TALES FROM THE CLINIC
Case Study
“Brendan” is a 23-year-old man with a psychiatric history of depression and anxiety who is admitted to a private psychiatric facility for worsening depression, anxiety, and suicidal thoughts. He has had multiple psychiatric admissions since his teenage years. He grew up in an affluent family with his mother, father, and 2 siblings. His mother worked as a neurosurgeon, and his father was the CEO of a well-known oil and gas company. His current admission was initiated at the request of his parents, who, Brendan states, would cut him off financially if he did not voluntarily admit himself to a psychiatric unit. He was admitted without insurance coverage, and his parents paid out of pocket for the 6-week admission.
Brendan 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 selective serotonin reuptake inhibitors, antipsychotics for augmentation, and most recently esketamine, transmagnetic stimulation, and psilocybin microdosing. Before admission, he had not engaged in long-term psychotherapy because his parents believed “talking won’t help.”
During admission, he attended individual psychotherapy, where he perseverated on his parents’ financial control over his life. He spoke about feelings of inadequacy since childhood, stating his parents would often compare him with his high-achieving older siblings. He admitted to heavy use of alcohol and cocaine in high school and stated that his classmates from private school had access to unlimited drugs. Brendan describes a poor sense of self and feeling disconnected from his parents, who remain committed to their careers. He admits to continued struggles with low self-esteem and substance use in college, leading to his return to living with his parents. He reports 2 suicide attempts via overdose by ingestion that required hospitalization. He has been to numerous private inpatient hospitals, including some of the most famous treatment centers in the country, at the request of his parents.
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; the Figure gives a depiction of the top 1% of incomes in the top 10 states in 2023.1 Although there is a plethora of evidence describing the correlation between low socioeconomic status (SES) and poor mental health outcomes, individuals growing up in highly affluent environments tend to be understudied compared with those from the opposing end of the economic spectrum.2
FIGURE. The Top 1% of Incomes in the Top 10 Earning States in 20231
We look to Brendan’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 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 Brendan, they still exhibited 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 issues, 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; this was 3 times higher than that of 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 among 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 in turn may lead to high-stress levels. More recently, the news 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 for affluent students 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 Increasingly, 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 a 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 how we conceptualize mental health recommendations.
In Brendan’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, and 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 in Houston, Texas. Dr Smith is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine.
References
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