to the super-rich: they are as miserable as Succession makes out. The Guardian. November 22, 2021. Accessed December 19, 2024.
10. Williams J, Chiu L, Livingston R.
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